By Barbara A. Hotelling, MSN, WHNP, LCCE, CD(DONA), IBCLC
I was recently speaking with a fellow doula about her experience with nurses at births, and she shared this with me:
“My general experience with nurses varies widely. Sometimes I am greeted right off the bat with warmth and welcome, sometimes with curiosity and a bit of awkwardness and at other times with open disdain and coldness. At a recent birth, the nurse came up and hugged me with great enthusiasm before she even greeted her patient ‐‐ much appreciated by the doula but maybe a little over the top.”
This doula’s experiences mirror those of many birth doulas, including mine. I’m always a little nervous going to a birth because I’m not sure how I will be received by the nursing staff. I would have heard from the mother if her provider was supportive of doulas and I’ve usually met the mother and her support people, but the nurse is an unknown team member. I’m ecstatic to work as a member of the mother’s team with collegial nurses and saddened for the extra stress when we don’t focus our energies on the mother.
From my own experience as a birth doula for 30 years and my experience as a nurse for even longer, I’ve wondered why the two don’t always complement each other. We are there for the same purpose of welcoming a new life into this world safely and with joy. To be honest, not all doulas or nurses feel this way. Some nurses and doulas have underlying agendas of protecting women from potential negative experiences. Some of those involve negative birth outcomes and some of those involve past history with nurses and doulas.
Complementary skills and goals
Our skills used to support this magical event are different. Doulas are not trained in the medical skills the mother may need. In fact, if we do perform vaginal exams, monitor vital signs or electronic fetal monitors, or even taking the monitors off for a trip to the bathroom, we are not functioning within the scope of practice we agreed to with DONA International certification. Nurses provide these skills and they can also support mothers with information, advocacy and intermittent emotional and physical support.
Doulas are the continuous presence that the nurse cannot provide no matter how much she or he wants. Without clinical responsibilities or decisions to make, the doula is free to be present in each moment with the mother. With doulas, mothers have continuous emotional support, information about choices, the ability to change her birth plan and the physical support to ease the passage of her infant.
The goals of nurses and doulas differ as well. The goal of the nurse is to ensure a safe outcome for both mother and infant. The nurse’s skills of assessment, treatment, and communication with the provider take time. Rarely is the laboring and birthing mother the nurse’s only patient. The goal of the doula is to ensure that the woman feels safe and confident. (Ballen & Fulcher, 2006)
Throughout the world we see teams of complementary caregivers working to meet women’s needs. In the Netherlands, nearly half of Dutch women have midwife-assisted births, attended by familiar caregivers. Family and friends provide continuous labor support.
We also see places where collaborative care could provide safer and more satisfying birth. In a section of Liberia, rural women who need life-saving care resist going to the hospital because they feel they are not treated well by the medical staff. They prefer to continue their care with the familiar midwives who unsuccessfully urge them to seek more intensive medical care. Lives are unnecessarily lost because of women’s refusal to go to the hospital. Doulas or attendance in the hospital by midwives would make the transition easier and more acceptable.
In Reykjavic, Iceland, mothers get prenatal care from midwives and then go to the NEST to give birth. The NEST is a birth center on the first floor of the hospital. If medicalization beyond the midwife’s skill is necessary, Icelandic women are transferred to the obstetric unit on the third floor. The mothers are then cared for by unfamiliar nurses and physicians. Doulas are available and for women with doulas, the transition is not nearly so traumatic.
Parents’ Expectations and Realities of Nursing Support
In a 2001 study by Tumblin and Simkin, 57 first time mothers in their second Lamaze class completed surveys of their expectations of nursing support in hospital births. The authors matched the mothers’ answers with dimensions of labor support including physical comfort and emotional support, and information and advocacy.
Women in Tumblin’s class reported that they expected 53% of nursing tasks would be providing direct supportive care in which 29% of their tasks would be to provide physical comfort and emotional support and 24% of their time would be spent in informational support and advocacy. The remaining 47% of responses pertained to direct and indirect clinical care activities, of which one-half were related to monitoring the mother, baby, or labor progress (Tumblin & Simkin, 2001, p. 54).
