How to Read Your Prenatal Chart

As of right now, I’ve gotten nearly 31,000 views on my post about understanding prenatal urine tests. Do a google search on orange urine, ketones in urine, pH of urine, or other urine features in pregnancy and the above post will show up on the second page if not the first. What does this tell me? That women want to understand their bodies and they want to be involved in their healthcare.

Some time ago, as I began to notice a steady increase in the daily views of the urinalysis post, I made plans to write a sequel of sorts, on reading prenatal medical charts. If many women want to know how to read their urine values, surely they must be interested in other aspects of their prenatal chart! So, after much postponing, here it is.

Prenatal charts vary from GP (general practitioner) GP, but though appearances may be different, all of them request the following information.

Dating. Dating of the pregnancy, or determing conception and estimated due date (EDD) is important for several reasons including confirmation of normal fetal growth and determining a safe time period for which the child should be born (the due month). You will see in this section of your chart, which is usually located at the top, the following terms:

  • Mensus. Here the GP records the regularity or irregularity of your cycle. This would influence the dependability of basing your EDD on your cycle. They will also record how many days your cycles last. A long cycle is associated with longer pregnancies, a short cycle with shorter pregnancies. A due date is usually based on a 28 day cycle.
  • LMP. This is your Last Menstrual Period, sometimes called Last Normal Menstrual Period. If your GP bases your due date on your cycle, they will mark the beginning of your pregnancy at the first day of your LMP.
  • Conc. date. This is the date or estimated date of conception. If you know when you ovulated it would be around this time.
  • EDC. This is your Estimated Date of Confinement, also called an EDD, Estimated Due Date. Also listed will be the basis for which the EDC was determined, options include LMP , Sono (sonogram/ultrasound), exam (cervical indications of the stages of pregnancy, fundal height or length of uterus), conc. date (if it was very clear), and arbitrary (a combination of the above.
  • Pregnancy test. Either blood or urine test and the date it was positive, as well as hCG level, if it was a blood test.
  • First exam. This will include the date and the size of the uterus, and whether it confirms the LMP or not. At 12 weeks the uterus is beggining to “pop out” from the pelvis and can usually be felt above the pubic bone. At 16 weeks it can be felt midway between pubic bone and umbilicus (belly button). At 20 weeks it’s at the umbilicus, and by the time of birth it will be at the lower ribs.
  • First FHT’s. The date and beats per minute of your baby’s Fetal Heart Tones. The date this is first heard can confirm the EDD or indicate the need for adjustment. A handheld doppler can locate FHT’s around 12 weeks and a fetascope, or fetal stethascope, can detect FHT’s by an average of 16 weeks.

Somewhere near the top or middle of your prenatal chart will be a quick reference code for your GP to remember your obstetrical history. I’ts called GTPAL and is an acronym for the following:

  • G stands for Gravida and a number will be listed next to the G indicating how many times you have been pregnant including your current pregnancy.
  • T stands for Term and this number will indicate the number of pregnancies you’ve had which have ended between 38 and 42 weeks.
  • P stands for Preterm. This indicates the number of pregnancies you’ve had which have ended between 24 and 37 weeks.
  • A stands for Abortion, which includes the total number induced abortions and miscarriages you’ve had before 24 weeks. And L stands for Living children, and of course indciates the number of living children you currently have.

Flow chart. The largest space in your prenatal chart is dedicated to your prenatal visits and their results. Again, charts vary, but the following information is standard to every version:

  • Date of the prenatal visit and visit number (e.g. 11/07/10, 4th visit)
  • Weeks gestation. This is the number of weeks you are currently pregnant, starting (usually) at your LMP. It is indicated by weeks and days and will usually be written as follows. A pregnancy at 20 weeks and 4 days will be 20.4 on the chart. A pregnancy at 35 weeks and 2 days will be 35.2 on the chart.
  • Fundal height. This is the uterine size measured in centimeters (cm) from the top of the pubic bone to the top of the uterus, medically termed the “fundus”. After 20 weeks, the number of cms usually matches the number of weeks, but normally varies up to 4cm on either side. For example, a 26 week pregnancy has a fundal height of 26cm or 22-30cm, but should be consistent with previous growth. A sudden drop or increase in the growth rate calls for a closer look at the baby’s health.
  • FHT. Fetal Heart Tones range from 120-160 in healthy babies, sometimes outside this range. This is measured in beats per minute.
  • Weight. A woman who is healthy and eating nutritional foods does not need to pay close attention to weight gain in pregnancy, but it can be an additional source of info for your GP to determine the health of you and your baby. A healthy total weight gain is about 40 lbs for a single baby, but this is just an average.
  • Fetal activity. GP will note that you said your baby is having periods of active movement every day which indicates fetal health.
  • BP/pulse. Your blood pressure and pulse are recorded to monitor your health. They indicate normal increase of blood volume when the are slighly lowered mid pregnancy, but may also be monitored to watch for numerous health conditions including Pregnancy Induced Hypertension and Preeclampsia.
  • Presentation and position. Although some GP’s depend on ultrasound for this informaiton, a skilled GP will use their hands to feel the position of the baby and determine the presenting part (head, butt, or other body part nearest to the cervix). Babies move around a lot all the way up to 30 weeks, but by 34 weeks most babies are head down and facing the mother’s back. This will be listed in your chart as LOA (left occiput anterior) or ROA (right occiput anterior). It is most important that the occiput (back of the head is the presenting part) is anterior (at the pubic bone). For more information and pictures of positions, see this post.
  • Urinalysis. At each visit you will be asked to give a urine sample. See this post for detailed information, but the most significant findings are protein, sugar, leukocytes, and nitrites.
  • Notes. A small place for notes is provided for the GP to write significant findings or your concerns or physical complaints and their recommendations. If a place is not provided for internal exam findings, they would be listed here when the procedures are done.

