Dear Sarah,
The great danger for doulas in this very common
situation is that they inadvertently set themselves up in an adversarial
relationship with the caregiver, forcing the client to "choose" between two
conflicting sets of views.
At an early stage in pregnancy, this may not be
relevant since there is very little decision making to be done. However, imagine
a scenario in late pregnancy where, for example, your client’s doctor tells her
that she is carrying a large baby and must be induced at 38 weeks. The doula
tells her that ultrasound estimates of foetal weight are notoriously inaccurate
and that if she has an induction she is increasing her risk of caesarean. Who is
she to trust? Whose viewpoint is she likely to follow? And how is this likely
to leave the doula feeling afterwards?
Such a scenario helps neither the
client, the caregiver, nor the doctor.
In this
situation it would have been much better to have identified at a much earlier
stage in pregnancy that her doctor is strongly active management in philosophy.
You can then discuss with her some "what if.." scenarios like "what if I
go past my due date?".
The
challenge is to help your client to see for herself that her personal
values and expectations differ from her doctors. Having discovered that, she is
then in a position to make a more informed choice about her options which may
include:
-
Reconciling
her vision of what she is looking for with the reality of how her caregiver
routinely practices and coming up with a more realistic, and more achievable
vision of what is possible
-
Negotiating
with her existing caregiver to make concessions on particular issues she is
concerned about
-
Changing
caregivers
In this
situation your role is to help her to see which of her expectations are
realistic and which are not. If you have worked with a particular doctor on
previous occasions then it is perfectly legitimate for you to share information
about how you have seen him/her practice - for example "I have been at 5 births
with Dr. X and he cut an episiotomy every time". However, your client may still
feel that in her case, things are different. She may have told him that she
wishes to avoid an episiotomy and been told something like "oh, I only cut them
if they are necessary". However, is that information really helpful to her?
A
better question for her to ask might have been "for what percentage of clients
do you find it necessary to cut an episiotomy?"
Asking her
to write a birth plan and going through this with her in more detail can be a
great place to start. If she is unsure what her doctor’s views are on a
particular topic, then you can help her formulate some questions to ask which
will give her a better idea.
For example,
if your client is keen on trying a range of different positions for second stage
and delivery, she could ask her doctor what positions he would be comfortable
with her adopting. Many active management doctors will only be comfortable with
their patients up on the bed, in semi-sitting or lithotomy position, since this
gives them a clearer view of what is going on and enable procedures like vaginal
exams, episiotomies, and assisted deliveries (forceps, ventouse) to be performed
more easily than if the woman was on the floor, or in a standing, kneeling or
squatting position. If she were to ask him a general question like "what
positions may I give birth in?" and receives a vague answer like "well, so long
as things are going well.." or "well, just so long as I don’t put my back out"
she may feel reassured that he her doctor sounds pretty flexible. However, the
very vagueness of the reply is a strong signal that the doctor is somewhat out
of his/her comfort zone. The chances are that when it comes to the actual birth
the doctor is likely to find a way of exercising control by asking her to climb
onto the bed. Your client will might need to ask much more specific questions to
get the information she needs. For example :
"What
percentage of your clients give birth off the bed?"
"Is there a
birth stool I can use and are you happy if I use it for the actual birth"
"I plan to
give birth in a kneeling or all fours position - will that be a problem for
you?"
"Under what
circumstances would you require me to move to the bed for the actual birth?"
In this
scenario your role is to help her with her communication and assertiveness
skills, rather than simply giving her information about birth positions. If she
discovers that her doctor will only be comfortable if she is on the bed, but is
happy for her to adopt a kneeling or all fours position when she is on it, then
you have a basis for discussion. If on the other hand it seems that the
lithotomy position is likely her only option, then you can discuss the
implications of that with her. How does she feel about it? What does she think
the impact of that might be on her wishes for a natural birth? What you are
likely to find is that, if she is really committed to her goal of achieving a
natural birth, but begins to receive a pretty clear message from her doctor that
this may not be possible, then she may begin to explore alternatives - such as
exploring alternative caregivers. The benefit of this approach is that is
something she has concluded for herself - at no stage have you advised her to
change doctors.
When somebody reaches a decision for themselves and acts upon it
they are likely to have a much greater level of commitment to achieving that new
reality than if someone else had suggested it.
