1. Introduction to Labor Support Presented byNew Beginnings Doula Training Rachel Leavitt RN, BSN, CD For more information on doula certification visit www.trainingdoulas.com

2. Goals

Define what a doula is

3. Describe the different roles various professionals play 4. Become familiar with the Cochrone Library 5. Describe the benefits of having a doula 6. Introduction into labor support for nurses 7. Understand the role doula's play in medicated/c-section births 8. Understand how doula's can become agents of change 9. Explore your feelings about being a doula 10. Reading Assignments

The Nurturing Touch at Birth chapters 1 & 2.

11. The Birth Partner chapter 3 12. All included material given in introductory e-mail 13. What is a doula?

People have given this various definitions.

A doula guides and supports women and their partners continuously through labor and birth...[she] is on call for you, arrives at your home or the hospital when you need her, and remains with you continuously, with few or no breaks, until after the baby is born.The doula is trained and experienced in providing emotional support, physical comfort, and nonclinical advice-Penny Simpkin, The Birth Partner

14. What is a doula?

Doulas...are trained labor assistants who nurture and assist the laboring and postpartum couple...Without adding her own agenda, the skilled doula assists parents in making informed decisions...the provide one-on-one, continuous labor support (without shift-changes) throughout labor and early postpartum.-Pam England, Birthing from Within

15. What is a doula?

doulas are sympathetic and knowledgeable labor companions who typically provide some form of prenatal preparation and stay at your side once labor begins until your baby is born.The doula's job is to make you as comfortable as possible and to reassure your partner as well-Ina May Gaskin, Ina Mays Guide to Childbirth

16. What is a doula cont.

• • • A doula

provides nonmedical physical and emotional support to a woman during labor and sometimes well beyond.She offers information about pregnancy, birth and hospital/birthing center routines, provides continuous support and comfort during labor, and acts as something of an interpreter between mother and medical staff when needed.Her job, in sum, is to support a woman's prenatal desires for the birth of her child while helping her adjust to the realities of the actual labor-Mark Sloane, Birth Day 17. What is a doula?

For purposes of this training, these are the tasks I feel are important to know:

Non-medical(not pertaining to medicine, medical diagnosis, or treatments)

18. Holistic care(pertaining to the physical, emotional, spiritual, and social) 19. Provides information 20. Continuous labor support 21. Facilitates communication between her clients and the medical staff 22. What is a doula?

My definition:

23. A doula provides non-medical, holistic care to the childbearing family.Prenatally, she provides information to help a family plan what they would like for their birth.During birth, she provides continuous labor support and helps the laboring family work smoothly through the process of labor and birth.She also helps facilitate communication between the laboring family and the medical staff. 24. What is a doula cont.

Something that makes a doula unique from other healthcare workers:

25. She stays with the mom from the time labor starts(or starts and stops and starts:)) to a few hours after birth. 26. She usually meets with the mom before and after the birth. 27. She is trained specifically in labor support techniques. 28. What does a medical professional do?

Performs clinical and medical tasks

29. This may include taking the blood pressure, checking the cervix, giving medication 30. Diagnosis medical conditions 31. Pre-eclampsia, dystocia, failure to progress etc. 32. Determines the best medical decisions to make along with the client 33. Case Study 1: medical terminology

G-2, P-1: Gravida(G) refers to the number of times a woman has been pregnant. Para(P) indicates the number of live births.

34. Pain intensity scale: scale used to quantify pain.0 is no pain and 10 is the worst pain. 35. BM: bowel movement 36. Rebound pain: pain felt after the removal of pressure 37. Palpation: using the hands or fingers to feel to exam a certain body part 38. Case Study 1: medical terminology

Cervix: the lower end of the uterus.It is about I inch thick.

39. Dilation: the opening of the cervix.It is measured as 1-10 cm.Once it is 10 cm, the baby's head is able to come through. 40. Pyelonephritis: a urinary tract infection that has reached the kidney. 41. Straight Cath: a tube is inserted into the urethra from the outside in order to get a sample of urine.It is then removed. 42. Case Study 1: medical terminology

CBC: complete blood count.A test that exams different parts of the blood.

43. WBC: white blood count.Done as a part of the cbc.Normal values are 4500-10000.This can be elevated normally during pregnancy. 44. Appendicitis: infection of the appendix 45. Purulant: pus like drainage 46. Chorioamnionitis: inflammationo of the fetal membranes, usually due to a bacterial infection. 47. Case Study 1: medical terminology

Electronic Fetal Monitor: a monitor that is strapped around the mothers belly.It measures the heart rate of the fetus which allows the doctors to make clinical judgments about the baby's well being.

