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The Doula Book
How a Trained Labor Companion Can Help You Have a Shorter, Easier, and Healthier Birth
By John H. Kennell
By Phyllis H. Klaus
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THE DOULA BOOK
ALSO BY THESE AUTHORS
Bonding: Building the Foundations of Secure Attachment and Independence
ALSO BY MARSHALL AND PHYLLIS KLAUS
Your Amazing Newborn
THE DOULA BOOK
How a Trained Labor Companion Can Help You
Have a Shorter, Easier, and Healthier Birth
Marshall H. Klaus, M.D.
John H. Kennell, M.D.
Phyllis H. Klaus, C.S.W., M.F.T.
A Merloyd Lawrence Book
A Member of the Perseus Books Group
Many of the designations used by manufacturers and sellers to distinguish their products are claimed as trademarks. Where those designations appear in this book, and where Perseus Publishing was aware of a trademark claim, the designations have been printed in initial capital letters (i.e., Demerol).
Portions of this book appeared in an earlier edition entitled Mothering the Mother, published by Addison-Wesley in 1993.
Copyright © 1993, 2002 by Marshall H. Klaus, M.D., John H. Kennell, M.D., and Phyllis H. Klaus, C.S.W., M.F.T.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Printed in the United States of America.
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eBook ISBN: 9780738211510
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Text design by Jeff Williams
Set in 12-point Bembo by the Perseus Books Group
First printing, November 2002
1 2 3 4 5 6 7 8 9 10—04 03 02
We dedicate this book to all the sensitive and caring women who have
provided continuous support during labor for the mothers in our studies.
They have helped us in immeasurable ways to evaluate, describe, and begin
to understand the power of their presence. We also dedicate this book to all
the doulas in the future who will enable mothers and their partners to have
a less complicated and more rewarding birth with long-term benefits.
Doula is a Greek word whose definition has come to mean a
woman who helps other women. The word has further evolved to
mean a woman experienced in childbirth who provides
continuous physical, emotional, and informational support
to the mother before, during, and after childbirth.
Our understanding of the needs of mothers during labor developed during our systematic studies over the last twenty-five years. Insights also came from discussions with doulas and with close colleagues Steven Robertson, Susan McGrath, Roberto Sosa, Manuel de Carvalho, Clark Hinkley, Penny Simkin, Nadia Stein, Roberta O’Bell, Susan Landry, Kenneth Moise, Marjorie Greenfield, Kathy Scott, Charles Mahan, and Debra Pascali-Bonaro. We also thank the medical students, and, especially, Wendy Freed, who more than a quarter century ago sparked our interest in exploring the needs of women during labor through observations she made when she stayed with ten mothers during labor as part of another study. Apparently benefiting from her supportive presence, these mothers all had a remarkably short labor and a complication-free birth. These observations were a critical stimulus to our exploration of the effects of a doula.
We appreciate the major conceptual additions to this book by Kerstin Uvnäs-Moberg and the Swedish midwives, Ann-Marie Widström, Anna-Berit Ransjö-Arvidson, Eva Nissen, Kyllike Christensson; as well as Beverley Chalmers, G. Justus Hofmeyr, Wendy-Lynne Wolman, and their Johannesburg research colleagues; and Christina Smillie with her new information about the “latch-on” in breast-feeding.
The perceptive comments of Laura and David Abada, Susan and Bob Sholtes, Devi and David Borton, Kristin Brooks and Glenn Meyer, Humm Berreyesa, Tracy Fengler, and Frances Bachman were especially helpful.
We thank our secretaries for their excellent work and patience: in Cleveland, Susan Wood, and in Berkeley, Nancy Pino. We are greateful for Peggy Kennell’s early contributions and her strong doula-like patience and support.
Finally, our heartfelt thanks to Merloyd Lawrence for her continuing encouragement, sensitive understanding, and remarkable editing skills.
The Need for Support in Labor
Continuous support from a doula during labor provides
physical and emotional benefits for mothers and health
bonuses for their babies. With less medical interventions,
fewer complications, and shorter hospital stays,
there may be financial savings as well.
HARVARD HEALTH LETTER
Women helping women give birth is an ancient practice that is still widespread today. For instance, according to anthropological data that we reviewed for 128 nonindustrialized hunting-gathering and agricultural societies, all but one offered mothers the continuous support of other women during labor and delivery. As childbirth moved from home to hospital, however, this vital ingredient in childbirth began to disappear. While efforts to involve fathers and to introduce other humane practices into hospital births have done much to improve this situation, an important link remains missing. Although the introduction of fathers into the birth room brought the couple together for childbirth, this practice tended to reduce the sensitive and individualized care of the obstetric nurse in their labor. Childbirth is usually now lonelier and more psychologically stressful for both parents. For some mothers, left to labor largely on their own, birth becomes “solitary confinement.”
