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Tuesday
Mar082011

Guest Post: Doula-ing for Cesareans

My friend Kristina French graciously offered her knowledge and experience to this intriguing topic we talked about a few days ago. She did a great job! This should give doulas a great starting point in how to serve women having cesareans... if they had not been before, of course. Thank you, Kristina! And thank you for the beautiful photos (which she took); the piece is illustrated perfectly because of them.

Kristina French is a DONA-certified birth doula in practice since 2007 and a Birthing From Within and Lamaze-trained childbirth educator in practice  since 2008. She supports birthing families and mentors childbirth classes and birth trauma healing workshops in the Tri-Cities area of Washington State. When she is not working in birth, you might find her at her day job in marketing or enjoying time with her husband and two children. She loves cooking, skiing, and travel.

She begins:

Just like with any client, taking on a planned cesarean birth is a doula’s choice to make. We all have our strengths and should be honest about our weaknesses. We also all have our personal boundaries. Just as a client chooses her doula, a doula can and should choose her client.

WHY NOT?

There can be several downsides to actively taking on cesarean clients. The first is that for doulas who have seen and been trained in gentle birth, being a part of a cesarean can be emotionally taxing and frustrating. Cesarean birth, the way it happens in most communities, is backwards to the way we have been indoctrinated. The woman is not physically active in the birth process and often experiences a loss of a feeling of control, the baby is taken from the womb without much warning, and the dyad is usually separated for much longer. Cesarean birth can be rough on the mother, the father and the baby – physically, emotionally, and perhaps spiritually. Cesarean is what we are trained to help our clients avoid at their births. 

The second disadvantage is straightforward – if you keep statistics, taking on a cesareans will change your numbers. You will have a higher proportion of cesareans on your record and more medicated births. However, this is easily gotten around by keeping separate statistics for planned cesarean (and planned medicated births, but that is an entirely different topic). 

Point number three is more complex, and is more of a question. I want to recognize that many of us entered birth work because of our own experiences. Some of us became birth workers because our own births were so amazing and transformative that we wanted to help others achieve the same bliss. And some of us, no less passionate, entered the world of birth because the bearing of our children was traumatic and we hoped to prevent what happened to us from ever happening to another woman again. Even those of us who haven’t birthed perhaps witnessed an ecstatic or distressing birth and felt called that way. Supporting a cesarean birth seems counterintuitive to these goals. It could feel to some like supporting a cesarean birth is supporting the same machine that we’d like to defeat, especially if we don’t personally feel the reason for the cesarean is medically warranted. When our client decides with her provider to have a cesarean, some doulas may feel they have failed to “save” her.

Yes, if you place value on “saving” women, cesarean birth support may not be for you. However, before you are quick to dismiss it, I’d ask you to contemplate – from what, or from who, are you really trying to “save” your client from? Their provider that they have chosen? The hospital they decided to birth in? Or are we trying to “save” women from themselves? Their own “wrong” choices? And is it really possible to “save” anyone from anything without that person actively saving themselves?

I have a follow-up question to ask birth supporters to reflect on: what is the nature – the real reason – we do this work? To “save” women? Or to protect the mother’s memory of the birth – to prevent emotional suffering and trauma? In many doula trainings, students are asked: at a birth, who or what are you most aligned with? The baby, the mother, or the birth? The answer will be different for everyone. If you are concerned most with if the birth itself measures up to some ideal, supporting cesarean may not be the work for you. But if you are most emotionally tied with the mother’s experience – helping her make the most of her birth, letting her own her own birth decisions and mothering the mother – then cesarean birth work can be deeply rewarding.

Finally, there is a longstanding belief that once a cesarean birth is going to happen, all is lost anyway, and there is little or nothing we can do as professionals to support the family (especially as the doula is typically not allowed in the OR). I disagree. I’d like to argue that even if we cannot enter the OR (though many doulas are finding they can) there is plenty that we can do, and in fact the cesarean mother may need MORE support than a normally birthing mother. In the case of an unwanted cesarean, frequently women are suffering emotionally and are very scared. Having their support person disappear who was with her for the duration of the pregnancy and/or labor could be devastating. Or, in the case she is choosing elective cesarean, this is often because of some past trauma (that she is either aware or unaware of) or some deep-seated fear of the birth process itself.

