By Sharon Muza, BS, CD(DONA), BDT(DONA), LCCE, FACCE, CLE
Earlier this month, the Association of Women’s Health, Obstetric, and Neonatal Nurses published a position statement entitled “Continuous Labor Support for Every Woman.” I was excited to read this article, thinking that it was going to agree with recent statements by ACOG acknowledging support by a trained doula was a critical component of improving maternal-newborn outcomes by reducing labor interventions that may increase cesarean births. Unfortunately, this was not the specific message of this position paper that I took away after reading. While AWHONN agrees with ACOG’s recommendations for doula support to reduce primary cesareans and labor interventions, this statement did not completely line up with those recommendations. I am curious about your thoughts after reading it.
The first paragraph opens with the statement “AWHONN asserts that continuous labor support from a registered nurse (RN) is critical to achieve improved birth outcomes.” AWHONN states that it is the nurses’ responsibility to assess and implement individualized care plans in collaboration with the laboring person. The nurse acts as the care team coordinator and works alongside the partner, family, friends, and doula to help the birthing person achieve their goals.
AWHONN’s position statement acknowledges that childbirth has a lifelong impact on a person’s physical and emotional well-being. This harkens back to Penny Simkin’s groundbreaking research “Just another day in a woman’ life? Women’s long-term perceptions of their first birth experience.” This position statement recognizes that continuous support provides many benefits (Bohren, Hofmeyr, Sakala, Fukuzawa, & Cuthbert, 2017) including:
- Increased spontaneous vaginal birth,
- Shorter duration of labor,
- Decreased cesarean birth,
- Decreased instrumental vaginal birth,
- Decreased use of any analgesia,
- Decreased use of regional analgesia,
- Improved five-minute Apgar score, and
- Fewer negative feelings about childbirth experiences. (Bohren, Hofmeyr, Sakala, Fukuzawa, & Cuthbert, 2017).
AWHONN’s position statement discusses how many birth facilities are inadequately staffed to allow for nurses to provide continuous support.The role of the nurse is complex and includes:
- Assessment of the physiologic and psychologic processes of labor
- Facilitation of normal physiologic processes, e.g., allow movement in labor;
- Provision of physical comfort measures, emotional support, information, and advocacy;
- Evaluation of maternal and fetal status, including uterine activity and fetal oxygenation;
- Instruction regarding the labor process and comfort and coping measures;
- Role modeling to facilitate the participation of the family and companions during labor and birth; and
- Direct collaboration with other members of the healthcare team to coordinate patient care.
They further state that during the use of an epidural, frequent positions changes should be encouraged and facilitated by the nurse to allow the baby to rotate and come down as labor progresses, and labor down further before the second stage begins. Should a nurse have sufficient time and training to do these tasks, outcomes can improve.
This policy statement firmly recognizes that hospital management, unit managers, clinical nurse specialists and nurse educators will need to step up and advocate for staffing levels that allow these tasks to take place, along with the clinical responsibilities that already exist. Additional training will need to be provided and policies should be instituted that include:
- Comprehensive and ongoing education on labor support techniques and tools for nursing staff;
- Policies and education on intermittent fetal monitoring and auscultation, including the identification of appropriate patients and procedures;
- Early labor support and therapeutic rest policies;
- Nurse staffing policies, including policies about contingency and on-call staffing, which plan for appropriate numbers of nurses to provide direct labor support consistent with national guidelines as well as RN coordination of the support team; and
- Liberal visitor policies permitting a woman to have the support persons she desires to provide her effective support, in accordance with maintaining a safe physical environment.
There is currently a nursing shortage in the United States and hospitals across the country are offering signing bonuses and additional benefits to attract and retain qualified staff. Developing the skills to be a talented L&D nurse takes time, patience and a qualified preceptor. While the goals are well-intentioned and appropriate, it may be many years before funding, staffing, skill levels and logistics fall into place to permit every nurse to offer the kind of support that doulas do while continuing their L&D nursing responsibilities.
Past and current research shows that the best maternal-infant outcomes are achieved by people acting in the doula role who are not family or hospital staff and can offer continuous support. Nurses typically work an eight to twelve-hour shift and then go home. The option for continuous support is not there. I have worked with many L&D nurses in my role as a doula. They are indeed hardworking, compassionate and caring *and* have a mountain of responsibility already. I have the deepest respect for them, but cannot see them being able to step into the role of the doula in addition to all their current tasks and extensive charting requirements.