In the past twenty-five years, together with colleagues, we have studied the effects of restoring to the childbirth experience this important element of having women as helpers during labor. Continuous support from an experienced labor companion has proven dramatically beneficial.1 In studies of over 5000 women involving comparisons of outcomes with and without such support, we have seen a major reduction in the length of labor, a greater than 50 percent drop in cesarean sections, a remarkable drop in the mothers’ need for pain medication, and several other important and measurable benefits, which we describe in the chapters that follow.
Getting acquainted and being reassured in early labor.
This continuous support was provided by caring, experienced women we call doulas. In searching for a term to describe this role, we wanted a word with a nonmedical connotation that would stress the value of a woman companion as attentive and comforting. We turned to the Greek word doula, meaning “woman caregiver.” Our first exposure to the word came from Dana Raphael’s use of the term to describe “one or more individuals, often female, who give psychological encouragement and physical assistance to the newly delivered mother.”2 We use the word in the now widely accepted sense of an experienced labor companion who provides the woman and her husband or partner both emotional and physical support throughout the entire labor and delivery, and to some extent, afterward. Other people use terms such as labor coach, monitrice, childbirth assistant, labor companion or mother assistant. Whatever the term, we hope our readers will come away with an understanding of the vital shared ingredient that makes this role so powerful and beneficial. In this book we describe what a doula can provide both during labor and birth and in the postpartum period, and how she is trained. We discuss the results of our studies on labor outcomes and differentiate not only between the assistance of a doula and the equally vital help of fathers but also between the work of the doula and that of the nurse, physician, or midwife. We also offer guidance in finding and evaluating a doula, and give, in Appendix A, information on how a doula is trained.
We realize that a woman having a baby may be married or single and accompanied by the father, her own mother, or a close friend. When we use words such as father, partner, couple, and parents, we mean to include all types of family arrangements. Also, for simplicity, we use the words mother and father, rather than mother-to-be and father-to-be, for a woman and man as they share in the experience of labor and delivery.
TYPES OF LABOR SUPPORT
When embarking on one of the most meaningful experiences of their lives—the birth of their first child—a couple fantasizes about what the labor and delivery will be like. They may have a dream of how it will be—perhaps hoping that this pregnancy and birth will be all their own, something they do together without anyone else’s interference. At the same time, they will have fears. On the one hand, they may picture being alone together, with the father being the main helper and support, and music playing in the background as they go through labor without interruptions or interventions and then have idyllic quiet time with their new baby. On the other hand, they may worry about pain, loss of control, problems for the baby, or life-threatening complications.
Given these hopes and fears, all mothers and fathers need emotional support and help during labor. Much of this support they can provide to each other. The mother needs to feel the father’s care, love, sense of connection, responsibility, and sense of sharing in the intimate experience of bringing their child into the world. The father or other chosen partner has a strong desire to help, to participate, to feel useful and active, and to feel important and necessary for the mother.
But when two people share an emotional bond and an ongoing relationship, it is very difficult for that companion to remain continuously objective, calm, and removed to some degree from the mother’s discomfort and, fears, or any danger to her. In most cases—and this cannot be stated too often—the father will have the unexpressed but deeply felt question, Will everything be all right? Also, a father often has had little or no experience with the birth process.
Steady support helping the woman visualize through a contraction.
For these reasons, every woman in labor needs not only the father or other chosen partner but also a nurturing, experienced person—a doula—who can calmly and skillfully help her cope with labor and be a reassuring and constant presence for both her and the father. The doula gives a level of support different from that of a person who is intimately related to the woman in labor.
These two kinds of support complement each other. A doula can help a woman work with her labor and guide her on how to stay relaxed and comfortable at home until labor is well established. Prenatally, the doula can show the pregnant woman how she will have the ability and confidence to be an advocate on her own behalf. In the hospital the doula can help the father or other partner be less anxious. With her practiced skill, the doula serves as a role model for the less experienced person.
Very often the couple worry that an outside support person will take over and control the labor experience, as many individuals providing labor assistance have traditionally done. The training of a doula is quite different, emphasizing quiet reassurance and enhancement of the natural abilities of the laboring woman. A doula is constantly aware that the couple will carry the memory of this experience throughout their lives. As we discuss in Chapters 3, 7, and 8, the doula is there to help the parents have the type of birthing experience they want.