Every woman has the legal right to see her file at any time, to take notes or get copies. If you are concerned about they way your care is being handled, if you want to do further research on your condition, or if you are just curious, don’t be afraid to say you want to see your records. Some practices regularly have patients fill out their own values after procedures are done so they can be an active participant in their care.

I plan to write more posts on reading your obstetrical charts, including medical history, risk assessment, lab values, labor and birth records, newborn exams, and postpartum care. Ambitious? Perhaps, but I think women want this information, and unless you buy textbooks it’s hard to find. Please tell me if this was helpful to you and if you have questions or comments, do share! Don’t forget to subscribe to this blog at the bottom of the page to receive free email updates when new posts are published.

Thoughts on Birthrape

A couple years ago I was attending the birth of a client who was planning a VBAC with a midwife in the hospital. She had doubts, as is normal for VBAC moms, that she would avoid another cesarean, but her midwife and I did everything we could to help her prepare for a wonderful birth.

View from Gunstock Mnt, Gilford NH

Unfortunately there was a hitch: the attending OB who was to be on call during her birth put it in her head that she was going to fail. His last words to her before she went into labor were, “I’ll see you in the O.R.” My client told me his words made her nervous, that she knew he was just pulling scare tactics, but that it made it more difficult for her to have faith in her body and the birthing process.

When my client’s birthing time began, we realized quickly enough that the OB was not going to make it easy on her. I can only describe his behavior like that of a vulture, which may sound extreme, but the stress and fear manifested by both mother and child could only have come from his everwatchful eye, just waiting for her to cry uncle and let him cut her. At one point my client made a complaint about him being there and I knew she had not consented to this kind of care.

When the decision was made to call the OB in to consider a repeat cesaran, his previously rude and grumpy behavior suddenly became quite jovial. He gave no consideration to the disappointment my client was experiencing but assumed a paternalistic role and was obviously happy to take over the show. I was speechless and quite honestly pissed off (can you tell this birth made an impression on me?) though I was compelled by my promise not to interfere to hide behind a smile.

View from Gunstock Mnt, Gilford NH

Yet after the birth, I was surprised at the reversal of my client’s attitude. All of a sudden she was defending her OB, saying that although he was a bit rough during her birth she could understand, and that really he was a very nice guy (if you follow his rules). When she got pregnant again she returned to the same OB and scheduled a cesarean.

Was that birth rape? Since I was not the one under the knife I’d hesitate to say yes, but I know if that was me I would not have been letting it go that easily. Here is a good post about birth rape I found a while ago and linked to my May Favorites. It gives a really good description of what birth rape is, if you haven’t heard of the term before.

One thing I certainly do find comparable between the story I just shared and the experience of rape is that it is not unusual for women who have been raped to downplay the attack and defend the rapist as a way of protecting her own mind from accepting the seriousness of what happened to her. “He really wasn’t that mean”, “He didn’t really hurt me”, “He’s been through a lot so I understand why he’s troubled”.

But here’s the thing. My client was cut, she was bruised, her spirit was broken, she will never again have faith in her body because what little faith she mustered up was ripped out of the soil as soon as it sprouted. What that man did to her I can only hope he will never do again to another woman, but sadly, I know better.

View from Gunstock Mnt, Gilford NH

Women, mothers, girls, please! Protect your bodies! Birth leaves you vulnerable, which is good, but you must choose your care provider with extreme caution! If you are hesitant about your doctor or midwife prior to birth, if you find yourself defending him or her but know deep down you can’t trust them, listen to your intuition! Respond to that voice inside you because pregnancy is the only chance you have to choose birth attendants who will protect you in your vulnerability. You can’t protect yourself while you’re giving birth. That’s how you end up with the fight or flight response causing your labor to not start or to stall or your baby’s precious heart to show signs of stress during labor – because you don’t feel safe! Please, listen to your birthing voice and obey it. It may not be easy to change care providers like this woman did (also see June Favorites), but you’ll thank yourself during and after your birth.

If you have experienced birth rape, felt manipulated or cheated, or forced to do something you didn’t want during your birth, please read this post, and talk to someone about it. You don’t have to protect your abuser, and it is good to stand up for yourself.

View from Gunstock Mnt, Gilford NH

Common concerns parents have about hiring a birth doula

This is the third post in my series on doulas, commemorating International Doula Month. The first two posts were: Do Birth Doulas Really Make a Difference? and Why Are Doulas Attending Only 3% of Births?

One topic I have touched on many times over my seven plus years of being a doula so far is, what concerns do parents have that prevent them from hiring a doula? I say parents because I have personally encountered situations where either the mom or dad says yes and the other says no. Here are the ten most common concerns I have encountered from parents who are not quite sure hiring a doula to attend their births is worth it, along with my thoughts.

1) Is it worth the money? In today’s economy, money is a big concern for many people, especially those who are or will soon be responsible for feeding little mouths. If babies can be born just fine without doulas, why should you spend your extra cash on labor support? This question is of course based on your personal opinion of birth doulas, and unfortunately you will not know for sure what your opinion will be until a doula has attended your birth. The only way for you to make an informed decision, on whether or not to take this financial risk, is to learn as much as you can about doulas, and then interview doulas in your community. You may find that all the potential benefits of hiring one will convince you it is worth the money. And if you are just not able to come up with the cash, please call doulas in your area anyway. Some towns or cities have free doula programs, many individual doulas offer free or sliding-scale services to those in need, most offer payment plans or a barter option, and some hospitals offer free doulas to any patients who requests one. I have even heard of insurance companies that cover the cost of a doula. Of course you would have to call before labor starts to confirm this. Another idea is to ask your family and friends to help you pay for a doula as a baby shower gift. In conclusion, the money you spend on a birth doula could ensure you and your family with multiple long-term benefits, and if you base your answer to this concern on the experiences of women who have used a birth doula, I would hesitate to think it’s not worth the money.

