Abstract
This updated edition of Care Practice Paper #3 presents the evidence for the benefits of continuous support in labor. The role of the doula is explained. Women are encouraged to plan for continuous support during labor and to consider including a woman experienced with childbirth among their labor support team.
Keywords: doula, continuous labor support, normal birth, pain management, childbirth education
Most recent update: May 2007
A partner in a Lamaze class asks, “How on earth can I provide the support she needs during labor? Will I have any help?”
In times past, women learned about childbirth from their mothers and sisters. Birth took place in the familiar comfort of home. Family rituals and traditions ensured that women were confident in their ability to give birth. Throughout labor and birth, family members and wise women surrounded the laboring woman and gave her constant support and encouragement. Community midwives attended almost all births.
As birth moved into the hospital early in the 20th century, women lost the valuable support and encouragement of women from their communities. Nurses gave support, but often they were responsible for several laboring women and could not stay continuously with one woman.
During the 1960s, Lamaze International and other childbirth organizations advocated successfully to allow fathers into the labor room. Fathers provide special emotional support to laboring women and deserve to be present for the birth of their child. This was an important step in preventing women from having to labor alone.
Now, in the 21st century, women are again discovering the value of additional support from women knowledgeable about birth. Women often assume that a nurse, midwife, or doctor will stay with them throughout their labor. In some birth settings, midwives and nurses are able to give continuous support to the laboring woman and her family. However, the reality is that other responsibilities often keep doctors, midwives, and nurses from being with one woman continuously. Even when a midwife is caring for only one woman in labor, it can be helpful for another experienced woman to provide emotional and physical support.
Before your baby's birth, you should decide who could offer you continuous labor support. You might choose a friend or relative who is experienced with childbirth, or perhaps you will decide to hire a doula, a labor support professional.
THE SIX CARE PRACTICES THAT SUPPORT NORMAL BIRTH.
Care Practice #3: Continuous Labor Support
Key Points
If you have continuous support in labor, you increase your chances of having a vaginal birth, you are less likely to use pain medication, and you will be less likely to have negative feelings about your birth experience.
Nurses, midwives, and doctors often are not able to provide continuous labor support to one woman in labor.
Doulas are labor-support professionals who offer continuous emotional, physical, and informational support in labor.
A supportive woman experienced in childbirth can be an important part of your labor-support team.
WHY IS CONTINUOUS SUPPORT IMPORTANT?
Labor may surprise you (and your partner) with its power. Having a woman experienced with birth there to reassure you and your partner that your labor is progressing normally will help you both to cope. A woman experienced with childbirth will also know how to give comforting touch such as massage and suggest positions that will help the progress and comfort of your labor.
THE ROLE OF A DOULA
According to The Doula Book, a doula is “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” (M. Klaus, Kennell, & P. Klaus, 2002, p. 4). A doula will remain with you and your partner throughout labor and birth, providing physical, emotional, and informational support. Your doula will never be away from you for more than a few minutes, unless you request time alone with your partner. She will work with you and your partner to help you have the kind of birth you want. She may help you into a warm tub or shower, walk with you and your partner, and massage your back, hands, or feet. She will support you in your decisions about pain medication. If you tell your doula that you want to give birth without medication, she will help you do this. After the birth, a doula usually stays with you for 1 to 2 hours to help you with breastfeeding.
Doulas are not trained to perform any medical or nursing tasks and should never offer medical advice. However, they should help you understand medical events. They also can encourage you to communicate your preferences to the hospital staff. If your labor takes a different path than expected, a doula can help you make clear your feelings and review your options.
One of the most important roles of the doula is to help you to have positive memories of your birth experience. After the birth, you will remember together the positive aspects of the birth, and she will answer any questions you may have. If the birth does not go as you planned, your doula will be there to listen to you and to offer you support.
WHAT RESEARCH TELLS US
The research regarding the benefits of continuous support by doulas during labor is impressive. A review of the research by the Cochrane Pregnancy and Childbirth Group, a respected international organization that defines best practices based on research, shows that continuous support for women during labor and childbirth is clearly beneficial (Hodnett, Gates, Hofmeyr, & Sakala, 2003). According to the review, compared with women who do not have continuous labor support, women with continuous, one-to-one support are less likely to
have a cesarean section;
give birth with vacuum or forceps;
have regional analgesia (e.g., an epidural);
have any analgesia (pain medication); and
report negative feelings about their childbirth experience (Hodnett et al., 2003).
Two other reviews of the research on continuous support (Leslie & Storton, 2007; Simkin & O'Hara, 2002) had similar findings.