For millennia the relationship of mother to daughter, of older experienced woman to younger birthing woman, was respected and understood. Today, although many women may want their own mothers’ help during labor, most of today’s grandmothers are not experienced around birth. The experience of women who gave birth in the 1960s and 1970s may not have been ideal. Also, many women are distant from their adult daughters geographically and some, psychologically. Many expectant women today prefer not to have their mothers at the actual birth, even if they have a caring relationship. Many prefer to have the father present, and it is often easier for the couple to have a nonrelated but caring person help them. Sometimes men who have become involved in birth through childbirth courses may feel their position is usurped if their mother-in-law or a close friend of the mother’s is acting as the main support during labor. Though laboring women’s mothers and friends can offer important support along with fathers, a doula’s nurturing, helpful, and objective support relieves the family member chosen to be present from sole responsibility for the labor. It is not an attempt to interfere with the relationship between the woman and her partner or other family member.
THE NEEDS OF FATHERS DURING LABOR AND DELIVERY
In asking fathers to be the main support, our society may have created a very difficult expectation for them to meet. This is like asking fathers to play in a professional football game after several lectures but without any training or practice games. Couples sometimes get the mistaken impression from childbirth classes that by using a number of simple exercises, the father can be a main source of support and knowledge for the entire labor when the nurse is unavailable. This is true for a small number of fathers, but most fathers—especially first-timers—do not get enough opportunity in the classes to observe and practice. Often the dilemma for childbirth instructors is how to get fathers to be more a part of the experience and appreciate what actually lies ahead. Fathers entering into this new role often feel nervous, joke frequently, and consciously or unconsciously wonder whether. They belong in this whole obstetrical arena. Dr. Martin Greenberg, an experienced physician who has done research with new fathers, commented:“I didn’t realize until later how frightened and angry I felt at the staff for being left alone with my wife when having our first baby.”
The nurturing presence of both the father and doula in early labor.
In no other area of the hospital is a family member asked to take on such a significant caretaking role as in childbirth. When working in the obstetrical unit, we have often been struck by how terribly relieved fathers are when an experienced nurse or midwife enters the room and remains with them. This feeling of relief enables fathers to be much more relaxed, loving, and emotionally available than when they bear the burden of responsibility alone.
We therefore want to enable the father to be present at his own comfort level and to remain emotionally connected to his partner and child. Few fathers want to be—or should be—the sole support person in the room. As we discuss in Chapter 8, the mother gains more assured, steady emotional support from her partner if he is less worried about what he is supposed to do and if they both can relax and trust the doula’s expert care. As one father noted: “I’ve run a number of marathons, I’ve done a lot of hiking with a heavy backpack, and I’ve worked for forty hours straight on call; but going through labor with my wife was more strenuous and exhausting than any of these other experiences. We could never have done it without the doula. She was crucial for us.” His wife added: “I want the doula there to assure me that everything is fine and to comfort me. I want my husband there for emotional support.”
A laboring woman’s rapid changes of mood may alarm an inexperienced father and compound the mother’s fears.“If you leave the mother alone for even five minutes,” a doula commented to us, “she begins to become distressed. She begins to fall apart and lose control, and when you return, it may take a half hour to get her settled down.” Fathers express feelings of mounting anxiety. Underlying this anxiety is often an unexpressed fear of danger for the mother or child, as well as distress for the mother’s pain. Although fathers have many positive feelings and great anticipation, these negative feelings can get in the way and, in turn, affect the progress of the labor itself. Over and over again we have been impressed by the calming influence the doula has for both the mother and father as she explains what is happening, uses her extensive experience to help the mother, and supports the parents in having the kind of experience they originally desired.
A VARIETY OF SETTINGS FOR BIRTH
Hospitals and obstetric caregivers, including physicians, nurses, and midwives, approach delivery from very different perspectives. The role of a doula or other provider of labor support will be affected by these differences.
On one end of the spectrum, childbirth is viewed as a normal physiological event that follows a natural course. Interventions needed for these natural deliveries are seen as minor, although the personnel must remain alert for any medical sign of complications. When childbirth is planned from this point of view, mothers are informed what to expect during the start of labor and, after checking with their caregivers, given the okay to stay at home during most of labor. They are guided to stay relaxed, take in fluids and light food as desired, rest, do distracting activities in early labor, and as labor progresses help with a variety of comfort measures. These include relaxation, visualization, massage, position changes, shower or bath. At the hospital they are further helped to work in a natural way, allowing their labor to continue without interventions (rupture of membranes, augmentation with pitocin). Minimal medications are used, and mothers attempt to give birth without an epidural. Episiotomies are kept to a minimum, and most mothers give birth vaginally.3
Supporting the woman in an upright position promotes the use of gravity.
On the other end of this spectrum, childbirth is seen as a medical event fraught with potential danger. For many mothers giving birth in such a setting labor begins with an induction between Monday and Friday. Other women, whose labor begins at home, are usually asked to come into the hospital early. There, they are monitored and receive IV fluids, and they are often limited to bed and unable to drink or eat. Often the membranes are ruptured, an early epidural is given, and contractions are augmented with pitocin. These mothers have a higher rate of cesarean sections and a higher rate of episiotomies. Many maternity hospitals or obstetrical practices, of course, fall in between these two extremes.