THE REWARDS

Just as there are downsides to supporting a cesarean birth, there are important rewards to consider. First, our knowledge, skill and calm presence can make what may be a very difficult moment easier on the mother/partner/baby triad, not just during the birth itself, but right before (during intense anticipation) and right after (when mom and baby are separated and/or other support clears away). We who are doulas know well the studies that demonstrate how doula-supported mothers have reduced feelings of trauma around their births, feel more secure and cared for, are more successful at adapting to motherhood, have greater short-term and long-term success with breastfeeding, have greater self-confidence, have less postpartum depression, and have lower incidence of abuse. Mothers even report “happier” babies and are more connected with their partners. We also know that Penny Simkin’s landmark study shows that a positive birth experience does not correlate to whether a woman has a cesarean or not. But positive feelings about a birth correlate well to how much she feels supported by others at the birth and how empowered she feels herself to make choices during her birth experience. Benefits of doulas go well beyond how many interventions a woman has and does not have. These emotional and breastfeeding benefits of doulas do not just happen at vaginal births.

Supporting a known cesarean birth allows for a clear opportunity for unconditional support. Opening to cesarean birth allows the doula to help more women and it allows the doula to act from a place of deep love instead of a place of judgment. It gives the birthing woman back the power in what can feel like a powerless circumstance – it allows her to walk her own path, and let her experiences shape her. It is about letting the mother make the choices about birth that are right for her and empowering her to have the best emotional experience as she defines it. We cannot see what the gift of support through an ordeal such as this will have on her future, but it may be that unconditional love and support in that moment can carry her through many journeys that we cannot even begin to imagine.

For doulas who have had a cesarean: take a moment and think back on your own birth experience. Really feel it. Then imagine how different it might have been for you if you had had a calm, experienced, and unconditional support person to help you cope through the process of surgical birth. If you are one of these women, your scars of experience can turn into rich understanding that the doula who does not have your experience can never have. This is coming from a doula who has not had a cesarean, but I wanted to recognize that thinking about seeing your possibly traumatic event re-unfold could open old wounds, but could also help another women in reducing the trauma that you may have had to endure.

BEFORE EVER MEETING A CESEAREAN CLIENT

 It is one thing to simply learn the skills that enable us to support the cesarean mother, but before that can happen, I feel it is of utmost importance to be fully ready and capable to create a safe and nonjudgmental environment. To be fully open to others, we must lift any burden from our own hearts, so we must deal with our own baggage. If you have had a birth experience (your own or attended) that leads you down feelings of shame, regret, embarrassment, fear, or anger, or if you find yourself saying “if I only” or “next time I will”, this is an especially important step before attending a cesarean birth. There are several formal ways one can do this. You could attend a Red Tent event or birth story circle, talk about your past history with birth with a counselor/therapist who has a knowledge of birth (look for a perinatal counselor if you are lucky enough to find one), talk with a very experienced doula who is also a therapist, attend a birth trauma workshop , or go to a training from Birthing From Within where you will not only learn how to mentor families but will begin to work on your own challenges as well. If resources are limited in your area, get creative. You may be able to find a resource out of area that you can utilize via phone, email or Skype. Or you can form your own birth trauma healing circle. If nothing else, journaling deeply about your experiences can be a great first step.

(Side note from Barb: I do this sort of processing with women a lot. If you are interested in processing your birth or births you've attended, feel free to contact me for an appointment.)