2) Will a doula replace my boyfriend/husband? I would dare say that the most common reason a woman either is not interested in using a doula, or changes her mind about hiring one, is because she wants her husband or boyfriend to be the primary support person and she thinks a doula will replace him. I am here to tell you that a good doula will do just the opposite. One of the core principles doulas are taught is to involve the husband as much as they are comfortable with. Most husbands at least want to be present for the birth to encourage their wives and to witness the birth of their child. Yet many men, who are not experienced in attending births, get overwhelmed with the intensity of labor and do not know how to support their wives they way they need it. As a result, it is not unusual for a man to back off and let the nurse and epidural do all the supporting. When the doula steps into the room, most men sigh in relief because, finally, someone is there who knows what is going on. The doula encourages not only the mother but the father, as to what is normal labor, and helps him to find specific pain relief and comfort measures that he can use to support his wife. Mothers report being more satisfied with their partner’s support, and the couples attended by a doula report increased bonding after birth, when a doula is there to support the couple through this life-changing event. Another way that the doula supports the husband is by allowing him more opportunity to create positive memories of the birth of his child. When the doula is present to support his role, he no longer feels the pressure to be a birth coach, and can instead just be there for his wife and love her, which is what women report wanting the most from their partners. And if the labor is longer or mom needs some space, her husband can leave for a short time to get a coffee, take a nap, or make phone calls, and know that his wife is being well-cared for. If the woman and her partner would like some time alone, the doula can step outside their room and “guard the door”, requesting the nurses or other staff to give the couple a few minutes alone. With a doula attending the birth, couples have more options, and tend to feel safer having someone there whom they met prior to labor and who will support the decisions they make about their care. Depending on the mother’s needs, as they change throughout labor, her doula may play an active role or remain in the background and let dad take over, but the overall atmosphere of the team is that the mother and father are the most important people in the room.

3) But my mom/friend/sister is going to be my doula. There was a time when the only birth attendants a woman had were her female relatives. The closest person she had to a “midwife” would be the woman of the town who had delivered the most babies for her friends and family. Although they did not have technology to help them handle complications, I’m sure the support women received from this network helped to keep birth as normal as possible. When women give birth in the United States today, they often ask their mother’s, or another close woman, to attend their birth, to support them emotionally through the work of labor. And while the intimacy of their relationship can be a huge benefit to the laboring woman, it is a much different dynamic than it once was. The birth knowledge of today’s mothers and grandmothers is only what they aquired through their own birthing experiences, which was usually clouded by pain medications. Female relatives and friends may have perfect intentions, but the physical and emotional support they offer is on a whole other plane from that offered by professional doulas. Doulas have attended trainings, may have attended dozens of births, has learned most everything there is to learn about normal birth, and will probably have a decent understanding of childbirth complications with their treatments. Both roles are vital to the well-being of the mother, but a female relative will not be able to offer the experience that a doula has. And, a study by Klaus, Kennell, and Klaus has shown that laboring mothers receive the greatest benefits when the doula is not related to her, although she cares greatly for her. This is because the emotional relationship the relative has with the mom-to-be cannot be objective at the same time. If you choose to bring your mother, sister, aunt, grandmother, or a friend to your birth, as long as you feel comfortable with that choice their support will probably be very helpful to you. But if you are looking for someone who has a large bag of ideas on how to cope with labor, with knowledge of how birth works and how to keep birth normal, it would be helpful to bring a doula with you as well.

4) Isn’t a doula pointless when you have a nurse-midwife? Nurse-midwives, who usually deliver babies in the hospital or in birth centers, are known for their woman-centered care. They spend more time with their patients, they encourage their patients to ask questions and express their concerns, they tend to prefer natural childbirth and are more reserved in their use of interventions. So wouldn’t a nurse-midwife offer the same support a doula would? Is a doula necessary when you have a nurse-midwife? Well, even if they did offer the same kind of support, having more than one person who has the same priorities and goals as you can be a strength in labor, especially if it turns out to be longer or more complicated than anticipated. However, doulas and nurse-midwives actually have much different roles. For one, the nurse-midwife’s first priority is for the mother’s health. She is responsible to monitor labor progress and the health of the mother and unborn baby. And while she will probably be more sensitive than an obstetrician, she may very well have other patients in labor, reducing the amount of time she can spend with one woman. Her clinical duties alone will restrict the amount and quality of time she is able to provide the mother for emotional support alone. A doula’s sole responsibility is to give continuous, one-on-one care for her mental and physical comfort, something that no medical-careprovider can offer. The study I mentioned above also concluded that the benefits of labor support are greatest if the support person is not a staff member of the hospital. If the only reason you are not hiring a doula is because you will have a nurse-midwife, I strongly encourage you to learn more about the roles of both your midwife and a doula, because they are much different than each other, and you will benefit the most if you have one of each.

5) Aren’t doulas anti-epidural? The answer to this concern is not clear-cut. It really depends on the doula. If a doula is following the DONA International definition of a birth doula, she will not be anti-epidural. A doula’s job is to present women with the information that is available about her options, including the pros and cons to pain medications, and then support the woman’s decision. I’m sure many doulas have used epidurals themselves. Labor is hard work and women should not be judged for choosing to accept pain medication in labor. On the other hand, the reason doulas are usually concerned about pain medications is because they do carry some very serious risks, and a few doulas will refuse to work for a woman who thinks she will use an epidural. My personal belief is that women should reserve epidurals for very long labors (more than 24 hours hours), for induced labors (which are most painful), for complications that require bed rest during labor, and for the possibility that she will not be able to cope with the discomfort after trying all alternatives. Yet if my client decides she wants an epidural and she doesn’t fit into any of these categories, I will encourage her for making the right decision for her. One of the roles of a doula is to help the mother find non-pharmacological pain relief options, so she will probably seek to find a more natural method of helping you to relieve pain instead of jumping to the epidural first, but it doesn’t mean that she is anti-epidural. To learn whether or not the doulas in your area are against, for, or neutral on the issue of pain medications, the only thing to do is call them and ask!