In planning or thinking about their own delivery, expectant parents should know about the different practices of the physicians and midwives in their community. By knowing which approaches these professionals tend to adopt, they can make a more informed choice in order to meet the mother’s medical, emotional, and physical needs.
PRESSURES ON THE HOSPITAL STAFF
Many people do not appreciate that an obstetrical staff of nurses and doctors provides care for a wide range of patients. In the United States, 90 percent of deliveries are normal and routine, but 5–10 percent require an intensive effort with the use of advanced technology, consultants, and additional ancillary personnel. When the special cases arise, this reduces the number of nurses available to work with the larger group of mothers who are having routine, normal deliveries. In addition, the numerous cesarean sections in most hospitals also tie up the nursing personnel.
Studies by Ellen Hodnett in Toronto noted that women planning a hospital birth rarely expected to have a nurse with them throughout labor.4 The women usually felt the nurses would be busy or viewed their role as purely technical. She commented, “Recognizing that laboring women require psychological support and realizing that nurses have little time to give it, hospitals have increasingly permitted and encouraged husbands to assume active roles in the care of their wives during labor.” In addition, in hospitals many different caregivers are often involved with one mother. A recent study found that women giving birth encountered an average of 6.4 unfamiliar professionals during labor. The presence of many strangers can disrupt the labor and confuse the mother.
At home and in some hospitals, midwives who care for only one mother at a time, continuously attending each from early labor on, meet both the medical and emotional needs of the mother and father. When a hospital or other birth setting provides such continuous one-to-one nursing or one-to-one midwifery care and that caregiver’s goal is to reassure, relax, comfort, and inform the mother rather than to tend only to the needed medical interventions, that person takes the same supportive role as a doula. Many nurses who care deeply for the emotional as well as the physical well-being of their childbearing patients are happy when they can provide such uninterrupted care.
In most cases, however, nurses on the delivery floor and hospital-based midwives generally care for several patients at one time, monitoring the progress of labor; the vital signs of the mother, such as heart rate, blood pressure, and temperature; and fetal well-being, with heart-rate changes. In non-high-risk situations obstetricians and family physicians are not in constant attendance but check in and out until late labor. Then they manage the delivery and attend to any medical aspects, giving strong support when they are present.
Many parents expect to handle childbirth alone, but within the circle of a “safe” hospital setting where help is just outside the door. Many nurses believe they should not interfere with labor and, instead, just come in to check on how things are going. When they or the physician come in only intermittently, they may not always recognize the great need that parents have for information and reassurance. It may be difficult for the father to ask for help or to realize when or what type of assistance his wife needs at each stage of labor. He may be getting anxious, and he will often think of “help” only as a medical intervention rather than as assistance with the emotional needs of the mother as she works through contractions.
Two widely respected, experienced, and caring teachers of obstetrics, Drs. Kierin O’Driscoll and Declan Meagher, whose work in Dublin is described in Chapter 9, have recognized the negative effects that a lack of support has on women in labor.5 When a woman does not have an experienced person to give her continuous personal attention throughout labor and when the father is uncertain, fearful, or becoming anxious himself, they note, “the scenario for many can be written in advance: the woman becomes progressively withdrawn from contact with her surroundings, closes her eyes and buries her face in the pillow, only later to become increasingly active, with contorted features and restless movements, interrupted by outbursts, until finally a state of panic is reached and self control is lost.” In our studies we have encountered several occasions in which couples who were reluctant initially to have a supportive companion because they wanted to be alone for this significant event changed their minds completely in midlabor and pleaded with us to supply them with a doula. The role of a doula is still being refined, and as we said earlier, labor support can be offered by several other types of professionals. Its essence, as we will show, is a “mothering” role, mothering both the mother and father as they are born into their new family. In Appendix A we describe the basic ingredients of doula training.
Our studies have led us to the firm conviction that a doula—a person providing unobtrusive, compassionate, and experienced support throughout labor—is needed by every couple during the delivery of their child. With such help, parents can capture the special moments and priceless experience of their own unique childbirth. This in turn becomes the foundation for strong attachment as the new family comes into being.
The Special Role of the Doula
We form such a rapport that a woman
can ask anything of me.
Sacramento Book Review, June 2012“Has been a mainstay for both couples considering hiring a doula and women in training to become a doula for years…This book is a great place for women to start when looking to learn more about labor companions. It is full of valuable knowledge and useful personal anecdotes that pregnant women and potential doulas alike will find beneficial. Spread the word and hire a doula!”
Portland Book Review, 9/12/12
“Clear, motivational, and inspirational.”
- On Sale
- Apr 3, 2012
- Page Count
- 272 pages
- Da Capo Lifelong Books