THE FIRST MEETING

The first time we meet with a client who has scheduled a cesarean (or at the first moment your existing client tells you a cesarean has been scheduled), great care should be taken. This mother is probably already expecting rejection before she says the words, and is bracing for a moment her choice will be challenged. It would be a great gift to her if she was surprised at your ability to listen instead of immediately wanting to educate. Listen with your gut and remember she is trying to walk her own path with the tools she has been given. She may have a life lesson or two she needs to learn before she is able to have confidence enough to request a VBAC, for example, and maybe that lesson is a long time from now. Pressure and animosity will only further alienate her. If she has questions, answer them. If she is already sure of her choice, believe her. This first meeting is about gaining trust and support.

Realize that there is probably a lot underneath her words and we may never know all the details, medically or emotionally, to be able to answer the question “why”. The cesarean may be medically necessary even if we do not think it is, as we do not have her chart in front of us. But even if we feel the cesarean is not medically indicated (though I’d argue telling her our medical opinion would be very much out of scope for a doula), asking “why” in the first sentence or offering up information on vaginal birth or VBAC will not be heard until the mother and her story is heard first. She will probably tell you at least part of her story even before you can ask many details. As she shares her story, you can validate her feelings of judgment, fear, anger, frustration, worry, or whatever else is going on, even if you don’t entirely agree or understand. There may be time for providing resources or building her confidence later, but really hearing her and validating her now will help her be able to listen to your words if and when that time comes. 

DURING PRENATALS OR CHILDBIRTH CLASSES

During prenatal meetings, especially after a cesarean has been scheduled, it would be helpful to discuss with your clients what happens at a cesarean and how to cope through one if it becomes a reality for your clients’ birth. If you know the hospital’s policies, this can be helpful to share, or at least you know generally what happens even if you’ve never been in an OR. You can talk to your client about the things they can ask about that may be an option for them during and after surgery, and the why’s of the way they do things the way they do. Even if you do not wholly agree with the hospital’s policies, your client’s knowing why can help them a) know the positive intention behind the various procedures (which can minimize trauma), and b) ask questions of their provider if they decide to challenge any of these procedures.

If you are a childbirth educator, consider providing cesarean preparation for EVERYONE in your childbirth classes. Some doulas or educators would disagree, saying that doing so would plant the seed of doubt in their minds. It is my opinion that this fear is already there in the minds of American birthing families and we must address it head-on by painting a picture of support and coping during their fantasies of what may be a feared event. Television, well-meaning family and friends, and maybe even their provider could have planted the doubt, which left to grow could create a lot of fear.  One-third of all American births are from cesarean. I’d argue that the chances of a woman mentally “creating” her own cesarean with her mind are much slimmer than the chances that a woman goes into a cesarean wholly unprepared to cope and comes out traumatized. 

THE MINUTES OR HOURS BEFORE A CESAREAN

If the mother has not been in labor, the woman will arrive ready, but there is almost always a lot of waiting around before surgery. If she is GBS positive, it is the standard of care to make sure the woman receives two doses of antibiotics before the baby is born. This can take four hours or more. Or if a cesarean is decided on during labor, unless there is a true obstetric emergency, there are still several minutes of waiting for the OR to be prepared. Often there are feelings of fear, nervousness, worry, relief, or excitement from the birthing family. Any of those emotions are normal. A doula can be the calm person in the room during this highly charged emotional energy. Although it is critical to be empathetic if she is upset, it is very important to not get bogged down into that emotion yourself. If a doula holds the strength in the room, it gives permission for the woman to flow through her birth experience. 

Last belly photos hours before a cesarean for breech baby and low amniotic fluid

Distraction can be a useful tool if she’s not too upset for it. Your client may just want small talk to get her mind off what is about to happen, or you might do something special for your client if it is your style, such as taking last belly photos, or painting her toenails and giving her a foot massage to prepare her for the journey to motherhood. 

