by Juli Tilsner
This article initially appeared in Vol. 1, Issue 1 (Winter 2020) of The Birth Mag and is now being made available online to improve accessibility.
What is the #1 reason people hire Doulas and Midwives? Satisfaction with the birth experience. Or, in other words: trauma prevention.
My goal here is to critically look at the role continuity and continuous support play in outcomes for the people we serve, and hopefully avoid pitfalls in the way we structure services that can negatively impact clients. How we can take care of ourselves physically, emotionally and financially, while simultaneously give our clients the care they deserve?
Continuity of care and continuous labor support are intertwined as one of the most difficult aspects of birth work. They can lead to severe burnout and limit our income when we don’t have partnerships or backups available. We can easily justify taking more clients in a month than we know we should, making these exceptions because we tell ourselves “they need us” and saying no breaks our hearts. Most of us have broken our own number of clients per month rule, maybe more than once. Maybe it turned out OK, possibly not. Maybe the stars aligned and mercy was showered, everyone was cared for and you made it out the other side with happy, healthy families. But at what cost? Burnout comes in many forms, and we might not even recognize it happening. If you are on the verge of burnout, you won’t be your best for your clients, and they deserve stellar care. Your clients deserve to have you, the Midwife/s or Doula/s they hired at their side for their labor and birth. You deserve to be happy, healthy and thrive.
What does continuity of care mean to you?
“The Midwives Model of Care™ is a fundamentally different approach to pregnancy and childbirth than contemporary obstetrics. Midwifery care is uniquely nurturing, hands-on before, during, and after birth. Midwives specialize in pregnancy and childbirth, developing a trusting relationship with their clients, resulting in confident, supported labor and birth.” https://mana.org/about-midwives/midwifery-model
The universally defined role of a Doula includes ‘continuous labor support’. Benefits of this continuous support are well documented. https://evidencebasedbirth.com/the-evidence-for-doulas/
I practiced as a home birth midwife with my Midwifery partner Deborah Simone, in the SF Bay Area, CA for 15 years until moving to Portland, OR in 2017. I’ve been training doulas since 2006, and have been a preceptor for a number of aspiring Midwives.
Early in my career, I learned the most important aspect of my work was the relationship between myself and my clients. My clients were depending on me and my practice partner to be there for their birth. This was the most important consumer decision they’d ever made: Hiring the team that would bear witness to and be safekeepers of their personal metamorphosis and ushering in of their beloved baby. They were putting their hearts in our hands.
This overarching truth about the responsibility I had to my clients was highlighted when people would come to me in second pregnancies with stories of abandonment and trauma from their first birth. And this happened often.
These abandonment stories all had a common theme. The hired Doula or Midwife, with whom they’d cultivated relationship and trust, was at some point not available when they were needed most. This could be in the days or hours before labor, or during labor and birth.
The contracted doula or midwife had a strict call period, usually 37-42 weeks, and was not available before or after those dates. Often, a vacation had been scheduled at 42 completed weeks for the client. Once a Midwife called me to request I take over her practice while she was on vacation, as she had 3 clients within dates while planning to be out of town! A home birth client hired a doula who planned a vacation when the client was in her 41st week, but felt confident it would be fine because the first baby came at 40 weeks. The client had talked themself into believing there would be no emotional affect, because they wanted this Doula so much. This was a very risky scenario. It ended with the Doula attending the birth, but not without some stress involved.
The Doula or Midwife has two people in labor simultaneously. They call their backup, with whom the client has had a prenatal visit and feels comfortable with, but that backup isn’t available. Instead, a Doula or Midwife from the community that is a stranger to the family comes to be with them.
Homebirth client transfers to hospital. The Midwife accompanies them to admissions and helps get them comfortable. The Midwife, in private practice with other clients due does not stay at the hospital. They may go home to rest or keep scheduled appointments so they don’t get behind. The midwife instructs the parent/s to call when they are close to pushing, or if anything urgent happens.
Doula leaves the labor at some point to get rest, often after the client gets an epidural.
All of these scenarios create stress for clients. Worrying they won’t have their baby before the Midwife or Doula goes on vacation often delays the onset of labor. Discovering that they’ll be attended by a stranger alters the hormonal cascade, affecting the birthing experience. Being left at the hospital exhausted with no advocate, wondering if and when to call the Midwife or Doula in time for the birth often leads to clients making snap decisions that would have been made differently had their support system been present.
In the last scenario, there also is a good possibility that no support person will get back to the hospital in time for the birth. From personal experience, you never want to live with the feeling that if you’d have just stayed, there wouldn’t have been a cesarean or…
What can be done to minimize these scenarios:
Work in partnerships. My practice found that 3 was our sweet spot. We had a rotation of 2 people on call and one off call at all times. A partnership of 2 as can work as well, with scheduled blocks of time off for the practice. Money is shared, but clients get to know each provider and are guaranteed to have someone they know at their birth.
