Chapter 4 Excerpt from Birth Ambassadors

Being a Team Member: Doula Strategies and Nurse-Doula Interactions

This excerpt highlights findings from Christine Morton’s sociological research on the history and experiences of doulas in the United States. The methodology is described in the book’s Appendix.

ImageAs outsiders to the hospital, yet as self-professed insiders to labor support, doulas employ several strategies as they enact their role providing information, advocacy, and physical and emotional support.  Some strategies occur during the prenatal visit, such as becoming familiar with the client’s birth plan and desires for interventions, and discussing communication and negotiation tactics should the birth plan be challenged by either the maternity clinicians or unexpected events, particular to, and complicating the birth.

Doulas utilize “reframing” as a major strategy to help their clients achieve a ‘satisfying birth memory.’

Strategies that doulas describe using in the hospital setting include becoming a team player; backstage negotiations; direct confrontation and silently witnessing depersonalizing behaviors.  All these strategies are associated with both benefits and costs.  The doula may be a ‘good’ team player, but leave the impression that she is ignorant or ill-informed about birth.  Requesting and using backstage time to go over various options in the situation can irritate a busy, time-strapped physician.  Direct confrontation can strain the emotional atmosphere the doula is striving to control, and can be considered speaking on behalf of the client, and thus outside the standards of practice.  Finally, when doulas witness what they consider to be impersonal, disrespectful or dehumanizing treatment of their clients, they may be left with strong feelings of anger and frustration.  In those situations, as in all births, the final strategy, ‘reframing the birth experience,’ becomes a challenging emotional task with the goal of helping the woman achieve a ‘positive birth memory.’

Most doulas report positive experiences working with physicians, nurses and midwives in the hospital setting.  Many invoke the notion of being a ‘team player.’ Nurses are typically the first obstetric clinicians doulas encounter when they attend their clients in labor.  Whether they accompany the woman to the hospital and encounter the triage nurse or arrive after the woman has been admitted, doulas actively assess a nurse’s attitudes with regard to labor support activities in general and to doulas in particular. Doula Deborah Rothman described her strategy of figuring out the nurse’s practice style, and adjusting to that:

Well, it’s really important to get some kind of partnership set up or at least division of labor set up with the nurses.   Most nurses—when there’s a doula—I find that they are content with their clinical assessment-monitoring role.  Or they’ll be chatty and supportive that way.  And there’s a few that obviously love labor support, and there’s always room for more labor support, you know.  That way I get to go to the bathroom, or work together, and that’s really nice.  But the ones that don’t seem to approve of labor support seem content enough to do their clinical role and I’m respectful of their job.

Several doulas in my study reported positive experiences working with nurses who were happy to engage in a division of labor, leaving the emotional support to the doulas. Not all nurses feel this way, and without knowing a particular nurse’s proclivity, many doulas make an explicit effort to reassure nurses that their presence does not mean the nurse has been ‘ousted’ in this area.  A doula described her approach this way:

I try to ask the nurses questions that we have, in a way that allows them to share their expertise.  I like to develop a ‘We’re learning from you, what do you have to share with us’ type of thing, so they don’t feel sort of ousted by the doula and that they’re just like the paper work person.  That they really have something to give to the situation.

This doula strategically orients toward the nurse as a potential source of knowledge and information, to help offset the possibility that the nurse might feel relegated to her documentation or clinical monitoring role.  Interestingly, the doula as hospital ‘outsider,’ works to ensure and reassure the insider nurse that she has a role to play, or ‘really have something to give to the situation.’

Another doula described her philosophy and how she demonstrates to the nurses that everyone is on the same team, but with specific roles:

I consider us all a birth team, there’s no, I’m on one side or another, we’re all on the mom’s side, basically. That’s certainly the way I like to think about it.  I kiss up a little bit in the beginning, I mean, not really, but I introduce myself and I usually ask the nurse what’s going on, if she was there before me, and [I also ask] the mom, but it comes out from both of them while the mom’s there.  I say, ‘Oh, that sounds great’, and I kind of reinforce back and forth, and it feels like a team, and I get out of her way and she does her thing, and I do mine.

She initiated the interaction by asking the nurse what has occurred prior to having come on the scene, and actively worked to create a three-way dialogue between her client, the nurse and herself.  Through this approach, the doula effectively positioned herself as someone with a right to know the patient’s medical history and future plan, based on the nurse’s current clinical assessment of the labor.  She aligned herself with the plan right from the start, affirming the decisions, ‘Oh, that sounds great.’