Father gives mother a foot massage before surgery

A light moment caught during the anticipation - dad goofs off with figuring out scrubs

If you haven’t had a chance before this to explain the cesarean procedure itself, this is a good time to do it if the mother wants some preparation. I’m not suggesting you give a medical run-down of what will happen to her body, but one that focuses on the emotional experience of a cesarean birth. Tell her what to expect and the positive intention behind it. For instance, she can be told the lights in the operating room are bright, especially if she has been laboring in a dimmed room, but they enable the medical team to see clearly. The room will be cold and that is commonly believed to reduce the number of germs, but also keeps the team from sweating into your open wound. Pressure and rocking will mean the baby is nearly there. Making sure she knows some women find the pulling and pushing sensations disconcerting -or even painful- and some women even vomit, will help her know she isn't abnormal if these feelings are hers. Reminding her that if she feels pain, to tell the anesthesiologist right away so he or she can give her more medication. These are just examples, but the entire procedure can be described this way. You can explain the roles of each member of the surgical team (doctor, assisting doctor, anesthesiologist, scrub nurse, circulating nurse and NICU or baby nurse) or just explain there will be several people in the room and it will be crowded, but they all have a specific role to play. You can tell her that the time to her baby is not long – five to fifteen minutes tops.

Besides what to expect, families may benefit from knowing what options they may ask about with regard to how their baby is born. You can let families know that however their baby is born, there are choices they can be a part of – ask them to look deeply and see what is important for them. If it is part of your practice to offer specific ideas, you could ask the parents if they want to ask their doctor about any of the following that resonates with them (depending on circumstances):

-          Dimming the lights in the OR for the moment of birth

-          Playing music of their choice

-          Silence

-          Lowering the curtain for the moment of birth

-          Placing a mirror above the table so the mother can see the birth

-          Slowing down the birth of the baby from the mother’s incision, to help squeeze mucous out of the baby’s lungs and to aid in a peaceful transition for the baby (have the mom ask about risks such as hemorrhage)

-          Mother’s arms free (not tied down)

-          Ask that non-birth conversation be limited 

-          Partner cuts cord

-          Baby on mom’s chest during surgical repair

-          Breastfeeding in the OR

-          Any procedures the family wants to have happen right away, delay, or not happen

-          Have baby back with mother ASAP in recovery

-          Anesthesia preferences (It is not commonly known that the anesthesiologist often gives something in the IV medication to help her relax and/or sleep after the surgery – some women may prefer to be awake and present to meet and feed their baby as soon as possible.)

-          Any cultural or spiritual requests (For example, a Muslim family may appreciate silence as soon as the baby is born and being able to say specific prayers into the baby’s ears, so it is the first thing the baby hears.)

-          Any other unique ideas of the mother to make her birth her own

Whether or not to have this conversation depends a lot on the family and on the circumstances of the birth itself. For instance, a family who is happy to trust their providers completely probably may not want to ask about other alternatives and obviously during an emergent cesarean there may be not be time to share ideas and focus should be on helping the mother feel strong, calm and focused.

There are several things on this list that may be common practice already in your area (especially if you are lucky enough to have a Baby-Friendly Hospital in your area), and others may be so rare that it may be quite unusual to get a “yes”. I’d have the mother pick her top three or four and have the family ask with no or very little attachment to outcome. Much of birth preparation is internal preparation, and even in the midst of great noise, trouble or hard work, she can still be calm in her heart if her preferences do not go exactly to plan.

If you haven’t talked about coping strategies for a cesarean birth already, before the birth is the time. Even though she should feel no pain, she will still be coping through a unique situation that will have emotional intensity. What does she normally do to calm herself in intense circumstances? Does she do anything internally – counting, saying a mantra or a prayer, meditation, or visualization? Most pain coping techniques she may have learned in childbirth class transfer over beautifully to emotional intensity coping during a cesarean birth (I’ll go over some ideas in a later section).

If the mother would like a doula in the operating room, you can remind the family that this is the time to ask about this possibility. In almost any hospital in the US, it is hospital policy that mother have only one support person in the OR and that usually ends up being the partner. But for many doulas, we quietly are an exception. If you (and your client) have a good rapport with the specific doctor or that hospital’s nursing staff, this is much more common. It may help to ensure the doctor that your role is emotional support and you aren’t about to tell them how to do surgery. This request will need to be approved not just from the surgeon, but from the anesthesiologist and possibly the assisting surgeon. And in some hospitals, it’s the circulating nurse that is the Gatekeeper. You probably will not know until right before the birth if you can enter the OR or not. 

