By Hayley Oakes LM, CPM ~doula

A mother choosing an out-of-hospital birth with a midwife might not consider hiring a doula for labor support. The usual rationale is that she has her midwife and partner for support, so a doula is one extra person who may not be necessary. Plus, it’s an added cost to an already out-of-pocket experience. Most people think of doulas as important roles for women planning a natural birth in the hospital to help navigate the potential ‘cascade of interventions’ that can take a woman far from her birth wishes. So why would one hire a doula for a planned birth center birth? When stacking the odds in your favor of having the birth you want, a doula is one of the top tools to make it happen.

What is a doula?

A doula is an emotional, informational and physical support person for both the laboring mother and partner. (1) She is a continuous support person (versus intermittent support of nurses, midwives, etc. due to shift changes) from the time the mother needs her to the birth. A doula is trained in childbirth education, comfort measures and massage techniques, exercises to help encourage a baby into a more favorable position (both in pregnancy and in labor) and works with the partner in reminding him or her that the mother may need water, a cold cloth, counter pressure to hips, etc.

“Having a doula wasn’t just for me but for my husband as well. There is no doubt that having a female energy around helped me during labor. She coached both of us and when he didn’t know what to do or say he would mimic her. She was such a wealth of knowledge prior, during and after the birth.”

How much does a doula cost?

Most doulas range from $750-$2000, however, there are doulas who work on a sliding scale depending on the family’s budget, income and planned birth setting. There are newly trained doulas (called “new-las”), who charge a significantly discounted fee.

What are the benefits of a doula?

Studies show that mothers who have birth doulas have more positive experiences and tend to use less pain medications. (1) Also, women are less likely to have cesareans. This is because when a woman feels safe and supported, she can trust the laboring process better and progress more efficiently without needing external interventions.

“When I was in early labor at home, the moment she walked in the door I progressed because we had already established such a wonderful relationship and I felt comfortable with her, which allowed my body to advance in the labor.”

At Del Mar Birth Center, we cannot admit a laboring woman until she is in active labor and/or at least 6 cm. New studies show that a dilation phase of less than 6 cm is still considered early labor and the risks of interventions for ‘failure to progress’ increase. In the case of a birth center, the risk of transferring to a hospital for this reason also increases. In order to minimize the risk of unnecessary interventions, the best advice is to labor at home until the mother is active.

A doula also acts as an advocate for the mother, reminding her of her birth wishes and prompting the mother and partner to ask for more information when discussing the plan with their care provider. A doula does not speak for the mother or become a body guard protecting the mother from the medical staff, she acts more as a concierge of the birth experience and/or mediator between mother and care provider. She helps a mother and partner understand their options so they can better make informed decisions. This is true in both a hospital and out-of-hospital setting.

Don’t we just go to the birth center at the ‘4-1-1’ contraction pattern?

The midwife will be on the phone with the mother in labor or texting the partner, and maybe even asking for a video of the mother during a contraction to get a visual. When the contraction pattern is consistently strong and close together and the mother is actively working with them (i.e. moaning with the contraction without much conversation in between.), the family and midwife will decide on a time to meet at the birth center.

In most instances, when a mother has rhythmically strong contractions for a few hours, her cervix will also be dilated. However, there are instances (a baby’s mal-position) when a mother arrives to the center and her cervix is checked and it is not quite open enough to be considered ‘active’ and/or to be admitted to the birth center. (Read previous post “Right Sided Babies”) The best thing the mother could do to conserve her energy is to go home and rest until the labor pattern is more active. This could be hours or a day or two.

While one may think of ‘early labor’ as still a mild and manageable phase when one can simply rest, watch a movie, or bake a cake, there are early labor patterns that are quite active. This is when it’s incredibly helpful to have a doula. Since one doesn’t know what kind of labor she will have until she is experiencing it, it’s best to have this back up tool, just in case.

A doula is called to the mother’s home to help her cope and settle into the contractions more easily despite their increasing strength and frequency. There is a lot of pressure on the partners to remember everything from the childbirth education class, be in communication with the midwives, while also maybe meeting his or her own basic needs. When a laboring mother has a doula with her at home, the partner can also remain calm and more likely him or herself, which inevitably will help make the laboring mother feel more at ease.

“My doula helped my husband by setting an example for what he should do. This way they could communicate without her verbally telling him what to do but he could just mimic her.”

As early labor progresses into active labor, there may be signs or symptoms that can be alarming to the inexperienced partner. This includes vomiting, shaking, vaginal bleeding, leaking of fluid, diarrhea, etc. and when a doula is present to reassure the family that all is well (and to also check in with the midwife) the laboring mother and partner are more likely to settle into these new changes more easily.

Personally, I feel that clients who have doulas are less likely to arrive at the birth center in early labor to then be sent home. There is an extra level of confidence and ease when a woman has another woman present in labor who is experienced – like a Sherpa. A doula guides the mother through this foreign trek of childbirth looking at her, reminding her to breathe, letting go of the tension in her shoulders, giving her some water, etc.

Well, if that’s what the doula does, what is the midwife’s role?

The midwife’s role is managing the safety of the mother and baby. While the midwife can suggest the same comfort techniques and activities as a doula, she will not be with you at home in early labor or in the room with you continuously once you get to the birth center. The midwife has to reserve a certain amount of strength and effort for the birth and immediate postpartum, whereas a doula is there with the mother for every contraction she needs the doula for. The midwife is present in the room at least every 30 minutes to check on the mother, listen to the baby’s heart rate with a Doppler ultrasound and discuss plans for progress, if need be.

Having a doula present can be especially helpful if it has been a long labor and the mother maybe losing motivation and steam. A doula is there to encourage her of her strength by reminding the mother of birth affirmations or suggesting ways of augmenting the labor. Or if her partner needs to lay down for a bit in order to regain some energy for the postpartum, her doula is there with her.

“…This made him feel safe so that he could step out when he needed to without feeling like he was abandoning me.”

In the case of a transfer to the hospital, if there is no one else in labor at the birth center, the midwife will follow the family to the hospital to get the mother set up and then leave to return for the pushing phase, if available. (See previous post “Transferring to the Hospital” to read what that process is like).

If there is someone else at the birth center, then she cannot go with the family but is available by phone. A doula continues to give support, no matter what birth setting, and can be very helpful during an unexpected transition like transferring to the hospital from a planned birth at a birth center. While in the hospital, the doula’s role is less about helping a mother turn down interventions (as that is why we are transferring) and more about helping the mother gain informed consent, process the experience and rest as much as she can in order to still achieve a vaginal birth.

Where can I find a doula?

There are many doulas in the Los Angeles area. You can look through Doulas of North America (DONA), Yelp, or Google. I personally like working with the doulas from Two Doulas Birth registry as they also teach a childbirth education series specifically for out-of-hospital birthers. I encourage all clients to at least meet with a few doulas to see if there is a fit or someone who suits their needs. There is no harm in meeting with someone, it’s a free consultation, and think of it as checking off more one more box in preparing for the natural and empowered birth you envisioned.

Resources

1. “What Is a Doula.” DONA International, www.dona.org/what-is-a-doula/.