Thursday, January 29, 2009

The Doula Book - Part II Reducing Discomfort, Pain & Anxiety

As a continuation of my coverage of the The Doula Book by Klaus, Kennell and Klaus here are the excerpts of the book that I highlighted in chapters 3 and 4.

Chapter 3 - Enhancing the Birth Experience

"Knowing the doula will be available anytime during labor lessens the parents' initial anxiety, and the couple can then remain at home longer with more productive labor and less pain." (page 35)

"The doula never interferes with the physician's advice, and the mother will need to follow that advice if there are other concerns." (page 36)

"Most mothers progress more rapidly in familiar surroundings" (page 37)

"During this period (the beginning of labor) mothers have found the following suggestions helpful:
1. Walk as much as possible
2. If the membranes are not ruptured, a warm bath can help you remain more relaxed. However in early labor a warm bath may slow labor; in late labor a bath may increase dilation. If the membranes are ruptured, a shower is preferablebecause of the risk of infection.
3. Change positions at least every half hour
4. Drink plenty of liquids... Urinate frequently" (page 37)

"The doula needs to notice the quality of the environment of the room and the woman's immediate needs or comfort level." (page 37)

"Asking the woman if a suggestion is or isn't working can validate her sense of control and choice as well as help her recognize her own needs and give her permission to voice what is important to her." (page 38)

"A doula will continually be
1. noticing
2. asking the woman
3. doing something to make an appropriate change
4. rechecking to see if the change is helping or not" (page 38)

"Being well hydrated has been shown to help labor." (page 39)

SIDE NOTE - One of my doula clients went to the hospital thinking she was in labor, but when we arrived her contractions completely stopped. After a thorough exam the doctor determined that she had an elevated temperature due to contractions. After receiving liquids via an IV her temperature went down and she was released. I have also read that dehydration can cause contractions and false labor which may have been what happened to my client.

"The doula can reassure the woman that the smells and fluids of birth, like blood, feces and amniotic fluid, are all normal parts of labor and are quickly taken care of by the staff" (page 39)

"The doula can be the one to have the somewhat difficult task to limit the number (of friends and family attending the birth) without offending anyone." (page 39-40)

"When mothers are in the hands-and-knees position infants often rotate in ten to fifteen minutes from a posterior position." (page 41)

"...Squatting during second-stage labor with each contraction. This position increased the area of the bony outlet of the pelvis by 28 percent." (page 41)

"The doula's ability to keep the mother informed is essential." (page 42)

"When a doula continually informs the mother, asks her gently what her thoughts, worries, or concerns are, talks to her confidently with real information, the doula can help the woman shift her fear to more inner security." (page 43)

"It is also important for the woman to feel that she has control not only over her labor but also has choices about what sort of interventions will be used." (page 43)

"...Although the PKU test is very important, it can wait a few days until the mother's milk comes in." (page 43)

"What is important to a laboring woman is sincere talk, not fake or glib reassurance." (page 45)

"The doula stays emotionally connected to the mother and by joining in her reality, may be able to move her to a more comfortable inner place." (page 45)

"Progressing toward full dilation of the cervix and delivery is near, the following signs may be noted:

1. Flushing of the face and body
2. An increase in bloody mucus
3. Longer and stronger contractions
4. Legs often becoming shaky
5. A feeling of nausea
6. feeling of an urge to push" (page 45-46)

"At this point (transition) the doula's support can give the mother the incentive to continue; the doula sometimes holds the woman, she reminds the mother (and the father) over and over again that she can continue and is doing great." (page 46)

"... Everyone attending a woman in labor 'has a responsibility to ensure that [she] genuinely understands the purpose of every medical procedureand the results of every examination' " (page 46)

"Often labor stops when too many people are present." (page 47)

"In reassuring the parents and enhancing their sense of accomplishment, the doula may be modeling the parental role for them - mothering the mother and parenting the parents." (page 49)

*** " The family is born in the delivery room." ***

Chapter 4 - Reducing Discomfort, Pain, and Anxiety in Childbirth

"When a woman comes into labor she brings her past with her." (page 53)

"Pregnant women have varied expectations of pain, based on what they have heard or experienced." (page 53)

"Though a doula cannot solve issues in the mother's past... she can begin her work being fully present with the woman to calm her fears, to validate her strength, to reassure her that she won't be alone, and to work with her on measures to alleviate pain." (page 54)

"Can you remember a time you met a challenge and conquered it?" (page 54)