48. Unaysn: an antibiotic used to treat certain infections. 49. Pitocin: synthetic form of oxytocin(which is a hormone) that will start labor or increase contractions 50. Case Study 1:

Melinda Halsey is a 31 year old G-2, P-1 at 35 4/7 weeks gestation who presented yesterday with abdominal pain. Her pain started in her right flank and was intense, lasting several minutes, before easing off. This would occur every 10 minutes. When she had the pain, it was an intensity of 9/10. The pain shifted to her central lower abdomen, where it is still cramping in nature. She took her temperature at home and it was 101.2 by ear thermometer.

51. Case Study 1

Shes had no trouble with urination other than her usual urinary frequency. She had three episodes of loose BMs this morning, but no BMs since then. She is hungry and would like some Pizza.

52. Her pregnancy has been uneventful and her previous pregnancy was also uneventful, resulting in a full term delivery. She has no significant medical or surgical history. 53. Case Study 1

Her exam is significant for uterine tenderness with mild rebound. The rest of her abdomen is soft and non-tender unless palpation impacts the uterus.

54. Her cervix was noted to be dilated 1 cm, and 2 cm thick, with the presenting fetal head at a -2 station. There was a foul odor coming from the vagina and there was a purulent drainage present in the cervix. 55. Case Study 1

When first evaluating her, the migration of her pain from the right flank to her lower midline suggested the possibility of renal stone, or possibly pyelonephritis. For that reason, we ordered a straight cathed urine specimen, which was reported as normal. This effectively ruled out both pyelonephritis and renal stone.

56. Case Study 1

I ordered a CBC, primarily to assess the white blood count, which in this case was 13,500, a little high for pregnancy.

57. I considered appendicitis to be very unlikely in view of her enthusiastic hunger. 58. With the foul-smelling purulent cervical drainage and tender uterus, chorioamnionitis seemed the most likely diagnosis. 59. Case Study 1

The fetal monitor tracing was normal, so we have started her on Unasyn to treat her infection, and pitocin to induce labor. For pain relief during labor, we have started an epidural anesthetic, with good results.

60. Case study used with permission from www.obgynmorningrounds.com 61. Case study 1: what the medical professionals do

Assessed for disease

Checked uterine tenderness

62. Noted symptoms present that might indicate disease Performed cervical exam 63. Inserted a straight catheter 64. Ordered and performed labs 65. Monitored fetal heart rate 66. Prescribed medication 67. Started IV, pitocin and epidural 68. Case study 1-what a doula does

In this scenario, the doctor diagnoses and treats a disease

69. This is not something that doula's are trained to do, but during this course, you will be taught to understand and identify different needs that a doula may help with. 70. For this scenario, these are described below. 71. Nurses training in labor support may use these in conjunction with their training in disease and disease process. 72. Need Identified-Hunger

If allowed, offer easily digestible foods.In this scenario, this woman wanted pizza.Knowing that pizza is a harder food to digest, I would offer something else and tell her why.If she still wants the pizza, honor her wishes.Peppermint tea might be a good thing to offer at this point(sugar or honey can be added).This relaxes smooth muscles and aids in digestion.Peppermint oil may be used for a similar purpose.If food is not allowed, clear liquids like jello, broth or popsicles may be offered.

73. Need Identified-Fatigue

This scenario didn't specify if this woman had been contracting through the night or how much sleep she got.This may be something you may want to assess. Things to ask or assess for: how long she has been laboring and what time she started, how much sleep she's had in the past 24 hours and the quality, does she look tired or exhausted, and does she say she is sleepy or fatigued.

74. Need Identified-Fatigue cont.

If she is tired, try helping her find positions that may be comfortable for her to sleep in.I always recommend bringing a pad of some sort to put on the laboring beds because they are so uncomfortable.Helping ease her pain may be of importance at this time as she may have been laboring for a while.This may include non medical means such as positioning, hot pads or water.But you may also want to discuss with her the possibility of getting some medicated help to allow her to sleep if she is needing it.

75. Need Identified- Thirst

If allowed, give her water or juices.She may have an iv bag already going.If that's the case she may not need as much liquids, but might appreciate ice chips or small sips of liquids.

76. Need Identified-Pain

There are a lot of different kinds of pain that need to be addressed here.First, she is having abdominal pain that is different than normal laboring pain as there is an infection present.For this kind of pain, hot pads or ice packs may help where it hurts the most.Different positioning may also be useful in decreasing the amount of pain she is feeling.Try different positions, like side-lying or reclining in a chair.

