[MamaMandaJ]

I am a Doula-in-training, attending my 3rd hospital birth. The mom wants to have a epidural-free birth, and would like to deliver in any position that feels right to her. Her OB has told her that she MUST deliver lying in bed, and is very pro-epi.

The mom has asked that I act as an advocate on her behalf in these matters, which I'm not exactly sure how to go about doing.

Can an OB ever dictate what position a mom delivers in? I'm thinking no...but I've has 3 homebirths and was able to do whatever I wanted, when I wanted it. The other 2 hospital births I attended had OB's that weren't even in the room until the baby was crowning, and one mom was already in the bed.

Can anyone shed some light on this for me, and maybe advise how much I should say or do on the Mom's behalf? I don't want a tense situation in the delivery room, but I want to do all I can for the mom.

 

[TO Doula]

Quote:

Originally Posted by MamaMandaJ I am a Doula-in-training, attending my 3rd hospital birth. The mom wants to have a epidural-free birth, and would like to deliver in any position that feels right to her. Her OB has told her that she MUST deliver lying in bed, and is very pro-epi. The mom has asked that I act as an advocate on her behalf in these matters, which I'm not exactly sure how to go about doing. Can an OB ever dictate what position a mom delivers in? I'm thinking no...but I've has 3 homebirths and was able to do whatever I wanted, when I wanted it. The other 2 hospital births I attended had OB's that weren't even in the room until the baby was crowning, and one mom was already in the bed. Can anyone shed some light on this for me, and maybe advise how much I should say or do on the Mom's behalf? I don't want a tense situation in the delivery room, but I want to do all I can for the mom.

This is a toughie. IME, the ob has a lot of say. I've had a woman in hands-and-knees and the ob came in and announced firmly that she could *not* deliver her in that position, that she had to turn over, and then had the nurse (and eventually me, to my shame) physically turning the woman over, practically mid-push.

The nurses also know what the ob on shift expect/wants. I almost never see a bed broken down, but I have seen it done before the ob even got in the room when the nurses knew that those were the standing orders.

If the ob doesn't get there until the baby's crowning, then the s/he may be forced to just catch. Earlier than that, though, and they can be pretty forceful at getting the position they want if they're so inclined. Nurses too, for that matter. (If you haven't seen a bullying nurse yet, just wait for it.)

Your client's putting you in an awkward place. She needs to understand that you cannot fight with her doctor. I usually tell my clients that I cannot speak to the doctor on their behalf, but I can help them do their own speaking. Suggest she keep talking to her doctor, encourage her to write a birth plan, and if she can convince the doc to initial it, so much the better.

The birth plan gives you the opportunity to remind your clients of what they said they wanted, and makes it more possible for you to speak directly to the staff about what they want. If you can forge a good relationship with the nurse during the labour that can help a huge amount, too. Get *her* advocating on your client's behalf and you'll be well on your way to helping your client get the birth she wants.

Another thought: if it's really going to be a battle, talk with your client about whether there are compromises that would be acceptable to her. For instance, if she wants to squat, show her how she can squat on the bed with support people on either side to hang on to. I've yet to see an ob who was willing to sit on the floor, but if you can help a woman do h&k, squatting etc on the bed, you have a chance of meeting both party's needs.

 

[TzippityDoulah]

how should it be? well it SHOULD be that the OB doesn't decide and the mom gets to decide...

realistically it doesn't work that way.

if an OB is set agianst it, it just wont happen. and she could be seen as combative if she tries it. and really? during birth is NO time to pick a fight. she needs her energy to birth, not to fight a battle about what position.

if she is that set on birthing in another position she needs to find a providor that will accomodate that. I can't stress enough - the birthing room should never be used as a the time or place to argue these things out. if it can't be settled on BEFORE the birth, she should look elsewhere.

secondly, as a doula you can only help her make these decisions... it isn't your place to try to get the OB to let her do it. that puts you in a VERY unfair place. not only is it unfair, it's unrealistic. there is no way an OB will listen to a doula about such a thing if they are set on it - likely it would only aggrivate the OB and cause more tension in the birthing room. and your client would feel let down by you.

bottom line, she needs to be working towards getting what she needs. it sounds like she has a misunderstanding about the role of a doula in the hospital birth setting. it seems she expects a lot out of you that you can't promise her and i would consider being upfront about it with her. maybe she needs ot better understand what your role is or can be for her... and what it can't be.

 

[MsBlack]

A doula simply cannot be the advocate this mom is looking for. There are many things you can say during labor to help the parents advocate for themselves--reminders you can make, questions to ask 'as a reminder'--such as "we discussed your birthing in a hands and knees position, is this still something you want to try?" You can explain medical or hospital policy stuff that they might not understand, to aid in their decision making. But you cannot sound off FOR them. Only a woman and her partner is allowed this role, and I think that is for the best since it is their birth and their power to choose that is at stake.

That said, I also agree that this OB sounds like one who will not be amenable to any changes. Now the parents know that he is both pro-epi, and unwilling to catch babies in any 'alternate' position. If they are not happy with this, then rather than wasting time arguing they should be looking for a provider whose thoughts on birth are more in line with their own. It would certainly SEEM that a hired helper like an OB should be willing to serve as parents wish (at least within the scope of the OB's protocols and knowledge), but this is very rarely the case.