The risks for a second support person in the OR are that one more person means one more chance for germs to spread, and that ORs are usually very crowded. Also, if the second support person is not accustomed to an operating room, the doctors may suddenly have more than one patient to manage. (Know yourself!) The benefits for a second support person in the OR, however, may outweigh the risks for your client. Mother can be guided through the intensity of birth with a professional just as she would have been guided through a vaginal birth. The doula can help the mother and partner through coping techniques and help her stay centered and grounded, present for their baby’s birth. Because the doula will know the family well and because they are solely focused on their emotional needs, they can read the family and explain anything that might be startling and confusing. And during the repair, the partner usually goes to the NICU/nursery/warming table with the baby, but with a doula present, the couple can relax knowing the mother won’t be alone during this time, which will take around 45 minutes.

IF YOU CAN’T GO INTO THE OPERATING ROOM

If you can’t to the OR with the family, there is still plenty the doula may be able to do for the birthing couple. 

You may be able to give the partner some concrete techniques or ideas about how to support the mother in the OR, or give the partner a camera and any tools that might aid in the mother’s coping. For instance, the partner may carry small aromatherapy bottles in his/her scrub pockets. Peppermint is great for nausea, and lavender is great for calming. They also may be used to cover up the smells of surgery. (It is good to let the woman know there can be burning smells, but that is also normal.) Sometimes I try and slip in a scalp massager tool into my scrub pocket, though I have yet to use it and generally just use my hands.

If the mother has asked and the doula can’t be in the OR, the mother could try to compromise with the doctor. Perhaps it would be okay if the doula can be dressed and wait right outside the operating room doors. She may be permitted to enter the OR once the partner has left with the baby or in case the partner can’t cope with being at a surgical birth (though this is very rare). Or the parents can ask if the doula can be present with the mother during recovery once she has left the OR to help keep her company while her partner and baby are in the nursery or NICU. Or another option would be for the family to ask if it would be possible for the doula to accompany the partner to the NICU or nursery. In that case, the doula could help calm the partner and facilitate any bonding with the baby (for example, teaching him how to do skin-to-skin if possible if the partner is comfortable with this), take photos of the baby and see if the camera could be taken into the OR or recovery so the mother could see for herself how her baby is doing, or although the doula isn’t probably in a position to say “Your baby is doing fine as that would be diagnosing something (unless a nurse or doctor has said the baby is doing well), a doula can say “Your baby is very alert and is looking all around and your partner and baby are enjoying their time together”.

Even if none of the above compromises work, there is still a role for the doula. You may be able to straighten up the birth suite (especially if she had been in labor for many hours), dim the lights, run any errands like getting their bags out of the car, put soft music on, etc. so when the mother meets her baby for the first time, the environment is receptive to bonding.

IN THE OPERATING ROOM

If you are permitted to go into the operating room, you and the partner will wear scrubs, a hairnet, a mask and booties. When the two of you enter the room, the mother may not recognize you right away. When you are seated next to her, smile through the mask and look into her eyes while talking to her so she knows who you are.

Once in surgery, the mother will already have an epidural or spinal in place, yet the anticipation of what is about to happen will probably be at its highest point. It will be your job to keep the parents focused on the baby, by asking what color hair the baby might have, how much hair each of them was born with, or guessing the baby's gender if it is unknown, baby names, or something like this if they are open to talking. Or mother may prefer to stay more focused. She can be encouraged to “talk” to their baby in utero and tell him or her that it is time to be born now and meet their family – to reassure their child and tell him/her how excited they are to meet face to face. It is also the time that hands-on comfort measures can be used now to deal with the emotional intensity of this kind of birth. Either you can lead the mother or teach the partner how to lead the mother, or maybe the mother can do something herself. A mother giving birth by cesarean cannot move in her body, but she can still be active in her mind. Coping ideas for the operating table might be but are not limited to:

