| |
October 2000
Volume 64 |
Number 10
|
| |
|
| Doulas - Who Are
They and How Might They Affect Obstetrical Anesthesia Practices? |
William Camann, M.D.
Childbirth.
It is one of the most important events in the life of a family
and an experience that most women will remember and, hopefully,
treasure for the rest of their lives. A pleasant birth experience
can facilitate the creation of a strong bond between parents and
infants. These powerful emotional ties should have lasting positive
effects on individual families and society as a whole. For centuries,
the concept of emotional support for women, by women, during labor
has been accepted practice. It is only in recent decades that
fathers have taken an active role in the birth process; women
have traditionally given birth in the presence of other women.
Artistic and literary descriptions of birth from ancient and primitive
cultures usually depict other women acting in support of the parturient.
The modern doula is a manifestation of this support person.
What is a doula? A doula is a woman experienced
and professionally trained in labor support. Doulas are usually
of lay background, but often have worked as labor nurses, as childbirth
educators or in other obstetric areas. They provide the parturient
with praise, reassurance, comfort measures and companionship.
The word "doula" is derived from the Greek for woman
servant. Doulas are to be distinguished from labor nurses in that
they perform no clinical tasks nor do they assist with traditional
nursing functions. Doulas are also to be distinguished from midwives
or obstetricians, as they perform no medical tasks nor do they
assist in the actual physical act of the birth.
The role of the doula is to provide emotional
support, companionship, physical comfort measures and encouragement
during labor and delivery. She also supports and guides simultaneously;
midwives and obstetricians are generally not in constant attendance
with the laboring woman, and even the women's partner despite
love, devotion, childbirth education classes and best intentions
may be of only limited (but certainly not unimportant) help during
the actual labor. In fact, one recent randomized trial of hospital-based
doulas found that over half the women rated the doula as more
useful than their husband during labor.1
Doulas are readily available and becoming
more popular. The Doulas of North America Web site www.dona.org
provides much information, including links to hundreds of doula
agencies and individual doulas in most locales around the country.
Some hospitals provide access to doula care, although most are
arranged by private contract. Fees are variable, often negotiable
and range from nominal to up to $1,500 per labor (the latter being
largely in affluent metropolitan areas).
In what manner will obstetric anesthesiologists
interact with doulas? Frequently, the interaction will be minimal
or nonexistent, as many doulas are strongly committed to nonpharmacologic
methods of pain control, and many patients who seek doula support
are equally committed to attempting a medication-free labor. Nonetheless,
an increasing recognition of the importance of emotional support
during labor, combined with the ever-increasing popularity (and
safety) of modern regional analgesic techniques for labor, has
resulted in some women requesting doula support even with the
intention of receiving regional analgesia in labor.
While some doulas will limit their client
base to those women who only desire to labor without medications,
it is not the role of the doula to make this decision for the
woman. Excerpts from the Doulas of North America Code of Ethics
and Standards of Practice include: Doulas do not offer second
opinions or give medical advice. Doulas do not make decisions
for their clients; they do not project their own values and goals
onto the laboring woman. The doula's goal is to help the woman
have a safe and satisfying childbirth as the woman defines it
[author's emphasis]. Many women choose or need pharmacological
pain relief. It is not the role of the doula to discourage the
mother from her choices. The comfort and reassurance offered by
the doula are beneficial regardless of the use of pain medication.2
Some obstetric anesthesiologists are of
the belief that doulas will exert undue pressure on women to avoid
epidural analgesia. There is reason to believe this to be true.