Have backup backups and childcare backups.
Doulas: Meet with your clients at least 4 times prenatally (instead of the standard 2). Have your backup/s attend at least one prenatal visit. If you’re in a partnership, split prenatal visits equally.
Be realistic with how many clients you take and how many backup gigs you have. If you’re in private practice, 3 births per month will be a good bet that you can attend every birth. In a 2-3 person partnership with solid back ups, 4-5 clients will ensure that your clients are covered. Another benefit in limiting clients numbers is sustainability for you and your family. Your clients get the well rested (not burned out) Midwife or Doula care they deserve.
Be on-call for clients from the time they hire you, until they have their baby. Be in town on ‘hard call’ from 36-43 weeks. Be available by phone or have a backup if you are out of town before 36 weeks. This gives your clients coverage in most situations.
Work on shifts with your partner or backup. Take turns relieving each other every 8-12 hours.
If you are a lone provider in a rural area with little to no backup, there may not be a choice but to be up for 2-3 days. Take care of yourself by not taking on too many clients at once. Practice radical self care between births. Midwives: Work with Doulas! You can rest assured that your clients are cared for, so you can be well rested when you’re called.
If you have no backup, bring a sleeping bag to the hospital so you can rest, yet be in the room with your client, in order not to miss anything.
Always have what you need to be nourished during a hospital shift. Carry a cooler with food and plenty of beverages.
When your client gets an epidural:
When the birthing person gets an epidural, it is usually after everyone in the birth team is tired from long hours or days of continuous support. This is often seen as an opportunity to get a ‘break’. After the epidural is placed, team and family go to the waiting room or leave the hospital to get some sleep. The birthing person may even say with a smile, “I want you to go get some rest now, I’m ok”
What’s being said and the emotional impact are two different things. The laboring parent most likely doesn’t understand the short or long term emotional impact or dangers of being left alone with no support person. The birthing person is still in labor, and the importance of staying connected to the work and connected with their baby cannot be overstated.
The epidural cuts off sensation, which in turn cuts off the cocktail of hormones that drive the primal experience of birthing and bonding. It’s hard to stay connected when lines of communication have been blocked.
There are also risk factors that come with the epidural. Even if the birthing person and baby are considered stable, the risk factors do not go away. There are physical, emotional and iatrogenic (hospital caused illness or injury) risks. Institutional risks include protocols, time limits, lack of trauma informed care, shift changes. The often seen opportunistic behaviors of the hospital team, when there’s no support person or advocate in the room must not be understated.
It is well documented that the security of the continuous presence of a doula helps birthing people feel safe enough to allow the process to unfold, in other words to ‘open’. Epidurals and pitocin are not miracle workers, they cannot force a pelvic birth if other essential elements with birther and baby are not in alignment.
The Doula needs to keep a hawks eye on everything while the birthing person rests, hopefully being undisturbed for as long as possible. Realistically, there isn’t much uninterrupted sleep. We want to believe providers when they say ” get some rest, we’ll be back in a couple hours” as the lights are turned off. However, the nurse is in and out, on the computer, evaluating the monitor, adjusting belts if baby moves or heartbeat aren’t being recorded, emptying the catheter bag or a number of other tasks. Also, things can change quickly, as in a rapid birth. A laboring person can quickly dilate to complete once they’re able to relax internally with an epidural. In some cases, the decision for a surgical birth is made when a baby shows signs of not tolerating the labor, and there’s no time to call support people back to the hospital.
Tips for the Doula when there is an epidural:
- Help the laboring person get blocks of rest by making a plan. This can be simply that they’ll sleep for an hour while you ensure nothing is done to them without their consent. The laboring person is more likely to sleep if they know their doula is watching over them and the baby.
- Ensure the laboring person is turned every hour.
- Massage, rock, visualize, sing with, read to, engage the client with the baby, and bring on the unique magic that each particular Doula has to offer.
- Keep an eye on the catheter bag and alert the nurse when full.
- Advocate that the laboring person is taking in food and/or liquids.
It is our duty as birth workers to care for ourselves, so that we can be fully present in body, mind and spirit for our clients. It can be challenging to find like-minded colleagues to be 100% responsible, solid backup. Pay backups generously for taking call. Be a stellar backup for others. Doulas and Midwives: Learn how to run successful, sustainable partnerships. The promises we make are not only to our clients, but also to ourselves, our families and communities.
Juli Tilsner is a California Licensed Midwife, CPM, Author, Educator, Consultant, Parent to a human and a fur baby, Grandparent, Co-Founder and Co-Executive Director of Cornerstone Doula Trainings. In service of reproductive rights for all people & birth justice, working towards a world where birth trauma does not exist. Insta: @cornerstone.doula.trainings https://www.cornerstonedoulatrainings.com/
*Header photo by Natalie Broders: Portland Birth Photographer https://www.nataliebroders.com