-          Breathing techniques

-          Finding a focal point

-          Using rhythm and ritual (for example: counting, singing a lullaby, tapping the table, saying a mantra or prayer either internally or out loud, or something else the mother falls into)

-          Encouraging the mother to relax her shoulders, jaw, arms

-          Touch and massage (hand holding, hand/arm/shoulder/scalp massage, grounding shoulders, rubbing temples, effleurage with the tips of your fingers)

-          Aromatherapy, if this is part of your practice

-          Guided visualization

-          Anything else that you may have come up with in previous conversations with your clients

Mother counts backwards from 10 to 1, a relaxation technique her grandmother taught her as a child to help with falling asleep, while father supports silently and watches the birth of his baby

The doula can let the parents know when the moment of birth is just about to occur. The partner might be able to watch by peeking over the curtain to witness this moment if the doctor gives permission. But the real reason to make this announcement is for the mother. Although she is not able to push her baby out physically, she may very much be thankful for the encouragement to mentally “push” her baby out at the moment of birth.

The doula can take lots of photos of the experience of the mother and partner together in their scrubs and even of the birth of the baby itself over the curtain if permitted. The mother may never choose to see the birth photos or maybe they may serve as a witness to the moment of birth for the mother that she wasn’t able to physically feel in her body. It is a verification that her baby came from her, and that she did in fact give birth.

Once the baby is born, if the family was not able to advocate successfully for skin-to-skin in the operating room or if there was some cause for concern, the baby will be taken to the warmer. But right before this happens, the baby will quickly be lifted over the curtain for the parents to see. Anticipate this moment so mom is aware when the baby is shown to her. At times, the baby might be brought around the curtain and If her hands are not tied down, this is a good time to remind the mother that she may be able to touch her baby. She can greet her baby with her voice as well.

Mother greets her newborn baby

Once the baby is born, in some ORs, the baby is out of eyeshot for the mother at the baby warmer as the curtain is in the way. Just as in a vaginal birth, or perhaps moreso depending on circumstances, the mother is often worried until she can hold her baby or at least hear her baby’s first cry. The mother may be able to see the baby if the curtain is held back slightly so she can see her baby, or the doula or partner may be able to take photos of the baby at the warmer and show the mother while she is being repaired. I’ve been able to go from the mother’s side to the baby warmer and back to snap a few good pictures for Mom without any problem. Or if photos are not possible (or even if they are), the doula can be the mother’s eyes and ears to know what is happening with her baby. She will appreciate updates on what procedures are happening to her baby and the doula may ask the mother right as the baby goes to the baby warmer (or out to the nursery or NICU) if there is anything she needs to let the hospital staff know about her wishes for baby care at this time. Sometimes, the mother might only want you to sit next to her and talk with her about the birth to distract from the sounds of the repair.

Father touches and talks to his newborn baby immediately after birth

Mother watches her newborn baby and husband at the warming unit while pushing the curtain out of the way just a bit.  You can’t see it in this picture, but she had a huge smile on her face. 

Father and baby say a compassionate good-bye as they leave for the nursery, and I stay to keep her company during the surgical repair.

IN RECOVERY

The mother may recover in their birthing suite or there may be a special recovery wing of the hospital. Often there is a time period (typically two hours, but can be longer) that the mother could be required to recover on her own, especially if this was a general anesthesia birth so they can keep a close eye on the mother and make sure everything is going smoothly. If this is not the family’s wishes, they need to ask about the possibility of being together in recovery, having the baby brought to the mother ASAP or having the doula in recovery before or during the surgery. The doula may be able to go between the nursery/NICU and the mother’s recovery area with a camera so mom can see pictures of her baby and partner can get updates on mom’s progress.

A picture from the nursery with father’s hand that was delivered to mother in recovery

In recovery, some mothers will be happy to sleep; others may want their baby as soon as possible; others may want to chat about things related or unrelated to the birth; still others may be overjoyed or upset. Any and all of this is normal and the mother can be given the space to do what she needs to do to cope through her unique experience.