Tiffany Smith, a doula and a nurse, acknowledges the potentially contradictory roles of informational and emotional support in the doula role, and says this was an ongoing issue in both her doula and nursing practice.  Tiffany’s tactic is different: “It’s a balancing act, to push up to the line but not over.  Always negotiation.  As a nurse, one of my roles is to advocate for patients.  So I use what I call my dumb nurse voice—playing stupid in a non-threatening way—non confrontational.”  Tiffany’s nursing experience and knowledge serves as a resource for her interactions with clinicians when she works as a doula.  She told a story about a birth in which the placenta was taking a long time to come out.  Tiffany noticed the doctor becoming impatient and tugging on the umbilical cord.  “So I asked, ‘Gee, how long does it take to come out?’ I bought the mom time, about 45 minutes, because the doctor was pulling on the cord.”  Tiffany was concerned about possible postpartum complications if the doctor rushed something that Tiffany knew could normally take up to an hour.  She used her ‘dumb nurse voice’ to redirect the doctor’s awareness to the wide variation in ‘normal.’ In so doing, Tiffany felt that she ‘bought the mom time’ to hold and admire her newborn before the nursing staff took the baby for institutional processing such as measurements, bathing, and vitamin K shots.  This strategy of using ‘classic’ feminine wiles was often described by doulas when they asked a question of the nurse or doctor in front of the client in an attempt to introduce another viewpoint.

In the best nurse-doula scenario, both assist each other and work for the benefit of the laboring woman.

One doula remembered a nurse’s behavior while recounting a birth story about a long labor during which the client got an epidural and fell asleep:  “The nicest thing for me in that birth, I was sitting next to her, dozing, around 3am, and a nurse came in and put a warm blanket on me.  She was a doula to me, her intention was so sweet.”  Here, demonstrating personal attentive care is described as acting like a doula.

Doulas who stress the importance of establishing a ‘team’ approach with the nurse acknowledge that part of what the doula is there to accomplish infringes on some part of the nurse’s job description: providing labor support.  Doulas are aware, however, that individual nurses vary in the degree to which they embrace hands-on labor support aspect.  By making initial overtures to the nurse, the doula is able to assess the degree to which the nurse will be an ally with the doula and support the woman’s desires.

Another strategy doulas use to counter medical information or unhelpful attitudes from clinicians occurs during their access to ‘backstage’ time with their clients when no clinicians are present.  This strategy can utilize information obtained prenatally about the client’s fears and desires for her birth and agreed-upon techniques for managing a physician’s recommended intervention or change of course.  A doula described it best when she said:

Well, one thing that I try to do is when the doctor’s not in the room—I’ve encouraged my clients to say, ‘We’d like to think about it’—and they ask the doctor to leave and then come back so that we have a chance to talk in privacy.  What I’m finding is that the doctors have egos and the last doctor we were with said to the client, when she started asking a few very simple questions about artificial rupture, ‘I’ve done a couple more births than you probably have.  I’ve done about 4000.’  You know, totally demeaning.  And I wanted to say, ‘Yeah, but you haven’t had your baby.  You’re not the one who’s giving birth right now.’  He was totally insulted that she wanted to ask questions.

This backstage strategy can be an effective way to validate women’s feelings about the medical interaction or to sort out possible approaches to the particular situation at hand.  It is also used by doulas as a practical strategy for challenging and countering medical information, and providing more advocacy.

Roberta King is another doula who provides a concrete example of the backstage strategy to help her client achieve her goal of an unmedicated birth when the nurse actively disregarded this desire by her continued offers of pain medication:

Another thing I do is to be that buffer in between that medical staff and mom … because nurses will continually come in and say, ‘You know, you can get medication,’ and the mom says ‘No,’ and they’ll come back and say ‘You know, you can have medication…’ So that’s what I talk to the mom about [when the nurse leaves].  I don’t talk to medical staff, I don’t give them any decision.  [I tell the client] ‘When she [the nurse] comes back in, just let her know that you will ask for medication, and tell her ‘Do not ask me again.’  And she told them that way.  Because medical staff, that’s what they do, it’s nothing negative against them, they’re doing their job. Since we did it that way, it didn’t put pressure on them, because when you’re in the midst of a pain, (laughs) if someone can tell you ok, I can take you out of the pain, you know, it’s difficult, it’s difficult.

Roberta uses her continuous presence at her client’s side to offer advice on how to respond to the nurse’s continued offer of pain medication.  She effectively uses the backstage time with her client to construct a response to the nurse’s offer for medication that kept her, the doula, out of the interaction.  Roberta didn’t construe the nurses’ behavior with sinister motives; rather, she saw the offer of medication as ‘their job’ but acknowledged that this offer can be tempting to a woman in the midst of a painful contraction.

This use of backstage strategy is made possible by virtue of the doula’s continuous presence at the birth.  Nurses come and go but the doula remains in the room, privy to the woman’s reactions to a particular nurse and to her knowledge of the woman’s goals through her prenatal contact.  In cases where the backstage strategy isn’t applicable or doesn’t work, doulas adopt varying styles of direct communication with maternity care clinicians, whether to challenge information, suggest alternative practices, or to enlist them in helping the doula support the woman’s desires for her birth.

Published by Christine Morton

Christine H. Morton, PhD is a medical sociologist whose research has focused on women’s reproductive experiences and maternity care roles. Since 2008, she has been at Stanford University’s California Maternal Quality Care Collaborative, where she conducts research on maternal mortality and morbidity.

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