A Labor Support Doula’s Story

By Susan Clement Cohen, CD (DONA)
Director, HeartSong Doula Care

I’ve appreciated the conversation here about undirected pushing, and want to share a specific experience as I continue to hold this question.

Last night a couple gave birth in a very strong and beautiful way.

They had worked at home for 36+ hours with a gentle labor. The first night she was awakened by mild contractions, suspected she was in labor, and went back to sleep. This was enormous on her part, her ability to return to sleep — a sort of keynote to what followed. They drifted through the next day as contractions very slowly deepened. She had all the time she needed to gradually adjust her management of them, finding positions that helped, his touch on her back, many small meals that she was hungry for. We were in touch by phone periodically, always her making the call, never him. It was my sense that she had taken ownership of the labor. She’d report what was happening (“pretty much the same, maybe a little stronger”). Her voice was always matter-of-fact, as if we were working on a grocery list. She really didn’t seem to need information about what would come next.

That night they slept only off and on, usually waking during contractions every 5-10 minutes. They didn’t report this as being difficult. The second day she was having to work more actively to manage contractions. Mid-day they spent a few hours in the pool and then took a very long shower. Still eating, still calm and centered in the midst of her not-knowing the time frame to come or when to move to the hospital.

At 3:30pm her voice over the phone had a tinge of restlessness, feeling out the idea of going to the hospital. She decided to live with the question for another hour and by then it was clear to her it was time. She arrived at 5:15 at 6 cm., went to 9 cm in 45 minutes and began pushing in another 45 minutes. Their son was born 45 minutes after that.

Most of my phone role was to tell her how beautifully her body was working. I’d ask her what was happening and what was helping and what was she thinking and say How wonderful that you could listen to that. Look how far you’ve come! Everything is working so well. What a gentle labor! On the second day I offered to come to the house if they wanted (they didn’t). Another crucial piece here is that she didn’t report in to her OB during any of this. (I’m looking forward to hearing more about this at the follow-up visit — what was going through her head not to make that call.) The medical chatter would likely have been: let’s get you in so we can see what’s going on, and the subtext: you don’t know what’s going on, you can’t do this alone, it’s dangerous, this is taking too long, we need to get things moving. Active management would likely have replaced patience.

At the hospital she became a patient and lost, for a while, her claim on managing labor. No longer free to let her body find the position it wanted, she needed help with pain: pressing my fist into her lower back, my talking her through contractions (how right and safe the sensations were, you’re doing it, stay with it, let your breath help you), guided visualization (variously, about opening, softening to it, about falling into the center of the pain, also flying up over the pain). Staff allowed her out of bed after the 20-minute monitoring. She got herself back for awhile in the shower, him touching her back, head, talking to her, me with the shower on her back, her finding that she needed to squat/kneel/sit on the floor. The lights were off, with the bathroom door open just a crack for very low light — an amazing peaceful interval where she was in full charge again, motionless, silent. We knew she was having contractions only because her breathing changed.

There’s a footnote to this birth, disheartening and, at the same time, an opportunity. When staff needed her in bed for pushing (bright lights, stranded beetle position), she became a patient again, asking “how do I do it? was that all right? will you tell me when?” — questions that had never surfaced the two days and nights when they were on their own. I asked staff if they ever went with natural pushing. I reminded her softly that natural pushing was another way, that her body knew exactly what to do, that her trusting it had brought her this far, etc. Staff continued to offer step-by-step instructions, which she earnestly followed.

I’m convinced this kind of direction for a person like her is unnecessary and that it hijacks something from her experience. The offer of instruction delivers the message that she doesn’t have the knowledge in her and comes at precisely the moment she needs reminding that she already has everything she needs. As her doula, I’m committed to preserving her positive birth memory and can only take this up with her in the gentlest of ways (probably indirect) at the follow-up visit. There’s nothing to be gained for her by bringing her to reflect negatively on what was an exhilarating moment in her life. [Vicki and Julie, this circles into your question about the frustration of trying activate clients after the fact.]

I continue to struggle with the question of what our role is with this over the long run — perhaps a different kind of prenatal preparation with couples, certainly staff education and growing our relationship with them. We need to be clear in our own minds that they are not the enemy — rather, we face together (with different levels of awareness) a custom intended to support medicated women (who aren’t getting full kinesthetic feedback from their bodies) inappropriately extended to women who are fully in touch with their birthing bodies. When we see natural pushing at a birth, we need to tell the story of it to pregnant couples. I hope we can keep talking with each other about our own experiences with and thoughts about this part of doula care. I invite us to join hands in our belief that there’s room in hospitals for another way.