6) Won’t my nurse give me emotional support? Most likely you will see your nurse much more than either your doctor or midwife, but again, the nurse could be responsible for several people, and her primary responsibility will be to monitor your baby’s and your health. In smaller hospitals, a nurse may be able to spend more time with her patients, and you may be lucky enough to be assigned to a nurse who supports natural childbirth, and has extensive knowledge about normal birth. Unfortunately, however, this is not something you can plan on because there is no way to know who is going to be on-call, or if there is any nurse available who prefers working with women who want a normal birth. If you arrive in labor and your nurse is rude and inconsiderate, you have the right to ask for a different nurse, but the best way to make sure you will have an experienced person to give you emotional and physical support is to hire a doula. And again, the same study I mentioned about labor support referred to nurses as well: the women who receive the greatest benefits of labor support (eg. fewer medical complications) are attended by a doula who is not a nurse working for the hospital. Most people who choose to be obstetrical nurses do so because they care for childbearing women and love to witness life coming into the world, but that doesn’t mean that you will be assigned a nurse who will give you the continuous, one-on-one emotional and physical support that you need.

7) I just don’t want an extra stranger at my birth. Birth is one of the few times in a woman’s life when she is extremely vulnerable and is unable to truly protect herself. In order to give birth, a woman needs to shut down the thinking side of her brain and go into what has been called, “Laborland”. Birth often or always involves the following: nudity, gas, poop and pee, amniotic fluid, multiple vaginal exams (sometimes by several different people), and not knowing who is going to come in the door next. Knowing who will attend your birth is probably a very important issue to you, as it should be. However, if you are planning a hospital birth, the only person you can count on being there, is your doula. If your doctor or midwife works in a practice with other careproviders, it is luck of the draw who will be on-call when you go into labor, and as I said before, you won’t know who your nurse is either. You could easily end up with complete strangers attending your birth, but if you hire a doula, she won’t be a stranger to you. Most doulas meet with their clients at least twice prior to birth, sometimes several times, so you can get to know each other, and so the doula can learn what is most important to you about your upcoming birth. You will talk on the phone, converse online, and she may even offer childbirth preparation classes for you to attend. As a doula, it is important to me that I develop a relationship with my clients prior to their birth, and except for two very fast labors, I have not missed one birth. Doulas focus on relationship because it is essential if the mother is going to feel comfortable having her there for her birth, and because the doula will know how to help her best if she has learned about the mother’s personal needs. By the time labor starts, your doula will be anything but a stranger.

Note: Part of having an extra person attend your birth is being comfortable with the idea of being vulnerable to that person. It is not unusual for me to have a potential client decide not to hire me out of concerns related to their modesty. And while I greatly respect their need for privacy, it may be helpful for you to know that most doulas understand that need (perhaps first hand if they’ve had children of their own) and make it a priority to protect their client’s modesty by keeping a sheet over them, making sure their gown is closed in the back if they are taking a walk down the hall, or keeping a towel wrapped around them as they step out of the shower. She will protect you by giving you more control over who sees you in your vulnerability.

8 ) I don’t need a birth doula if I’m having a home birth, right? Doulas are known for advocating a woman’s wishes to the hospital staff, and for trying to prevent uneccessary interventions, so if a woman chooses to give birth at home with a midwife who is all about whole-body care, is it worth hiring a doula? I would argue that if a doula doesn’t have to spend time advocating a mother’s wishes to her careproviders, she can spend more of her time on what matters most: supporting the mother. And while staying at home makes it much easier to keep birth normal, labor is still very hard work and the mother, father, and even the midwife will benefit from having a doula present. Because there are no shift changes, potentially long labors can wear out the only birth team a mother has at home, and therefore, midwives will appreciate the support of a good doula, who will enhance their own role and make it easier for the midwife to to do what she does best: to facilitate a normal birth experience. Just as a doula is not the same thing as a nurse-midwife, doulas are not the same thing as a home birth midwife. Instead they can work together to help make your hopes for birth comes true.

9) I’m planning a c-section, so why should I hire a doula if I won’t be laboring? One in three women give birth by cesarean section, some planned, some emergency, and some because the doctor thinks labor will go on too long. When a woman is attended by a doula and her labor ends with surgery, the doula’s role does not end. She helps the mother to come to terms with the situation, talks to her about the pros and cons of the decision, helps to calm her fears, explains how this will affect immediate postpartum care, and allows her time (if is is given by the staff) to process the change of plans before she is wheeled into the OR. If the father or other significant other does not or cannot be present for the delivery, the doula can go into the OR with the mother to support her through surgery. After the birth, the doula will meet the mother in the recovery room, praise her for her work, answer questions, take pictures if desired by the mother, and help to get her started with breastfeeding if she wishes to. If the c-section is planned, the doula will support her much the same way, by helping her to learn about cesareans ahead of time and how to make it a positive experience, encourage and reassure her, help her to get settled into her hospital room before surgery, attend the birth if the father can’t be there, and meet her in recovery. Although doulas are known for their expertise in pain-relief techniques during labor, their experience with birth can be a very reassuring asset to a woman who is nervous about her upcoming cesarean birth.