Unless the mother insists, this is probably not the best time to process the birth or talk about future births. This can wait, though it may be infinitely helpful to plant a few seeds of healing by telling her a moment or two where she was especially strong.

Because recovery from a cesarean takes longer than with a vaginal birth, the doula should stick around longer than she normally does. Statistically speaking, there are often more challenges with breastfeeding following a cesarean birth. A doula can help with these challenges if they arise. If the mother had drugs to help her sleep in her pain medication or IV, or especially if she had general anesthesia, she may appreciate you being near to help with the baby care or partner support. I’ve held the baby while she nurses on the mother while the mother slips in and out of sleep after a general anesthesia cesarean birth for most of an afternoon and evening and the mother asked me the next day when she was more lucid, “Did the baby eat?” Make sure to have someone take pictures so she can know her baby did, in fact, nurse.

POSTPARTUM SUPPPORT

Studies have shown that mothers who give birth by cesarean have a higher chance of a postpartum mood disorders. But studies have also shown that mothers with a wide support network have a lower chance of PPMDs. Make sure she has a good support network or teach her how to build one. And you can be a part of that web of resources. Pay more attention than usual for cues of possible postpartum mood disorders and pass on any information that could be helpful to the mother or other support person in the family. Stay in touch and check up on her by phone or email periodically. It will be helpful to have resources available to the mother so she can create and cast out her support net and feel encouragement and assistance. Resources can be but are not limited to: cesarean healing support, lactation consultants, postpartum doulas, postpartum support groups, La Leche League, housecleaners, and parent groups. Websites like ICAN and PSI will have great information specific to cesarean healing and postpartum mood disorders.

If writing a birth story is part of your practice, definitely do it, and do it from a place of love. If there were moments of the birth that were less than ideal for you to witness, she may not have had the same experience, so ask to listen to her tell her story before you tell her your version. I would steer clear of telling your client all the “bad” parts of her birth, but just state the fact without judgment then move on to the places in the story she was strong. The worst thing you could do is plant the seeds of anger (at her providers, or otherwise), especially if they are not already there. Our job is to listen and give unconditional support as she moves through the stages of grief. It may take her longer for her to be able to talk about her experience, so check in with her now and then. Some doulas try and remember the baby’s birthday and send a card to the mother a year later.

Or, she may not be grieving at all, but you may be, and it can be easy to confuse the two. In that case, know it is natural and normal for a doula who cares deeply for her client to be upset, but make sure you don’t project your own feelings on hers and do take care of yourself and talk to someone else in birth who is a good listener.

ACKNOWLEGEMENTS AND THANKS

In my 2008 Birthing From Within training, Virginia Bobro gave me many tools with which to work with birthing women, cesarean moms included. But mostly, I want to thank the strong women I’ve supported through their cesarean births. Through the births of their children, I’ve opened my heart and learned so much. Thanks especially to the family in the pictures included in this post (I’ve included them with their blessing).

From me: Beautiful, Kristina! Thank you so, so much for your love and experience being put on "paper." We are all very grateful. To reach Kristina French, email her here kristina@threeriversbirth.com.

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    - Navelgazing Midwife Blog - Guest Post: Doula-ing for Cesareans
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    - Navelgazing Midwife Blog - Guest Post: Doula-ing for Cesareans

Reader Comments (9)

kristina... what a thorough and informative post. thank you SO much for sharing. this is exactly what i needed to read as i've been thinking much about this topic and how it pertains to my work as a doula and also as a friend to women who are having cesarean births.

March 9, 2011 | Unregistered Commenterjenna

Thank you for this thorough and informative post! I really appreciate all the specific ideas.

March 9, 2011 | Unregistered CommenterChristie B

Thank you so much for this post! I wished I had had someone like you teaching my prenatal class... I did have my doula with me for my unplanned cesarean and she was very helpful. Most of all she kept me focused and relaxed and helped a great deal with breastfeeding (she basically saved my breastfeeding relationship with my son...). But nonetheless, I really advocate now about talking about cesarean birth during prenatal classes and giving tips on how to make the best out of it so I will we sharing this post widely!! many many thanks !