The authors of all three reviews (Hodnett et al., 2003; Leslie & Storton, 2007; Simkin & O'Hara, 2002) found that continuous support is more effective when the person providing it is not part of the hospital staff than when it is provided by staff members such as nurses or midwives. In one review, better results were found when the support started earlier in labor (Hodnett et al., 2003). Another review showed that support was most helpful for low-income women who would have labored alone if they had not had a doula present (Simkin & O'Hara, 2002).
THE DOULA AND THE LABOR PARTNER
Most partners want to participate in the birth of their children and to provide support for their significant others. However, most men and some women have little if any experience with childbirth. As your contractions become more intense and you struggle with pain, your partner may become frightened. Your partner may not have the experience to know whether your labor is proceeding exactly as it should. As labor progresses, it may become more and more difficult for your partner to reassure you. Most partners breathe huge sighs of relief when an experienced childbirth professional is there to assure them that labor is going just fine.
A good doula takes her cues from the labor partner. If your partner is sitting close to you, holding your hand, and providing eye-to-eye contact and supportive words, the doula will not interfere in the intimate relationship between the two of you. Instead, she supports and encourages both you and your partner. However, if you need more support than your partner can give, the doula will work along with your partner. She might give you a back or foot massage while your partner provides the eye-to-eye contact and reassuring words. Or she may suggest a change of activity, a new position, or a comfort measure you and your partner had not tried. The doula can show your partner how to give effective counterpressure or massage. She can also offer support while your partner takes a much needed bathroom or meal break.
PLANNING FOR CONTINUOUS SUPPORT
A friend or family member experienced with childbirth may be able to provide continuous support for you and your partner. These women do not need to have formal training as doulas, as long as they have confidence in your ability to birth your baby and are willing to stay with you continuously during labor.
However, many women find that hiring a doula is the best way to be sure that they have continuous emotional and physical support throughout labor and birth. You can ask for referrals from your childbirth educator, your health-care provider, DONA International (www.dona.org), or another doula organization. After you have decided whom you want with you, plan at least one visit with her to talk about the type of birth that you and your partner hope to have. Share with her the comfort measures that are important to you, including medications.
Some hospitals or birth centers may offer free or low-cost doula services. If there is a language barrier between a laboring woman and the doula, both usually find that eye-to-eye contact and gentle touch overcome the lack of a common language. Some hospitals also provide a translator, if needed.
Some health plans will reimburse you for the cost of doula services. You can call in advance to see if services will be paid for, and advocate for doula coverage if they are not. Insurance companies and health plans may not know that, by providing continuous support, doulas decrease health-care costs from interventions such as cesarean surgeries. Doulas charge varying amounts, and some may even offer barter (trade) options or provide free services in order to get their certification.
RECOMMENDATIONS FROM LAMAZE INTERNATIONAL
Lamaze International joins with the World Health Organization (Chalmers & Porter, 2001) in recognizing the value of continuous labor support as a key element in normal birth. Lamaze believes that all women should have access to continuous labor support, without financial or cultural barriers. Lamaze encourages you to plan for a supportive birthing environment that includes continuous emotional, physical, and informational support.
A supportive woman experienced with childbirth can make a valuable contribution to your care during labor and birth because of her commitment to staying continuously with you and your family, her knowledge of both physical and emotional comfort measures, and her confidence in your ability to birth your baby.
Acknowledgments
The six care practice papers were originally developed in 2003 by Lamaze® International and published in 2004 in The Journal of Perinatal Education 13(2) issue. The following members of the Lamaze International Education Council contributed to and reviewed the first edition of Care Practice Paper #3:
Elena Carrillo de Reyes, CD (DONA), LCCE, FACCE
Diana Chiaverini, RN, MEd, LCCE, FACCE
Jeannette Crenshaw, RN, MSN, IBCLC, LCCE, FACCE
Joyce DiFranco, RN, BSN, LCCE, FACCE
Caroline Donahue, RN, MA, LCCE, FACCE
Judith Lothian, RN, PhD, LCCE, FACCE
Michele Ondeck, RN, MEd, IBCLC, LCCE, FACCE
Teri Shilling, MS, IBCLC, CD (DONA), LCCE, FACCE
Sandra Steffes, RN, MS, LCCE, FACCE
The updated (May 2007) edition of Care Practice Paper #3 was edited by Amy M. Romano, MSN, CNM.
Footnotes
For more resources and to download a copy of each updated care practice paper, visit the Lamaze Institute for Normal Birth link at Lamaze International's Web site (www.lamaze.org).
REFERENCES
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