10) I’ve heard doctors don’t like doulas because they get in the way. It is true that some doctors do not like to have doulas attend their patient’s births, but that is only because he doesn’t understand the role of a doula, he has had a bad experience with a doula, or he has heard stories from other doctors. Sometimes doulas are more “natural childbirth activisits” than they are doulas, or perhaps they are a mix of both. If the doula is vocal to the nurse, doctor, or midwife and challenges their knowledge or decision-making, the careprovider will feel threatened and may ask the doula to leave the hospital right away. Most of the time that is not what happens, and a doula will politely ask questions, ask about alternatives, but most importantly they will encourage the mother and father to find their own voice and talk to their doctor about what is important to them. If you have met with your doula prior to birth, you will know if your doula is the type who will challenge the doctor, or if she is more concerned about being with you through till the end. Some women prefer a doula who will stick up for them, and some prefer their doula let them do their own talking. There is no wrong answer, but it would be a good idea to at least talk about the subject with your careprovider ahead of time. A lot of doctors and midwives really like to work with doulas, and they may even know the names of a few reputable ones in your area (I personally have had very good experience working with most obstetrical teams in my area). If you are not satisfied with your careprovider’s answer, it may be a sign that you are not compatible with each other and maybe it is time to start interviewing other doctors or midwives. In the end, please don’t let negative media attention taint your view of doulas. Just like there are “bad doctors”, “bad nurses”, or “bad midwives”, there are some doulas out there who should probably be looking for a different field. Yet most doulas’ first priority is to help keep things as smooth as possible, including the relationship between you and your doctor.

Why are doulas attending only 3% of births?

This is the second installment of my series on doulas, in honor of International Doula Month.

When I first read the results of the second Listening to Mothers Survey, I was disappointed (although not surprised) to learn that only 3% of the respondents hired doulas to attend their birth. Three percent is a small number for sure, but considering that the modern doula has only been in existence for 15-20 years, 3% actually represents a growing number of doula-attended births, and in the years to come I expect that number will continue to rise.

As I will soon explain, I believe there are two reasons why so few births are currently attended by doulas, in addition to the fact that doulas are a relatively new phenomenon. They are 1) many women have never heard of doulas, and 2) a larger number still have heard of doulas but do not fully understand their role.

Efforts have been made by organizations, like Doulas of North America, and grassroots movements promoting chilbirth options, natural childbirth, and more supportive childbirth care in general, to publicly recognize doulas. As you can see here, news reports about the benefits and use of doulas have been on the rise for several years, and it is now highly likely that a pregnant woman will encounter the word doula while reading a pregnancy or parenting magazine, while sitting in on her childbirth preparation class, chatting with friends in her mommy group, or while perusing blogs and forums. Efforts to spread the word about doulas are being rewarded as more and more women are hiring doulas to attend their births. But the work is far from over, as hearing about doulas is not enough for women to believe that they should hire one, which explains the following result from the Listening to Mother’s Survey II:

A few questions were asked of the women who chose not to hire a doula. How many had heard of doulas? 81% How many claimed to have a clear understanding of what doulas do? 61% Knowing that well over half of the women who did not hire a doula claimed to understand their role, but chose not to hire one anyway, and that 100% of those who did hire a doula were HIGHLY satisfied with their service, it makes me wonder, do people really understand what a doula is?

A couple years ago, I had an account with CafeMom, the social networking site, and while there I posted a poll to learn a little more about this question of mine. This of course was not a scientific poll, but I think it fairly accurately described the understanding of American women. My question to them was, “Do you want a doula at your next birth? The results were as follows:

  • 15% said yes
  • 50% said they didn’t think it would be helpful
  • 13% said maybe, if they knew more about it
  • 20% said, what’s a doula?

While women may happen to hear about doulas, the general public is for the most highly unaware of them. A male relative of a client of mine told me after she gave birth that he had thought a doula was a wet nurse. Thankfully I was able to enlighten him, but misunderstandings about the role of a doula still abound.

So what is a doula? The following are a few posts I’ve already written on the subject. They describe what a doula is, what a doula isn’t, and the many reasons why every woman should have one.

Only a small number of women hire doulas today, but that number is steadily growing, and the more we tell women about them, the more that number will grow. And the more women hire doulas, I believe we will see a greater increase in the number of normal births and in the percentage of women who are satisfied by their birthing experience. If you are pregnant or planning a pregnancy, I highy recommend that you call your local doula and ask questions, even if you don’t think a doula would be useful for you. And if you have used a doula and know how wonderful it is to have one, tell everyone you know! Pass your doula’s business card on to your family and friends, or consider becoming one yourself.

Do Birth Doulas Really Make a Difference?

This is the first of four special posts I will write this month in honor of International Doula Month. I’m not typically fond of staying up on all the months, weeks, or days of the year set aside to remember certain people or things or events. I’d rather remember them all year or when the occasion is called for. But when I learned May 1st that this month is all about doulas (and I am doula myself) I decided to set aside other posts I’ve been working on and focus on doulas. Each of these posts have been or will be a major undertaking, so I hope they are helpful to you. The topic of this week’s doula post is as above, do birth doulas really make a difference?

First of all, if you are not familiar with what a doula is, please read this post first, the rest of this post will make much more sense to you if you have a basic understanding of what a doula is and does.

Two years ago a midwife friend of mine attended a seminar where Nancy Wainer Cohen was speaking. She is the famous author of Silent Knife and Open Season. My friend told me Nancy boldly stated doulas are not making the difference so many claim they are. Naturally, I was quite surprised. As a doula, I was not willing to accept such a suggestion without investigating this claim myself. So I called Nancy, told her what I had heard and politely asked her for an explanation.

“Do you really not think doulas are changing the way women give birth?” I asked her. After learning my vocation she replied with a few questions of her own. “Have you convinced any of your clients to have a home birth? Have you managed to avoid unnecessary cesareans? Have you had to fight to protect women against interventions and lost?” Well, to be honest, she had me in a corner.

Yes, I have had trouble persuading women that home birth is a good option; yes, I’ve had my fair share of unnecessary cesareans and other interventions; and yes, I’ve even come home from the hospital crying because I felt like I couldn’t help my clients avoid them. Now I had to ask myself, do birth doulas really make a difference? I had to set aside my bias and really look at the situation. Are they actually changing the way women give birth like the studies say they are?