77. Need Identified-Pain cont.

While movement is great for normal labor, this may not be true in a labor with an infection.It may be useful to see if things like rocking or walking help, but don't push it.Massage may also be useful as this helps to release her own endorphins to help her cope.I would also try lavender, rose, or jasmine essential oils.

78. Need Identification-Pain cont.

She may also be feeling uncomfortable from the fever.You may be able to talk to her care provider to see if she can have a Tylenol to bring it down.Wet washcloths can also be used.Soaking a washcloth in a little bit of peppermint oil and water may be useful as peppermint has a cooling effect.Other things you can use to help a woman feel cool are ice packs and fans.

79. Need Identification-Pain cont.

Numerous cervical exams can also be uncomfortable.Discuss with her and her care providers how many are actually necessary.For those that are needed, help her start some deep breathing exercises and visualizations before, during, and immediately after the exam.It is also helpful to have her ball up her fists and place them behind her hips during the exam.This helps tilt the cervix closer.

80. Need identified-Pain cont.

While this may not be important to some women, many woman find it distracting if they do not have anything to keep them covered.This in turn can lead to more focus on the pain of the procedure.

81. Need Identified-Pain cont.

The woman also needed to have a catheter placed in her briefly to get a sample of urine.I would ask whether or not she could have a clean catch, as this is how I have done it in most places.If not, much of what you did to help with pelvic exams, will help with this procedure also.

82. Need identified-Pain cont.

To obtain a blood culture, an iv or needle must be used.I would request that a warm cloth be wrapped around the hand or arm prior to the procedure to help bring up the blood vessels.Again, deep breathing can help before, during and after the procedure.Afterwards a warm or cold compress may be useful to decrease the pain.

83. Need Identified-Anxiety

Things that work well for this include foot massages, lavender oil, and deep breathing.Music may also help.

84. Need Identified-Fear

Knowledge helps to alleviate fear.Make sure that she has all the information she needs to understand what is going on. Since this baby is early, she is also going to need information on what to expect with a baby this early.Assessing her spiritual resources may also be useful.Encourage her to use whatever she feels comfortable doing.Things like prayer, meditation or other spiritual practices can help when she is feeling fearful.Focus on the things she does have control over.

85. Need Identified-Social Network

Discuss with the woman who she really feels comfortable having at this birth. Allow her to make the decisions, but help her to explore who may or may not be good to have there.Also discuss whether or not she wants outside distractions like the phone or computer network.Help the spouse or significant other to feeling included in the birth process.

86. Need Identified-Feelings of being cared for

Encourage her to express her needs or desires, even if they don't seem significant.

87. Need Identified-Decision making

Encourage her to ask questions and discuss what she would like to have happen.Make sure that she is OK with any procedure that is being done.Before any procedure is done(ie vaginal exam, iv, medication), make sure she gives at least her verbal consent.

88. Case Study 2

Read pg. 33-40 in Homebirth in the Hospital by Stacey Kerr

List everything the care providers to that is medical in nature

89. List what others did that you would consider labor support 90. For extra help in seeing what the difference is,read chapter 3 of The Birth Partner by Penny Simkin 91. The role of the doula and medical professional

On the surface, this may seem simple to understand, but sometimes the roles can be confusing.

92. It is important to keep in mind why your client hired you, which include some of the reasons listed earlier. 93. A medical professional is hired to safeguard the safety your client. 94. No matter what situation, it is always appropriate to ask your client if they feel they have enough information or have questions. 95. The role of the doula and the medical professional-example

A woman who is going natural wants to be in the shower, but it is time for her to have the baby's heart checked and the nurse wants her in bed.You offered to hold the heart rate monitor on, but the nurse feels this is over stepping your bounds because you have not been trained to do that.

96. One woman wants a warm compress with oils on her perineum during crowning.Her care provider is used to being in charge during pushing, and does not want you to help. 97. The role of the doula and the medical professional-example

Your client is laying down in bed when the nurse notices that the babies heart rate is not doing very well.She wants to turn your client on her side to help, but your client is very uncomfortable on her side.You ask if she can be on her hands and knees instead.The nurse gets flustered and feels you are over stepping your bounds as a doula as this is more of a medical issue.

98. The role of the doula and the medical professional

We will be discussing situations like this later on in the course, but keep in mind that you will probably encounter some time when the roles between providers are blurred.

99. What is the Cochrane Collaboration?

The Cochrane Collaboration is an international, non-profit, independent organization, established to ensure that up-to-date, accurate information about the effects of healthcare interventions is readily available worldwide.