McNiven, Hodnett, and O’Brien-Pallas conducted a work sampling of the activities of labor and delivery nurses in 1992. They observed the activities of 18 nurses in 616 randomly scheduled 15 minute blocks over four daytime shifts. Activities were divided into two major categories: supportive care and other. There were subcategories under each of the major categories below:
- Physical comfort: cool cloths, warm compresses, bathing, assist w/shower, linen changes, ice chips/fluid, position for patient comfort, massage back/other body parts, reassuring touch
- Emotional Support: reassurance, encouragement, praise, keeping patient company, laughter, joking, social chitchat
- Instruction/Information: instruct or coach (breathing/relaxation/pushing), give advice (suggest techniques to promote relaxation, comfort, improve physical condition), explain/provide information about progress, fetal well-being
- Advocacy: Support patient’s decisions, negotiate patient’s wishes with other team members
- Other Direct Care: all other activities in the presence of the patient, such as all physical assessment, performing or assisting with procedures
- Indirect Care: teaching other than with patients, documenting care (not in patient’s presence), notification of physicians, attendance at meetings, all other activities not involving direct patient care (McNiven, Hodnett, & O’Brien-Pallas, 1992).
We see from the graph below that the expectations of nursing care by pregnant women in 2001 were not aligned with the realities of McNiven and Hodnett’s work sampling in 1992. Nurses were not able to spend more time supporting each mother due to heavy demands of communication and documentation. I expect nurses’ care in 1992 did not change much almost a decade later when Ann Tumblin surveyed her class parents. Documentation has increasingly become more difficult and nurses now work 12 hour shifts, leaving them tired and strained. The team approach of nurses and doulas working together would meet mothers’ expectations of more supportive care.
Hodnett, Lowe, Hannah, et al, studied the capacity of nurses to achieve similar decreases in cesarean rates when trained by a professional doula and given one-on-one care with laboring and birthing women. 6,915 women participated in a randomized controlled trial during a two-year period from 1999 to 2001. Women were randomly assigned to receive usual care or continuous labor support by a specially trained nurse. The primary outcome measured was cesarean birth rate. Other outcomes included intrapartum events and maternal/neonatal morbidity both immediately postpartum and in the first six to eight postpartum weeks. There were no significant differences between the two groups in the measured outcomes including cesarean birth rate. The mothers with continuous labor support did state a preference for that care in the future. These researchers concluded that in hospitals characterized by high rates of routine interventions, continuous labor support by nurses did not achieve the same outcomes as seen in research of continuous labor support by doulas.
For optimal birth outcomes, nurses and doulas need to respect each other’s talents and gifts and center their focus on the woman giving birth. The doula I quoted earlier, related her positive experiences with nurses:
“There is one hospital that is known to be very doula friendly and we work so well together there! Everyone understands each others’ roles and assumes good intentions. The women benefit so much!
I love these experiences! Everyone is successfully serving in their role. The nurse is able to get what she needs (heart tones, questions answered, vitals taken, connection with her patient), and the doula is able to fully support the woman (comfort measures, helpful suggestions, encouragement, advocacy). The nurse and the doula see one another as important parts of the team. We can ask questions and learn from one another.”
About the Author
Barbara Hotelling has been a Lamaze educator and trainer, DONA birth doula and trainer for the past several decades. She is passionate about the way humans enter this world and about their families. She has become a IBCLC, Hug Your Baby teacher and trainer, and has studied infant massage to further her knowledge. Presently she is a clinical nurse educator at Duke University School of Nursing where she trains Dukelas every semester – nursing students who are also passionate about caring for pregnant, birthing, and postpartum women and their families. Nana has 5 children and 7 grandchildren ranging from 12 to 1 week.
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