To be fair, we first have to recognize that only 3% of pregnant women choose to hire a doula, so the nation’s cesarean, induction, and epidural rates cannot be expected to drop due to a small number of women having doulas attend their births. But, if we look at the women who DO use a birth doula, we find that essentially 100% of them were satisfied with their doulas’ care (a percentage higher than that received by doctors, midwives, nurses, and even partners). As a side note, women who hire a doula generally rate their husband’s/boyfriend’s labor support better than those who do not hire a doula, as doulas support the partner as well as the mother in labor (Hofmeyer, et al. 1991; Wolman 1993).

When looking at the 3% of births that are currently attended by doulas in America, and asking the question, “do doulas make a difference?”, two obvious questions come into being: 1) What kind of difference are doulas expected to make? And 2) What do women want from doulas?

Q.1 The studies conducted on the effects of doulas at births refer to a reduction in common medical interventions as well as emotional and mental benefits to mother, fathers, and babies. They all conclude that every woman would benefit from the presence of a doula at their births because they will most likely report greater satisfaction from their birthing experience and because it may reduce their chances of having interventions, which often lead to complications. When I spoke to Nancy, she also referred to “the sought after difference” being births that are as natural and normal as possible, preferrably outside of the hospital, but at least a birth in which the mother is seen as the primary caregiver and intervention is kept to the absolute minimum. From this I can conclude that, generally speaking, when a person asks what difference does a doula make? They are probably asking how much a doula enhances the overall experience of giving birth, as well as how much a doula reduces complications from occuring or unwanted interventions from being used. We must also keep in mind, that what might be unacceptable intervention for one is fine in the mind of another, although research consistently concludes that keeping intervention to a minimum is best for all women. 

Q.2 While the first question can be answered mainly by research and statistical information, the second question cannot be answered so concretely. Because, as I stated above, what is a good birth experience for one may be an unhappy experience for another, and vise versa. Some women expect their doula to offer them emotional or informational support, but to leave the physical support to pain medications, while other women already know they want an intervention free birth and hire a doula to “protect them” from medical staff. Still other women plan an out-of-hospital birth and hire a doula to be an additional support person on their team of midwives. This question is more personal and is affected by the individuality of each pregnant woman. This is where Nancy’s expectation of a “good doula” varied slightly from my own idea. While I think it is essential for a doula to ensure her clients know about pros and cons to all their options (informational support), it is also essential for the doula to recognize that it is not her place to step between the birthing woman and the doctor, midwife or nurse. Confrontation is very rarely a necessary tool for the doula. Ideally, women giving birth learn their options prior to the onset of labor, and decide on a birthing location or care provider who will strongly support them in their personal goals for birth. When such a relationship is made, a confrontational doula is not necessary, and thus, the difference a doula makes in the birthing room should not be based on how many times the doula protected her client from an unwanted intervention, or just convinced them to give birth at home. The mother and father need to say yes or no themselves. Advocacy, where the doula reminds staff of a wish the client had, or politely, yet firmily, asks questions of the staff (in front of the cient) that may help the client understand the decision at hand, are appropriate. But telling the doctor or midwife what they should or should not do is not the role of a doula. In fact, many doctors and midwives greatly appreciate having a non-confrontational doula available for their clients’ births because it frees them up to take care of the medical aspects and yet know their clients are still being given one-on-one continuous supportive care. In conclusion, women hiring a doula should interview a few if possible, and hire one whose desires closely resemble their own (be they an intervention free birth or a home birth, or whatever), and one who will do what they want her to do. Perhaps a mother wants her doula to confront the doctor if necessary. While I don’t think that’s a great way of gaining the support of the doctor to approve her birth plan, at least the mother will be satisfied when the doula gave it her all. That is entirely between each mother and doula.

Here is the description of what a birth doula does, as given by DONA, the most highly recognized organization training birth doulas:

  • Recognizes birth as a key experience the mother will remember all her life
  • Understands the physiology of birth and the emotional needs of a woman in labor
  • Assists the woman in preparing for and carrying out her plans for birth
  • Stays with the woman throughout the labor
  • Provides emotional support, physical comfort measures and an objective viewpoint, as well as helping the woman get the information she needs to make informed decision
  • Facilitates communication between the laboring woman, her partner and her clinical care providers
  • Perceives her role as nurturing and protecting the woman’s memory of the birth experience
  • Allows the woman’s partner to participate at his/her comfort level
  • This leaves much room for individuality of both mothers and doulas, and still offers all the benefits described by research.

    Other studies and individuals supporting doulas

    “Continuous doula support reduced cesareans by 51%, forceps use by 57%, and the length of labor by more than one hour.” K.D. Scott et al, “A Comparison of Intermittent and Continuous Labor Support During Labor: A Meta-Analysis”, AJOG May 1999.

    “Asking your husband to be your sole guide through labor is like asking him to lead the way on a climb of Mt. Everest. He may be smart and trustworthy, you may love him, but in the Himalayas, you’d both be better off with a Sherpa!” Pam England, CNM, MA, author of Birthing From Within

    “The evidence is that the constant presence of a birth companion who is focused on your needs is one of the most effective forms of childbirth care introduced in the last 25 years.” Sheila Kitzinger, author of The Complete Book of Pregnancy and Childbirth

    A study in Houston (Kennell, et al, 1991) showed the following: Women who had no doula were in labor for an average of 9.4 hrs, 55% had an epidural, 43% had pit to augment, 18% had a c/sec, and 26% had forceps. Those who had an observing doula were in labor for an avg 8.4 hrs, 23% had an epidural, 32% were augmented with pit, 13% had a c/sec, and 21% forceps. Those who had an active doula were in labor for an average 7.4 hrs, 8% had an epi, 17% pit to aug, 8% c/sec, and 8% forceps.