March 9, 2011 | Unregistered CommenterElodie

This was an amazing and timely post. I wish I could have been there for my 3-so-far cesarean moms, but I always meet with so much resistance to the whole doula support process from the staff, never have I been allowed even in the mom's room after recovery, and by the time I can see them again, they seem to have "checked out" of the experience and baby is getting bottles and pacifiers and who knows what else. I would love a chance to practice all of these great tips but so far I've been blocked from being part of their birth process. Are there any tips for the meeker doulas out there to convince the medical team to let them be with the mother or baby?

March 11, 2011 | Unregistered Commenternikki

Nikki, I also live in a conservative-ish birthing area where doulas are not well understood. When I first started out, I went to many a birth where I was the first doula a provider had worked with, or they reported having a bad experience or at least had heard a bad story about doulas. It has only been after several years of doulaing that I have seen a change in provider attitude about me being there. I would say that my biggest piece of advice to lay groundwork for getting to go into the ER at some future birth is to know your place as a doula. I never try to push my agenda on a birthing woman, never speak for the birthing family, and never disagree with a provider's advice (even when sometimes inside I might be screaming). I am DONA certified and their code of ethics and practice limitations on scope have really helped me and I am so glad I have them. The providers here trust me enough to let me into the OR because they already know i don't tell them how to do their job - ever. For a new nurse i have never worked with, i take her out in the hall early on in the birth and tell her exactly that (and tell them whay i can and cant do and anything about this particular family that may help them just a bit). I would also say you can tell the birthing mama that she will need to advocate for you to be in the OR if she would like, and remind them of this if a cesarean becomes part of the plan. Hope that helps!

March 17, 2011 | Unregistered CommenterKristina

Thank you for a wonderful article. You have helped me with a great idea. I have at times been allowed in the OR and sometimes not in the same hospital. Almost depends on a mood of the hospital staff. Now I know I can offer to go in after the partner leaves with the baby. (the reason given when I am prohibited is room size) My goal is always be there for the mother. If denied access, I already do what you suggest by straightening up the room and assisting the partner with baby with SSC until Mom can join us. Although I personally dislike c-sections, I have no problem helping to make the situation as positive as possible.

July 19, 2011 | Unregistered CommenterMona White-ortega

As a 3 time cesarean mom and one who attempted a home birth, let me add some suggestions:

-Don't project your feelings about the cesarean to the mom. That's unprofessional and inappropriate. Sometimes cesareans are life-saving. My husband would likely be a childless widower without them. If you act like a cesarean is the worst thing that can happen, you might transmit those feelings to the mom, or annoy her during a difficult situation.

-Request the catheter AFTER the anesthesia is placed. This was not routine hospital policy during my first c-section, and that was so uncomfortable. For the other two c-sections, I requested it and it was not a problem.

-An abdominal binder made my postpartum weeks so much more comfortable. Is suggesting that she ask her provider about one of these outside the scope of practice of a doula?

-Videotape the baby if it is out of the mom's sight. With my second and third baby, my husband did this and it filled in a lot of unknowns for me.

-Remind her she can request warm blankets if she is cold in the operating room.

-Teach her a little about how to deal with the hospital bureaucracy. Know when shift change is and time your requests to avoid shift change, if possible.

-If the hospital policy is that the baby rooms in with the mom, try to have someone there to ensure the safety of the baby if mom is drugged! My first baby nearly smothered when I was trying to breastfeed, and I had no idea because of the pain meds I was on. Thank heaven my mom was there to notice my navy blue baby...

August 10, 2011 | Unregistered CommenterSara

Those are great suggestions, Sara!

Not out of the scope of practice for a doula to mention a binder at all. Great idea!

Thanks so much for taking the time to write these things out. I know women will benefit from your experience.

August 10, 2011 | Registered CommenterNavelgazing Midwife

Sara, I agree! All wonderful ideas!

August 11, 2011 | Unregistered CommenterKristina French

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