"If labor is slowing down, a doula might ask 'How are you feeling righ now?' and then when the mother answers, the doula should restate her answer to be sure she understanda the mother's meaning." (page 55)

"By validating themother's fear, instead of dismissing it, the doula can offer new ways to think about the pushing stage." (page 55)

"Relaxin, which causes the tissure to be as stretchy, strong, and supple as soft elastic." (page 55)

"The mother's urge to push and ability to judge how to push in the second stage is reduced [with an epidural]." (page 58)

"If the epidural goes too high, some women feel as though they can't breathe." (page 58)

"Frequently, there is a rise in the woman's body temperature which reaches the level of a fever during an epidural." (page 58)

"During labor, some women copmlain of shivering and itching and experience urine retention requiring a bladder catheter." (page 58)

"The doula can remind the woman to stay relaxed, create positive images with her, help her with breathing and calming techniques, and validate how well she is doing." (page 59)

"The doula has to be sure there is no threat to her breathing." (page 58)

"With cool washcloths to the mother's face, neck, and chest, if all is well, the doula can cool the mother who is overheated or who develops a fever." (page 59)

"Helping women express feelings and utter sounds may relieve tension." (page 67)

"Make sounds along with the woman, encouraging the mother to let tension go with each sound." (page 67)

"Making low sounds or groans deep in the throat through a comtraction has an effect parallel to opening the birth canal." (page 67)

SIDE NOTE - To be honest making noise and validating the need to make noises was a concern of mine when I went to my first birth as a doula. Like a mother going into labor I was concerned that I would sound or feel silly doing this, but after reading this book I realized that no matter how I felt on the inside I had to always project complete confidence and not be concerned about what other people would think about what I was doing or how I was acting. My goal and my only focus was to make my mom focus on herself, relax, and let her let go of any inhabitions she was holding on to. It only took a little time for me to get over any insecurities and I just kept focusing on what my good friend Laurie told me, she said "Trust your instincts, mother your mother and everything else will follow." Now that was amazing advice from an experienced doula!

"When a doula remains accepting, nurturing, competent, and strong, the woman can internalize a model that might help her remain both nurturing and strong with her ownchild during tough moments." (page 68)

"The doula needs the confidence to help the mother express her needs to the caregiver especially before and during intervention." (page 70)

"The doula needs to know her limits, and occasionally when a fetal malposition does not change, ot a woman is not progressing as expected or feels great discomfort, medical help can give her relief. When this is necessary the doula must validate the woman's courage as well as her decision to have such help." (page 70)

Side Note - This is the exact situation I had with my first doula client (as you may have already read) she had been laboring for 5 days prior to the day we decided to go to the hospital. So she had not gotten more than 3 or 4 hours sleep each night for 5 days prior to going to the hospital and had labored at the hospital for 15 hours at the hospital only to discover that in that time she had only progressed 2 cm. Although epidural was not even a consideration for her and her hsuband before the birth, it became apparent that the epidural was something she needed. She was tormented by making the decision and we hugged, cried and proceesed what was going to happen, but I kept reassuring her that no one was judging her and that we would all honor her choices and that getting the epidural did not make her any less of a mom. After receiving the epidural, we hoped she would relax and progress, but it was still another 12 hours before the baby was born. Although she is still working on processing her choice to get the epidural I keep reminding her how hard she had worked and not only for that one day at the hospital, but for the 5 days before as well.

"Reducing th stress response enhances the body's own production of oxytocin, as well as natural opiates called endorphins." (page 70)

"When labor is not impeded by undue stress and fear, the woman's own natural oxytocin is secreted from the posterior pituitary gland intot he bloodstream. At the same time, her brain also secretes oxytocin to other areas within the brain itself. This has four effects:

1. First it markedly increases the pain threshold, so that the mother has reduced sensitivity to pain.
2. Second, it results in drowsiness
3. Third, it results in some relaxation or calming
4. Finally, after the birth it helps the woman feel closer to the baby" (page 71)

"Comfort measures cna be divided into five categories

1. actions and behaviors that give emotional and psychological support
2. mental activites that divert attention from pain or focus attention on thoughts or images that increase mental and physical relaxation
3. physical activities such as relaxed breathing, muscular relaxation exercises, movement, position changes, use of water, heat, cold
4. touch, including massage, acupressure, pressure, and counterpressure
5. rhythmic activities, music, chanting, singing etc." (page 72)

Side Note - Much to my client's pleasure and their ability to relax, there is about a 0% chance that I will ever sing to them to help them relax. However, I could consider my singing a diversion or a relocation of pain (from the abdomen to the ears).

To be continued.....

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