Secondly, as the AWHONN position paper stated, many nurses will need training in labor support, nonpharmacological coping mechanisms and labor comfort techniques. These skills are not something that is typically acquired during their academic training. What is the plan to provide this training? I live in Seattle and we are lucky that community standards call for 1 on 1 nursing care for patients in active labor through the first few hours post-birth. Many places around the country do not offer this intense nursing coverage that would be required for continuous labor support. How will hospitals increase staffing to accommodate this and how will those staffing costs be absorbed
While AWHONN discusses and acknowledges the role of doulas and childbirth educators in improving outcomes, and even encourages health care coverage to provide funding for both items, I felt that the position paper discusses what might be the ideal situation for nursing staff with little thought into how that will actually come to fruition.
I would like to invite AWHONN to encourage the use of doulas for all patients, offer training and skill workshops to help nurses learn labor comfort and coping techniques and assist the nurses in developing the skills to work effectively and cooperatively with the doulas as a labor team who together can support the birthing person and their family. Many of the nurses in my community are amazing in working together when a doula is there, but other parts of the country and the world may not be as familiar with the doula role and skillset. Supporting the training of more doulas, making doulas a covered expense by insurance and Medicaid and affordable for all families, especially those most impacted by health disparities due to the color of their skin, would go a long way to improving outcomes.
I invite DONA International and other doula organizations to partner with AWHONN to develop a collegial relationship between our professions. This relationship can be built on mutual respect, understanding of the roles of both the doula and the nurse and strategies for working together effectively.
I applaud the position statement but worry that piling more responsibilities on a pool of nurses already stressed and overworked will not provide the effect that is desperately needed to bring about better outcomes for parents and babies. Please take a look at the AWHONN position statement linked above and let me know what you think in the comments section below.
Bohren, M. A., Hofmeyr, G. J., Sakala, C., Fukuzawa, R. K., & Cuthbert, A. (2017). Continuous support for women during childbirth. The Cochrane Library.
Hodnett’s research over decades dispelled the idea that 1:1 nursing care by nurses trained as doulas could achieve the same outcomes as doulas.
As a postpartum nurse and a mother, I always reccomended the support of DOULAS ( postpartum or labor) because labor is a stressful and magical time for families. It is well documented Doulas play a integral role for laboring women. Indeed, LD is a high acuity area with mothers coming in with cormordities and monitoring both mother and newborn is imperative. That monitoring at times makes it hard to truly be supportive holistically of the woman. Additionally, a seasoned LD nurse will have more skills and experience caring for women needs during labor and be able to balance responsibility/ coaching. Therefore, I am for nurse residency programs in speciality such as labor and delivery.
Time, staffing, and the dynamics of the unit all play a role in how nurses care for the laboring mom. Some enviornments are extremely stressful such as hospitals settings. Whereas in birthing clinics with nurse midwives it is calmer and doulas are utilized more. The AWHONN position paper is a call for better nurse to patient ratio, educational training, and the need I feel to get back to the basics—caring for the woman. However, AWHONN must also acknowledged the benefit of DOULAs, the need for doulas in low-income enviornments, and caring for women of color. Collaboration, mutual respect, and transparency is cruical.
However, with the additional respoinsiblities nurses have, it is essential LD nurses know how to care for women naturally and be in tune with the family on a spiritual level. This is more than a pipe dream, this can be a reality ( but will take time and more collaboration). I am optimistic that we ( Doulas and Nurses) can improve the birth outcomes for all women.
To follow up on my previous response. I believe the AWHONN wants and see the need to collobrate with Doulas and Birth educators to support all women before, during, and after labor.
Providing coverage and reimbursement for
childbirth education and doula services that
improve birth outcomes and save health care
dollars should be a priority. As covered
benefits for all pregnant women, these
services could enhance goals to reduce racial
and ethnic disparities in birth outcomes.
AWHONN supports continued research about
the effect of nursing support on maternal–
newborn outcomes and the potential financial
benefits of such support for health care
systems ( AWHONN, 2017.)
Reimbursement is key. As many women are unable to afford the services of doulas. The question is how can AWHONN and nurses advocate for doulas in obtaining compensation through Medicaid and other insurances?
I encourage labor and delivery nurses to consider becoming a licensed presenter of the Lamaze Evidence-Based Labor Skills workshop. This is a good way to train nursing staff on evidence-based labor support skills thay may not have learned in their nursing training. For information, visit: http://www.lamazeinternational.org/workshops
L&D Doulas should be part of the writing as well as the introduction of the Pp Doula preferably one who is also a breastfeeding specialist.
I adore the push for L&D nurses to learn more about non medical comfort techniques in labor, and I adore partnering with a nurse who actually has within her scope the responsibility to advocate for the client’s wishes, when a doula has such a tight-rope walk to help her client self-advocate. I wholeheartedly agree that nursing schools and curriculum should include non-medical techniques for improving labor and birth outcomes. It is not difficult to learn these things.