Further, it would be a fatal mistake to underestimate the degree of power over patients that med providers, and med institutions on the whole, are willing to exert over their clients. As TO doula points out, even she was harangued into helping exert force over a laboring patient, against her wishes and her beliefs. This is NOT AT ALL UNCOMMON for OBs and hospitals--doctors will shout at laboring women, make threats, use physical force and/or order nurses to exert physical force. YOU, as a doula, do NOT want to be put into this position. SHE as a future laboring woman, should not be going into this with eyes closed to these awful possibilities.

I can only say again--if this doc does not already practice the way the mom prefers, then she needs to find another doc--or resign herself to doing birth HIS way, for her own peace of mind. And your client needs to understand that you simply cannot be the advocate she is asking for.

 

[MidwifeErika]

The truth is that she doesn't sound like she wants to really be responsible for her choices. I know that sounds harsh, but she is the one who gets the choose the doctor. A doula cannot save people from their own poor choices in care providers. A big part of a doula role is to point out when this just isn't going to work and then the mom needs to find a care provider who will be a better fit. It is like if a client is going to a dr with a 95% c-section rate and then figures that if she hires a doula then she will magically get the vaginal birth she wants.... it is not going to happen.

It is a rotten thing to go into a birth feeling like you need to fight. It isn't a fair position for you to be in and it isn't going to turn out the way she wants either. No one needs to have tension and argument at the time of birth. And during transition women are very open to suggestions too, even if they don't want to be. So, it is likely she will go along with what the doctor says and then be upset about it later that you didn't fight for her and what she wanted. Not at all a good situation to be in.

 

[mysticmomma]

She needs a different care provider.

 

[TO Doula]

Quote:

Originally Posted by hotwings640 The truth is that she doesn't sound like she wants to really be responsible for her choices. I know that sounds harsh, but she is the one who gets the choose the doctor. A doula cannot save people from their own poor choices in care providers. A big part of a doula role is to point out when this just isn't going to work and then the mom needs to find a care provider who will be a better fit. It is like if a client is going to a dr with a 95% c-section rate and then figures that if she hires a doula then she will magically get the vaginal birth she wants.... it is not going to happen.

Keep in mind that not everyone has choices. Around here obs work in group practices and you get whoever is on call. I think we also need to help our clients understand how to work with what you've got.

 

[MidwifeErika]

Quote:

Originally Posted by TO Doula Keep in mind that not everyone has choices. Around here obs work in group practices and you get whoever is on call. I think we also need to help our clients understand how to work with what you've got.

Yes, this is true, but this sounds like a situation where it isn't the ob on call who is the problem, but the one the client has chosen to be her ob. So she has a clear indication already that things will not go the way she wants and so now would be an excellent time to explore her options more thoroughly.

 

[mandib50]

from what i've seen here, what the doctor says goes

 

[kltroy]

I'm not a birth professional but I think this mom is asking you to do something that is not in your job description. She needs to have a frank talk with her doctor ahead of time about what her expectations are. And then she needs to assign someone like her spouse/partner who actually CAN make medical decisions and speak on her behalf to do the in-hospital advocating.

You can remind her and her family about her wishes, as in, "The doctor just said she was going to do X, but you told me last week you didn't want this. Do you and your husband want to discuss this before going ahead with it?"

Sounds to me like she would do best switching providers, but depending on how soon the birth is, this may not be possible. The other option is for her to show up in the hospital and take the on-call doctor (this is actually what I ended up doing for my VBAC).

 

[mamato3cherubs]

Laura and MsBlack have both already said it so well. I also agree that in order for her to take charge and get the birth she wants, she will need to take charge and the responsibility to find a care provider that will help her to get the birth she wants. If she is not willing ot do that, there isnt a whole lot more you can do beyond you're normal doula service for her.

TO Doula- Lets hope she is not in that situation. It is systems like that that would have me running. Id rather give birth in a barn than take "who ever is on call" from a whole group of OBs I dont know. How hard.

 

[angelapittman]

Quote:

Originally Posted by mandib50 from what i've seen here, what the doctor says goes

:

This makes me mad. I would hope the laboring woman who has HIRED an ob would get to do as she wants. It's not hurting anything, and where exactly do doctors get the idea that they can FORCE that on a woman? Seriously, where did you sign saying you agree to whatever the doctor wants? If they tried to force me out of my best position for me, I would threaten to sue anyone that touched me!

 

[klocke]

Quote:

Originally Posted by angelapittman : This makes me mad. I would hope the laboring woman who has HIRED an ob would get to do as she wants. It's not hurting anything, and where exactly do doctors get the idea that they can FORCE that on a woman? Seriously, where did you sign saying you agree to whatever the doctor wants? If they tried to force me out of my best position for me, I would threaten to sue anyone that touched me!

Unfortunately most hospitals do make you sign a paper as part of your registration process that gives them (and their Dr's) full permission to do as the please and gives them the right to make medical decisions without having to ask consent in the moment. It is a standard intake form and I'm sure most moms sign it without even noticing. And most hospital make you sign it if you plan on delivering at their hospital.