    A special support person reduces the incidence of pain relief meds, operative vaginal delivery, a 5min apgar below 7, c/sec, negative ratings of birth by mother, her feelings of tension during labor, of finding labor worse than expected, less perineal trauma, less difficulty in mother, and of the early cessation of breastfeeding. The authors concluded that all women should receive continous labor support from specially trained care givers who offer hands on comfort, praise, and encouragement. Enkin, Keirse, Renfrew, and Neilson, authors of A Guide to Effective CAre in Pregnancy and Childbirth

    “Overworked nurses cannot provide continous support, and when the birth attendant is supposed to be an obstetrician, and there is likely to be no one around, a doula can be a godsend… Doulas walk a fine line between supporting and protecting a woman giving birth and offending the hospital staff. Good luck.” Marsden Wagner, MD. MS. author of Born in the USA

    Nancy suggested that a good doula is one who is willing to risk getting kicked out of the hospital in order to protect women from bad medical treatment, and while some hope to find a doula who will do this, I have heard from other mothers who regretted their doula remained cemented to the idea of natural childbirth when they personally were ready for an epidural. So while I admire her goal of saving women from difficult births, I must admit, I think doulas are making a difference in birthing trends, even if all they do is hold the mother’s hand while intervention is being administered. Honestly, admitting that is a hard pill for me to swallow because I want to stick up for normal, healthy births, and protect women from bad medical practices, but when it comes down to it, that is not the place of a doula. That is the place of being a childbirth educator, promoting awareness in the community, of being a natural birth activist, etc. all of which belong outside of the birthing room, helping women to see the dangers of overused technology before women give birth. Doulas make a difference in birth through their active participation in birth preparation, and in emotional and physical support during labor. This one-on-one continuous support by non-staff members of the clinic or hospital is what has resulted in reduced difficult births, even if they can’t prevent all difficult births from happening.

    Something to Think About #19 – Pitocin and Baby’s Heart Rate

    I found this quote in Midwifery Today’s E-News issue 10:15, from July 2008:

    Routine fetal heart rate (FHR) monitoring is a part of most hospital deliveries, in part to monitor the effect of oxytocin induction on babies. What is lacking is evaluation of excessive stimulation of the uterus that is often an effect of such induction. A small retrospective study of women who were electively induced evaluated the effects of oxytocin-induced uterine hyperstimulation on fetal oxygen saturation and FHR, using electronic fetal monitoring and oxygen saturation sensors.

    In all cases, the FHR patterns showed no problem, but when the researchers looked at contraction patterns, they identified oxygen desaturation of the babies occurring “within the first five minutes of excessive uterine activity,” and progressing before any problems can be identified by FHR.

    The researchers concluded not that oxytocin shouldn’t be used routinely in low-risk pregnancies, but that oxytocin use requires “closer surveillance and attention” from medical professionals.

    American Journal of Obstetrics and Gynecology 13 Mar 2008; [e-pub ahead of print], reported in Journal Watch Women’s Health June 19, 2008

    A bit ironic isn’t it? The baby’s heart rate is supposed to be our best determinent of his or her health, but we now know that the damage to their systems by induction often goes undetected for some time. This means that when the doctor orders “pit to distress” (the point when the heart rate shows the stress), you’re looking at an overly stressed out baby. Yet instead of suggesting that doctors save induction for when it is really needed, we just say we need to watch those heart rates more closely. Hmmm.

    My Top Ten for an Easier Birth

    When I teach a childbirth class, I prefer to do an all-day event so there is plenty of time for discussion, practicing techniques, and working on emotional aspects of giving birth. When I don’t have time (for example, an evening class), I focus on the most important things I feel will help women to have an easier birth. Here are my top ten for an easier birth:

    1) Choose your birth place and birth team very carefully. What should you look for?

    • Proven safety, and feeling of safety (do not disregard your intuition about a potential birth place or care provider)
    • Low intervention rates, implying more hands-on care and the promotion of normal birth
    • Takes the time to listen to your concerns and answer your questions with respect and interest
    • Has assisted women having your ideal birth (epidural, natural, water birth, vbac, etc.)

    2) Prepare for an easier birth, now!

    • Don’t watch A Baby Story! Instead (if you are interested in watching birth videos), watch movies like The Business of Being Born, Orgasmic Birth, Pregnant in America, Water Birth, Special Women, and normal birth videos on YouTube which represent birth as it usually is. TV specials on birth are designed and promoted to offer drama and attract viewers, not to support women preparing for birth.
    • Don’t read What to Expect When You’re Expecting. Nearly every woman I have spoke to said this book scared them more than it gave them confidence and reassurance. Instead read books like Ina May’s Guide to Childbirth by Ina May Gaskin and Creating Your Birth Plan by Marsden Wagner. Other good reads can be found on my lending library list.
    • Eat well, getting a variety of foods in your diet, focusing especially on protein, green veggies, water, limiting sugar and processed foods, and salting foods to taste.
    • Rest up, both for your current health, your energy level during birth, and for the late nights you’ll spend with your baby.
    • Exercise. This means pelvic rocking and tilts, kegals, tailor sitting, squats, walking, swimming, and similar activites.
    • Practice relaxation and visualization. Both of these are extremely helpful in having a tension free and easier birth. Hypnobabies is helpful for many in this respect.
    • Position baby well. The position of your baby prior to labor greatly influences how easy or difficult your birth will be.

    3) Have continuous labor support by a birth doula

    4) Do not get induced!

    • 40% of women are induced for lots of reasons, but it is only medically necessary in 5-10% of cases, for the following reasons: Pregnancy beyond 42 weeks, evidence of placental malfunction, baby small for age, preeclampsia, membranes ruptured beyond 4 days with no labor (less than that if there are signs of infection), true fetal distress confirmed by fetal scalp sampling or a biophysical profile.
    • Alternatives to medical induction are waiting it out or using natural methods.