100. What is the Cochrane Collaboration? cont

It produces and disseminates systematic reviews of healthcare interventions, and promotes the search for evidence in the form of clinical trials and other studies of the effects of interventions

101. http://www.cochrane.org/about-us/newcomers-guide 102. What does the Cochrane Collaboration do?

The Cochrane Collaboration prepares Cochrane Reviews and aims to update them regularly with the latest scientific evidence. Members of the organization (mostly volunteers) work together to provide evidence to help people make decisions about health care.

103. What are Cochrane Reviews

Cochrane Reviews are systematic assessments of evidence of the effects of healthcare interventions, intended to help people to make informed decisions about health care, their own or someone else's. Cochrane Reviews are needed to help ensure that healthcare decisions throughout the world can be informed by high quality, timely research evidence.

104. The Cochrane Library

The Cochrane library has the Cochrane reviews as well as other research.

105. This is something you should become familiar with to help you look for abstracts on research about birth. 106. This will help you keep up to date as well as educate our clients. 107. http://www.thecochranelibrary.com/view/0/index.html 108. Type in labor support into the search button 109. The Cochrane Library

If allowed, give her water or juices.She may have an iv bag already going.If that's the case she may not need as much liquids, but might appreciate ice chips or small sips of liquids.

110.

There are a lot of different kinds of pain that need to be addressed here.First, she is having abdominal pain that is different than normal laboring pain as there is an infection present.For this kind of pain hot pads or ice packs may help where it hurts the most.Different positioning may also be useful in decreasing the amount of pain she is feeling.Try different positions, like side-lying or reclining in a chair.

111. Cochrone Review

Click the first link that is listed under the search results entitled Continuous support for Women during childbirth

112. This should take you to an abstract of the review I've given you to read. 113. The abstract is a brief description of the review and it's conclusions. 114. 115. Assignment-Cochrane Review

Think of a topic that you are interested in.

Do a search for it in the cochrane library.

116. Find one cochrane review.E-mail me the topic, name of the review and the conclusions that were drawn.[email_address] 117. If you have any questions let me know. 118. Play around in the cochrane library for awhile.There is a lot of information to explore. 119. Continuous support for women during childbirth(Cochrane Review)

Historically continuous labor support has been the norm for women in labor.

120. In current history, this is no longer true and is more the exception rather than the rule. 121. This particular review was done to look at the effects of continuous support versus the usual care. 122. They also wanted to look at what effects certain variables may have on continuous support. 123. Cochrane Review-Benefits of labor support

More likely to have a spontaneous vaginal birth

124. Less likely to have intrapartum analgesia 125. Less likely to report dissatisfaction 126. Labors were shorter 127. Less likely to have c-sections 128. Less likely to have instrumental deliveries 129. Less likely to have regional analgesia 130. Less likely to have a baby with low apgars. 131. Cochrane Review-When is labor support most effective?

When the labor support was not a part of the hospital staff

132. When the labor support was not a part of the woman's social circle 133. In settings where epidural analgesia was not readily available. 134. Conclusion from the review

Continuous labor support has clinically meaningful benefits for women and infants and no known harm.All women should have support throughout labor and birth.

135. Cochrane Review-Who should provide support

Continuous support from a person who is present solely to provide support, is not a member of the woman's social network, is experienced in providing labor support, and has at least a modest amount of training appears to be the most beneficial.

136. Support from a chosen family member or friend appears to increase woman's satisfaction with their childbearing experience. 137. Cochrane review-How does labor support help? Theorectical foundations

Certain environmental influences may effect the progress of labor and feelings of competence in the new mother

138. These factors include:

Institutional routines

139. High rates of intervention 140. Unfamiliar personnel 141. Lack of privacy Continuous labor support provides a buffer for these situations. 142. Theoretical Foundations cont.

Having continuous labor support helps the fetus move through the pelvis and soft tissues

143. This may happen due to:

Encouraging mobility

144. Helping to effectively use gravity 145. Supporting women in whatever position they choose 146. Recommending specific positions for specific situations 147. Theoretical Foundations cont.

Anxiety and fear during labor may lead to complications for both mother and baby

148. Continuous labor support helps to decrease anxiety and fear by:

Offering emotional support

149. Information and advice 150. Comfort measures 151. advocacy 152. The Benefits of a Professional Doula vs nurses or midwifes

Nurses and midwifes often have other patients that they are taking care of

153. They also have to spend a large proportion of their time managing technology and keeping records 154. They may begin and end shifts in the middle of the woman's labor. 155. They may lack labor support skills. 156. Professional Doula vs friends or family

Friends or family may not as be familiar with birth

157. They themselves may need support when working with the laboring woman 158. Statistics of satisfaction of support from Listening to Mothers Survey

Percentage of women who feltthey had received supportive care with:

An ob-37%

159. A family physician-44% 160. Midwife-66% 161. Husband/partner-88% 162. Doula-100% Proportion of excellent ratings given for their supportive care: Doulas-88%, family member or friend-73%, partner/husband-72%, doctor-71%, midwife-68%, nursing staff-68% 163. End of Unit Project

Teach a course in your community about the benefits of using a doula.

