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.