    5) Stay home as long as you can

    • Staying home until contractions are consistently less than five minutes apart and distracting you from other activities helps to ensure that active labor has begun and you will not be sent home from the hospital for false labor. It also reduces your chances of having interventions used on you that may not be necessary.
    • In the meantime, rest, eat well, drink lots of fluid, visualize your birth going well, and carry on with normal life as much as possible.

    6) When you get to the birth place, stay active

    • Your pelvis is flexible, especially by the end of pregnancy, and staying active helps to ensure freedom of movement of your pelvis so that your baby can move down and be born easier. Staying upright and moving also helps labor to go more quickly and be less painful for you.
    • If you are restricted to bed, first make sure it is actually necessary, then ask for help in finding different positions to use in bed to keep baby moving and make labor easier for you.
    • Make sure to change positions frequently, drink and eat, and take breaks to rest, using upright positions which keep you fully supported.

    7) Avoid uncessary interventions

    • Do your homework on all possible interventions and ask questions anytime one is suggested to you!
    • Possible interventions which are common include: vaginal exams, electronic fetal monitoring, IV, rupture of membranes, pitocin, episiotomy, epidural or other pain meds, restriction to bed, restriction of food and drink, and cesarean section.
    • Interventions used which are not justified carry risks which do outweigh the benefits of using them. Unless there is very good reason (see articles linked above) to use them, you are likely to suffer consequences that could easily have been avoided by not using the interventions.

    8 ) Don’t push on your back

    • Remember your pelvis is flexible
    • Pushing on your back is rarely a good thing and unless baby needs extra help being born, carries multiple risks.
    • Ask about alternative pushing positions like hands and knees, squatting, sidelying, or standing.

    9) Keep your baby with you

    • Having your baby put on your chest after birth offers you and your baby multiple health benefits and is great for bonding.
    • All routine newborn exams and procedures done immediately after birth can be done on your abdomen or right beside you, unless your baby needs extra help starting to breath.

    10)  Remember, you were designed to give birth!

    • Even if you have had a difficult birth before, or know someone who has, your body was designed perfectly for birth. Sometimes things can make that more difficult, like a less than ideal diet, a pelvic injury, or interventions used in labor which made birth more difficult, but 90+% of women giving birth are able to have normal births if they are healthy and well supported during birth.
    • Labor is hard work, it may hurt, and you can do it. That’s the bottom line, everything else you learn is icing on the cake (statement adapted from Birthing From Within).


    -> A mother’s story of saving her baby from a heart attack by carrying her in a wrap. A MUST READ!

    Hospitals to crack down on induced labors

    Medical risks of epidurals

    Taye Diggs on Jimmy Kimmel talking about home birth

    Why Babies Should Not Sleep Alone

    Dr. Sear’s research on co-sleeping

    Merck admits Gardasil protects against basically nothing

    Benefits of a natural approach to the third stage of labor

    Pre and Perinatal Psychology video, part one

    Bishop Scores and what they mean

    The Labor Market, an article by TIME

    Breaking water does not speed labor

    Diagnosing Tongue-Tie

    An OBGYN’s thoughts on long labors

    It’s Okay to Grieve!

    When I became pregnant with my first child I knew exactly how I was going to give birth. He would be born at home, possibly in a birth tub, surrounded by my trusted midwives and my family. But it was not to be.

    Five weeks before my due date I developed mild hypertension, and I was having trouble raising my iron level. Although my liver was showing no signs of developing preeclampsia, my midwife was still very concerned, so at 38 weeks pregnant, I found myself having to decide what hospital I would birth at, and who would catch my baby. (More on my first birth story here)


    A lot of people think that stories like mine are no big deal. Most babies are born in the hospital anyway, right? Thankfully I still had a couple of weeks left to process what was happening, to mourn the loss of my ideal birth, and to decide what my next best choice would be, but many women are not that lucky.

    I recently had a conversation with a previous client of mine whose plans to have a water birth at home turned into a cesarean hospital birth during the course of her labor. She had no time to learn about cesareans, to decide who would help her to give birth, or to coem to terms with the change emotionally. And as predicted, well-intentioned family and friends made it sound like it was no big deal. Her baby was healthy, right? She recovered from the surgery right? It’s only birth after all, you have a whole life left of parenting!

    Comments like these not only prevent women from heailng from difficult births, they prolong the damage. When we pass off their births we make women feel guilty for not being able to “get over it” or “move on”. Telling a woman who had an unexpected cesarean, a home birth transfer, or a difficult vaginal birth that she should just be greatful for her baby is the equivalent of telling her she is mentally unhealthy and a bad mom to boot.

     Of course, comments like these come from well-meaning people, they just don’t know what else to say. So here’s a message for you, if you know someone who lost something at their birth, or if you are that women: It’s okay to grieve! Cry, yell, cuss, complain, speak against it, write or draw out your thoughts and feelings, tell someone who will listen to you. They can’t fix it, but it needs to be acknowledged that birth is important to women and babies.

    Although not so for some women, the majority feel that birth is one of the deepest and most meaningful expressions of their femininity. Having one’s baby cut from their womb, or pulled from out of them (whether necessary or not) leaves them feeling incomplete and wounded. These are normal feelings not to be ignored, surpressed, or underestimated. This rite of passage called birth must be acknowledged for what it is: a highly physical, emotional, spiritual, and yes, sexual event.

    You cannot move on or be truly greatful until you have allowed yourself to admit and mourn the loss of your birth. And healing will come. That birth experience will never be better, but you will no longer feel guilty for admitting that.

    And perhaps if you have another child your next birth will go differently. After my son was born I went through a lot of emotional work so that my next pregnancy and birth would be different. I am proud of myself for that, and my daughter was born at home as planned.


    Please read this woman’s story about healing from a difficult birth.  She describes it much better than I ever could.