 

[MamaMandaJ]

Quote:

Originally Posted by TO Doula Your client's putting you in an awkward place. She needs to understand that you cannot fight with her doctor. I usually tell my clients that I cannot speak to the doctor on their behalf, but I can help them do their own speaking. Suggest she keep talking to her doctor, encourage her to write a birth plan, and if she can convince the doc to initial it, so much the better.

I agree. I've told her I will not "fight," and that that is not something she wants happening in her birth room. I've encouraged her to write a birth plan, (she's working on it...she 'didn't know you could do such a thing.' ?!?!) and suggested she get the doctor to initial it. I'm afraid it won't happen tho.

Quote:

Originally Posted by hotwings640 The truth is that she doesn't sound like she wants to really be responsible for her choices.

TRUE.
She is a self-proclaimed "push-over" and really just doesn't want to be bold enough to put her foot down with her doctor. (her words) She is also 3 weeks away from her due date, and is scared and not motivated enough to search for another DR that may be more willing to work with her. So, I'm afraid she will have to get what she gets. ):

Quote:

Originally Posted by TO Doula Another thought: if it's really going to be a battle, talk with your client about whether there are compromises that would be acceptable to her. For instance, if she wants to squat, show her how she can squat on the bed with support people on either side to hang on to. I've yet to see an ob who was willing to sit on the floor, but if you can help a woman do h&k, squatting etc on the bed, you have a chance of meeting both party's needs.

We have discussed this also, and she is willing to try these alternatives, but is pretty sure the Dr won't allow it. We'll see.

Quote:

Originally Posted by angelapittman If they tried to force me out of my best position for me, I would threaten to sue anyone that touched me!

DITTO!

:

Unfortunately, this is really a case of a Mom suddenly trying to educate herself weeks before her due date. I am working hard with her to answer questions and suggest reading materials and other resources; but I fear that the choice of OB was not well thought out beforehand, and that it will have a big impact on what she now wants at her birth.

 

[TO Doula]

Quote:

Originally Posted by mamato3cherubs TO Doula- Lets hope she is not in that situation. It is systems like that that would have me running. Id rather give birth in a barn than take "who ever is on call" from a whole group of OBs I dont know. How hard.

Oh, it's incredibly frustrating. OBs and midwives are in such short supply that women wind up just taking what/who they can get. There is no such thing as interviewing care providers any more.

 

[clovergirl33]

FWIW -- I work at a relatively liberal L&D -- the best in this area as far as allowing choice for birthing. We have a group of midwives that deliver, as well as many MD's. I have been there almost a year now and have never seen anyone deliver in any position but on her back. The most deviation I have seen is a slight tilt to the side (although I have been yelled at by a provider for having a patient pushing on her side, even though the baby was OP and she had been pushing for 3 hours with no progress -- the only chance she had was if the baby turned, which I was trying to facilitate by changing position as much as possible with the epidural). Our midwives are more open to what patients want to try, and I have seen them do some pushing in hands and knees, but ultimately everyone has wound up delivering laying down. None of our MD's would even consider anything anything else.

Like the PPs said, if her provider already said no, it ain't gonna happen. They will move her. And, honestly, he really has no idea how to catch a baby in an alternate position anyway, so safety might be a concern. Probably the staff will push an epidural on her anyway, then it won't even be an issue.

Good luck...

Cindi

 

[MamaMandaJ]

Quote:

Originally Posted by clovergirl33 I have been there almost a year now and have never seen anyone deliver in any position but on her back. Like the PPs said, if her provider already said no, it ain't gonna happen. They will move her. And, honestly, he really has no idea how to catch a baby in an alternate position anyway, so safety might be a concern. Probably the staff will push an epidural on her anyway, then it won't even be an issue.

Why is this? They DO know that different positions can help aid in a difficult delivery and keep intervention to a minimum, right? It seems like such an easy option to spare mom and baby from stressful situations that require longer recovery periods, bonding/breastfeeding interruption, etc. Makes me very sad/mad.

 

[1littlebit]

I was in a similar position as your patient and i told them (OB and midwife) what i wanted, wrote a birth plan, etc. basically they smiled and nodded and then told me i had to have a section the week before me EDD. if the doctor isnt obviously supportive she should find a new one. you can only do so much and if alt. birthing positions aren't aa patients right then there isnt much you can do yk?

 

[paintedbison]

Quote:

Originally Posted by MamaMandaJ Why is this? They DO know that different positions can help aid in a difficult delivery and keep intervention to a minimum, right? It seems like such an easy option to spare mom and baby from stressful situations that require longer recovery periods, bonding/breastfeeding interruption, etc. Makes me very sad/mad.

Yes... but who is trying to avoid intervention? Intervention makes the big bucks. Why get mom into a more comfortable position when you can use modern medicine instead?

 

[MamaMandaJ]

Quote:

Originally Posted by paintedbison Yes... but who is trying to avoid intervention? Intervention makes the big bucks. Why get mom into a more comfortable position when you can use modern medicine instead?