The DONA Web site reports that meta-analyses of randomized controlled
trials find that doula use is associated with fewer requests for
epidural analgesia. 3 However, some
individual studies have not found this to be true. One recent
randomized study claimed that doula use was associate with less
overall requests for epidurals, yet closer examination of the
data reveals that this finding was barely statistically significant.1
Furthermore, it was only true in two of the three hospitals where
the study was conducted, the third site having actually more requests
for epidurals in the patients with doulas. Nonetheless, other
studies do support less frequent requests for epidurals in women
with doula support and also less need for operative delivery and
oxytocin use. 4
Are doulas necessary if a patient receives
an epidural? Relief of pain does not obviate all emotional distress
and anxiety during labor. Concerns about welfare of the neonate,
length of labor, fear of the return of pain, fear and anticipation
of the approaching second stage of labor, fear of alterations
in body image and loss of dignity during childbirth, among many
others, are all valid sources of anxiety even in the presence
of a well-functioning epidural analgesic. Support and reassurance,
as professionally provided by a doula, can be invaluable to some
women in these circumstances.5
There will be instances where a woman and
doula, both staunchly committed by prior agreement to achieve
natural childbirth, will find that epidural analgesia or operative
delivery is requested or suggested owing to a variety of unpredictable
circumstances during labor. Disappointment may prevail, as both
mother and doula may sense a feeling of failure in their respective
roles. It is here, in my opinion, that the mature doula can have
a great impact. Reassurance that not all labors unfold as planned,
that mother and baby are safe and reminders of the good intentions
of relevant medical care providers is paramount at these times.
Anything less would be a disservice to the parturient.
It is for precisely these circumstances
that, in my opinion, all doulas should have experience with regional
analgesia as part of their certification process. Even the most
ardent proponent of natural childbirth will be a better doula
to all her patients, both with and without epidurals, if reasonable
exposure to and knowledge of modern-day obstetric anesthesia techniques
is obtained. Exposure to new and innovative techniques of regional
anesthesia, such as combined spinal-epidural analgesia, patient-controlled
epidural analgesia, walking epidurals and ultra-low-dose epidural
infusions, should be an absolute minimum. Most importantly, doulas
must recognize which patients may, for medical or anatomical (e.g.,
airway) reasons, present anesthesiologists with particular challenges
in the event of general anesthesia. In such patients, the relative
risks and benefits of having versus not having an epidural need
to be considered carefully and discussed with the patient and
the primary obstetric care provider.
This dialogue must be a two-way street.
Just as doulas must acknowledge that not all obstetric anesthesiologists
are the enemy,www.dona.org/positionpapers.html"
so must obstetric anesthesiologists acknowledge that not all doulas
are created simply to talk their patients out of receiving epidural
analgesia. We must be aware of and acknowledge the tremendous
life-event that childbirth is and should be. We must be aware
of the centuries-old tradition and importance of emotional support
in labor. Relief of pain and emotional support and reassurance
are both important contributors to a positive birth experience.
Not every woman in labor wants or needs a doula, but neither does
every woman want or need a regional analgesic. Nonetheless, we,
and all our doula colleagues, must agree that doula support and
regional analgesia in labor are entirely compatible and complementary
adjuncts to a safe and satisfying birth.
The author would like to thank Penny Simkin,
one of the founders of DONA, and Debra Brewster, a past president
of DONA, for valuable assistance with the preparation of this
article.
References:
1. Gordon NP, Walton D, McAdam E, et al. Effects
of providing hospital-based doulas in health maintenance organization
hospitals. Obstet Gynecol. 1999; 93:422-426.
2. Doulas of North America Web site. Available
at . Accessed September 22, 1999.
3. Hodnett ED. Caregiver Support for Women During
Childbirth. Oxford, England: Conchrane Library; May 17, 1999.
4. Zhang J, Bernasko JW, Leybovich E, et al. Continuous
labor support from labor attendants for primiparous women: A meta-analysis.
Obstet Gynecol. 1996; 88:739-744.
5. Simkin P. The doula and the epidural. Childbirth
Instructor Magazine. 1996; 6:34-35.
| |
|
William
Camann, M.D., is Director of Obstetric Anesthesia, Brigham
Women's Hospital, and Associate Professor of Anesthesia, Harvard
Medical School, Boston, Massachusetts. |
|
return to top
|