Defensive Doula

You often hear about "defensive medicine." Providers who at the very least, chart every possible interaction and occurance with their patients so they are somewhat protected if the patient later sues for a bad outcome. At worst, providers use an intervention just to say they did something, which is thought to be better than doing nothing. Lately I feel like I've been practicing defensive doulaing.

I've begun to feel like, when I attend a hospital birth, the doctors and staff very much assume that my client will have an epidural, pitocin, and very possibly a cesarean. They are justified in the assumption: at one local hospital, 90% of women have an epidural, adn 36% have cesareans. When 90% of your patients have an extremely abnormal birth, abnormality becomes the new paradigm. The staff at the hospital with the highest epidural rate is clearly uncomfortable with normal birth. All the moaning, all the pesky position changes, the sheer duration of a normal birth. They are uncomfortable with women in pain, women who are tired, women who need emotional interaction and support. They are so used to an immobilized, chatty, TV watching laboring mom that when my sweaty, moaning, vomiting and shaking, hip rocking, crying, squatting, normal birthing mom is in the room they feel they must DO something. And what do they know how to do? For a while they might sit next to a bed (where many women assume they must stay during labor, or are stuck with a routine IV and fetal monitors) and tell a woman to "just relax, breath it out." But, they have other things to do, and I really get the feeling that many of them think the idea of unmedicated birth is just heinous, an unnecessary cruelty. And if you offer a woman in that much pain an epidural, they have an awfully hard time saying no.

Anyway, lately I've been feeling like I need to prepare my clients, really, really prepare them, to defend themselves from the new normal. Wait to go to the hospital until the last possible moment in labor. To say no (repeatedly, confidently, and assertively) to pretty much everything the staff tells them they 'have' to do. To close their ears to the innumerable discouraging comments, and to close their legs to the innumerable, discouraging, and pointless-unless-you're-in-a-hurry vaginal exams. I've even resorted to encouraging the use of very defensive, almost legal language in birth plans, to put the fear of god and litigation into the staff. "I DO NOT CONSENT to any cesarean that is not an emergency." Telling patients they might want to cross out the section of the admitting paperwork where they sign a general consent for a cesarean. This is not stuff that encourages the team spirit, mutual respect, and collegial vibe that I have always worked for in my relationships with staff.

Although I'm not happy about these ways in which I've changed my practice, I'm not ashamed of them. There are changes, however, that I am more worried about. These are where I am truly taking on a practice similar to defensive medicine: I'm doing something (something I don't even believe in) just to do something, to change my clients behavior because I can't change the providers' behavior. I'm ashamed to admit that I've used directed, purple pushing with unmedicated moms, because I know we have 3 hours to get the baby out before the staff start to move for a cesarean or if we're lucky, a vacuum. An unmedicated mom with a good urge to push may take 4-5 hours to push her baby out, both mom and babe are perfectly healthy, and she pushes when and how she feels she needs to. Lately I've told moms that they're better off to flat out lie to staff about their pain, frustration, or fatigue. Of course the mom is tired. That is NOT a valid reason for major abdominal surgery. Even worse, telling women you think they are too tired to push at all, before they even try, and before they have said boo about being tired. I feel terrible encouraging my women to change their normal birth to save them from an abnormal birth. Wait forever to go to the hospital so that you have to practically crawl down the hall in transition. Furitively sneak gulps of apple juice when the nurse is out of the room. Outright deny your perfectly normal feelings of fatigue, frustration, uncertainty. Lie when they ask you to put your (level unspeakable) pain on a 1-10 scale and say it's not too, too bad, maybe a 7. Lie and say you aren't at all tired when it's time to push, say you have all the energy in the world. Because the staff has 0 faith in women's ability to give birth, they latch onto the slightest indication that she too is doubtful, and exploit it to push intervention.

All of this bugs me on the obvious level that it is unjust for the laboring woman. But it bugs me in a more insideous way too. Because I am not a rule breaker. I am a rule maker, a rule follower, a research and science and fact junkie. I'm the kid who cried when I was even mildly scolded for breaking a rule. I'm not one of those fanatical, radical, 'use nothing but your intuition to make decisions about your birth' people. I believe firmly that there is a time and a place for everything, including epidurals, pitocin, and cesarean birth. I believe that we should base medical recommendations on good research, and that clients should base their decisions on solid, honest information about the recommendation, the alternatives, and the risks and benefits of each. It bothers me that sometimes I hear myself talk about birth, and I hear the voice of a frustrated fanatic, not the logical, down to earth, pragmatic person I am. Of course it bothers me that believing a woman in labor has the right to full informed decision making makes me sound radical.

Moreover, I have to walk a very fine ethical line between my scope of practice and standards of care as a doula, and doing what the situation demands to defend my clients from ridiculous hospital policies and bad provider attitudes. It's hard on my self image; it's hard on me emotionally to go to births where I feel like the woman is truly treated unjustly, and it's hard on me to feel like I'm constantly toeing a line between actually helping my clients get good, healthy outcomes, and stepping outside of my very restricted scope as a doula. Technically as a doula I am supposed to "protect the woman's memory of her birth, recognizing that birth is a peak life experience." But I am quite sick of trying to protect women's memory of their unneccessary cesarean. And it's hard to qualify an afternoon spent napping, doing cross-words, and watching TV as a peak life experience, even though it does end in a new human being.

I'm doing my best, and I'm not sure I'm doing enough. That sucks, because I care. A lot. About birth as a peak life experience. About the health of moms and babies. About the way a woman remembers her birth and perceives her strength in birthing, and takes that memory and knowledge of how strong she is, and uses it to get through sleepless nights, teething, smarty pants eight year olds, snotty teenagers, sending her baby to college, supporting her daughter when she has a baby of her own. It really, really matters.