164. You may use any of the slides I have presented, or you may make your own. 165. Specifics for this project should be sent to you. 166. There is no deadline for this, but you must finish this before you move on. 167. If you need help finding a venue e-mail me, and I will help you look for one. 168. Labor support for nurses

While the work environment does not always allow you to just focus on continuous support, having you there to provide support when needed is still important.

169. This course will help you to find strategies to help you provide support when you can, and to advocate forpolicies that help promote the abilities of the nurse to provide labor support. 170. AWOHNN position on the need for nurses to provide labor support

Continuously available labor support from a registered nurse(RN) is a critical component to achieve improved birth outcomes.....labor care and labor support are powerful nursing functions, and it is incumbent on health care facilities to provide an environment that encourages the uniquepatient-RN relationship during childbirth -AWHONN position statement

171. Barriers for nurses in providing labor support

Two High-alert drugs are commonly used in labor and delivery(oxytocin and magnesium)

Require intensive administration precautions

172. Continuous monitoring and assessment Competing priorities

Higher acuity than in past

173. More inductions and cesareans 174. These demand more attention to technology and documentation Institutions have not increased staffing to help 175. Advocate for change

As we discuss the doula's ability to advocate for change this also applies to nurses.

176. AWHONN staffing recommendations are a good place to start. 177. Other situations which doula's may help with

Epidurals

178. C-Section 179. Pre-term labor 180. Goals during an epidural/c-section/pre-term labor

Minimize emotional and physical distress during the procedure and afterward

181. Provide the opportunity to discuss with care providers 182. Minimize pain if still felt before, during and after the procedure 183. Minimize the complications of the side-effects 184. The specifics of each of these will be taught later in the course. 185. Assignment

• Read Listening to Mothers, particularly the quotes from mothers.

186. Pick one situation that you agree with and how her situation could have been better with the use of a doula.

187. Pick three situations which contain choices made that you wouldn't have chosen.Describe how you would have served these women as a doula. 188. Doula's as change agents

Part of the revolution involves changing disease care to health care based on health, healing and empowerment-Paulina Perez

The focus is on creating health rather than treating problems.

189. Doula's as change agents

We must build bridges with others and invite views that are divergent-Paulina Perez

190. We have the opportunity to work with all birthing professionals to provide the best care for women and their babies. 191. Doula's as change agents

We can be prepared to make new paths and be innovative in our care-Paulina Perez

192. This involves:

Seeking alternative ways to reach our goals when needed

193. Anticipate crisis and working together to solve them 194. Educating yourself, so that the paths available to you are more open 195. Doula's as change agents

We have the opportunity to find out what families really need and provide that for them-Paulina Perez

196. How this course will help you to become an effective change agent

• What women experience during labor is not always a disease or diagnosis, but a life process.

197. In this course, you will learn toidentify and focus on the labor and birth as a life process specific to each individual.

198. In this way, you will be promoting health rather than treating disease. 199. How this course will help you become an effective change agent

Part of my goals for this course is to help you learn to communicate and work effectively with other care givers.

200. There will be various assignments that will stretch you to do so.By doing this, you will learn to work with others who may think differently, but you can also help them to see things differently. 201. How this course will help you become an effective change agent

You will be provided with the education and experience to be able to adapt to many different situations and people.

202. You also be taught skills to help women in many different situations, from the very few interventions to numerous interventions being used, as well as how to help women make the choices they desire. 203. You will be provided with the information that will help you form your own opinions on what should be changed. 204. What does being a doula mean to you?

Caring that comes from the heart and soul brings back humanity and kindness to the birth process that has lately been dominated by machines, tubes, and wires.We often get so caught up in the 'ought to,' and 'need to' of our jobs that we forget completely the 'want to' and 'why' of what we're doing in the birth room.-Paulina Perez

205. Assignment

As a tool for you to remember why you are doing this, as well as letting potential clients know what your goals are, prepare a 1-2 paragraph description of why you care about labor support and what you hope to bring to the woman's birth.

206. Chapter 2 of The Nurturing Touch at Birth has some good ideas of what some of those reasons may be, but feel free to add whatever you feel is important.