What is overlooked, though, is the part about continuous labor support that brings on the most effectiveness as far as a woman’s satisfaction with her experience (and the other clinical outcomes): the one-on-one relationship built prior to the labor with the doula. Nurses cannot visit the client’s home during pregnancy, educate her or offer options when she’s uncomfortable at the end of pregnancy, attend her prenatal appointments, hold space for her on her pregnancy and parenting journey, learn the names of her kids and her pets, or, as we do at our nonprofit, visit an incarcerated pregnant woman one on one, attend her birth, attend the separation from her baby, and continue the visits when she returns to prison. The reason nurses do not have the emotional impact that doulas do is b/c you cannot develop that type of relationship during the hospital stay (and we know emotional impact affects the mother’s feeling of safety and being cared for, not being in a foreign place with foreign people..all of which leads to better birth outcomes). The nursing staff works the shift and then goes home. That is not the definition of continuous support (although many return to the same laboring mother on their next shift, which is awesome). The unique relationship between a doula and her client is 1. she knows the wishes and pet peeves and heart of her client, she may even understand the client’s relationship with the partner if there is one; and 2. she knows about birth in all of its forms b/c she likely sees all different kinds of births in multiple facilities. This is something no one else on the birth team can offer.
Since this position statement does not push for RNs instead of doulas, I’m fine with it. I think the sticky part is the us of the phrase “continuous labor support” b/c it’s simply not possible for a nurse to offer this along with her other responsibilities. Maybe if the position statement said something like “one on one nursing support” instead or maybe if it advocated for spending more than 30% of the time with the patient (most nurses spend 30% or less in the room), that would have been better. But as another commenter said, the improved birth outcomes in the research were most improved when the person was not a hospital staff member and was not in the social network of the mother.
Thanks so much for sharing your thoughts – I appreciate hearing from you. I do think that the position paper pushes for nurses to provide continuous support. Did you not find that to be so?
Yes, I do. I think what I was so poor at conveying in my comment was that, AWHONN is advocating for more administrative and policy support for RNs so they can spend more time in the room with the patient tending to emotional and physical needs, and it is calling that “continuous labor support.” A lot of nurses that work with doulas say, “you get to do the part I really love and wish I had more time to do and am supposed to do.” Meaning the nurse wishes she were free to do more physical support and emotional caring at the “bedside”. But, as you said in your blog, a nurse physically can’t provide continuous labor support like a doula throughout the entire labor in addition to all the other charting and responsibilities a nurse must do and through shift change, even if she has only one patient. And she can’t offer what a doula offers from a relationship development standpoint before and after the labor. But because the position statement uses the term “continuous labor support” which is so often associated with what doulas provide, it’s confusing. I am still doing a bad job of verbalizing what I mean, but I didn’t see this position statement as AWHONN saying nurses need to be able to offer what doulas offer. I saw it as nurses need to be free to spend more face to face time with their laboring patients caring for them in a physical and emotional way, which falls under a nurse’s scope of practice but is difficult for them to provide with current staffing issues.
thanks for clarifying – I think you may be spot on!
If a woman is to receive continuous support in her labor, by definition, it could be by the next nurse on staff. There is research from team midwifery practices that show positive outcomes for women offered continuous care from multiple midwives. The criteria needs to include no break in support, and (which is what’s missing in this suggestion by AWOHNN) time over pregnancy for the woman to build a relationship with each provider.
My doula team does just this. We have shifts among 4 of us, we spend 2 evenings a month with the families leading up to the birth and provide support for the first 3 months after birth. If nurses are going to offer continuous support, they would be wise to add prenatal relationship building with all possible attendees to each woman.
That is my first concern.
My second concern is an echo of other voices already heard here. Adding a layer of support onto clinical responsibility sounds unnecessarily complicated. Let nurses be nurses and let Doulas do their jobs. Giving the role of Doulas to nurses sounds like absorbing and deleting an important role. It reminds me of when businesses downsize and try to put whole departments on less staff. It usually is accompanied by stress and strain and is felt by all parties.
I completely agree..
As an RN who has worked in L&D in 3 states and is a certified Childbirth Educator, I thing the doula should be licensed by each state, drug tested and finger printed and have to take CED’s like nurses. I would have a problem as the nurse who it legally responsible for the mother & baby and seeing a problem on the monitor and giving an order to the mother to reposition and then have a doula interfere! If the doula is trained by the hospital. works for the hospital, and is licensed by the state that would be different!