Sarah Lavonne: Hi, I'm Sarah Lavonne, and I'm so glad you're here. Here at Bundle Birth, we believe that your life has the potential to make a deep, meaningful impact on the world around you. You, as a nurse, have the ability to add value to every person and patient you touch. We want to inspire you with the resources, education, and stories to support you to live your absolute best life, both in and outside of work. Don't expect perfection over here. We're just here to have some conversations about anything birth, work, and life, trying to add some happy to your hour as we all grow together. By nurses, for nurses, this is Happy Hour with Bundle Birth Nurses.
You're about to find out that you are in the presence of a legend, actually. This has been seasons in the making. I can't believe we haven't had you prior to now. Honestly, you've always been on our list, but I have been like, I want to do it right, it has to be the right timing, and today, we are going to go there, and we are going to talk about the nurse-doula relationship with a legend in the world of doulas. I'll let her introduce herself but this is Mrs. Ana Paula Markel. She has actually been a mentor of mine for most of my career, really. It's been, when did we meet, like 20--
Ana Paula Markel: 15--
Sarah: 15 ? 10 years?
Ana Paula: More than 10 years.
Sarah: More than 10 years? If you have been through our mentorship program, if you've taken our Coping with Labor class, one of the many things that I teach in a lot of my classes have been influenced by her, one of which you'll know because if you've done any of those classes, and that is the Welcome and Goodbye Breath, that comes from Ana Paula. She's taught me most of what I know about being a doula. She's helped me with my business. We have taught together. She's mentored me as a childbirth educator, and so you're getting just a little bit into my history of my growth with one of my mentors, let alone, again, a legend in the doula world.
Welcome to the pod. It's about time, AP, as we call you. Why don't you introduce yourself, and just tell us about your career, who you are, what you're passionate about, and what you've done.
Ana Paula: Thank you, Sarah. I'm so honored, and your words are very humbling to me. I also want to say that you're one of those people that it makes it worth doing it for because, yes, I've met you, and I have mentored you, but to see how far you are taking this conversation and your reach, it really, as I get closer and closer to retirement, this makes me so alive and so hopeful for the future. You have a wisdom that is beyond your years, a beauty that is inside and out, a light that sparks in you that will never be taken away. I am just so, so happy to continue to be part of your life and see all that you're doing.
My name is Ana Paula. I was born and raised in São Paulo, Brazil. I am the mother of four kids. I am married for almost 27 years. My first two kids were born by cesarean, and my two younger kids were born vaginally, so I had two VBACs after two cesareans. My oldest child was born in Brazil, and the other three in the US. It was through this personal journey, which is very long, and you could take an entire podcast just to go through, just going from a very paternalistic and male-centered relationship in between doctor and patient, and in a culture that has extremely high C-section rates, in a culture that really does not value vaginal birth in the same way, to then become, go through two VBACs after two cesareans, and then become a doula and childbirth educator. It really has been not only a change in careers, I come from a fashion background, but also a change in life.
I think learning my rights, learning about choices, and then what to do with that information, finding my voice, finding my confidence. It was not until I was pregnant with my third baby, when I was preparing for my first VBAC, that I switched doctors and took a childbirth education class and hired a doula, and this whole world opened to me. I just became that weird person that wanted to tell everybody that you do have options, and you can have better care, and you should have a voice. There are things we cannot control in birth, but there are some that we can control. That led me to become a childbirth educator first, and then a doula on the tailwinds of that.
Sarah: Then you became a doula, and what have you done as a doula? I think also, just for context, many of our listeners, we maybe have or haven't experienced a doula. I know for me, I didn't work with a doula until I changed hospitals. My first hospital that I was trained at, it was not the culture. It was like, a doula, what? What is that? Then I went to another hospital where it was like, probably 70% of people had a doula. I was like, okay, I get this doula thing. I think for all of us to understand what is the career path of a doula in general, and then what have you done to influence the world of birth? She's being very humble, by the way. If you've ever seen The Business of Being Born, or you've heard of DONA International? Tell us what you've done.
Ana Paula: I really cannot. I appreciate you so much. It's like, I'm part of a movement. There are so many people that came before me, like the founders of DONA, and even the Welcome Breath and Goodbye Breath. That's from my mentor, Julie Freidus. It's like, each one teaches one. We're just passing on wisdom. I didn't invent childbirth or doulas. It's like, we're just passing on wisdom. I think a lot of the doula movement is that. It is like the rescue of something that perhaps we have lost along the way with the industrialization of birth in regards to birth coming from our ancestors.
One of the things that I love to talk about is that it doesn't matter where we come from geographically, our great-great-great-great-great-grandmothers gave birth with very low tech and high touch. They all had community. They all had other women around them. They all had a place that they could go and talk about these issues and bring some normalcy to something that they are experiencing for the first time.
If I grow up in an environment that I am surrounded by other women, and the wisdom of the elders, and watching women pregnant, and watching women give birth, and watching women take care of babies, when it's my turn, I have seen a long labor, I have seen a short labor, I have seen a big baby, I have seen a small baby, I have seen meconium, whatever it is, so there is a normalization of that. I think the doula movement rescues a little bit of that ancestry of birth that we need in our spirit. That is the very meaningful, the spiritual transformational aspect of going from not having a child to becoming a parent. It's a much bigger picture than just the labor.
Then, if you think about also Western culture, that the average doctor's visit for the majority of people is so short that leaves out the conversations about fears, and anticipations, and aspirations, and dreams of what you want to achieve in becoming a parent, not just for the labor, but also everything else that comes. I think, again, the doula meets that gap in the sense that most people don't realize how much time doulas spend with people before they give birth.
One of the things that I love to say is doulas are sitting in pregnant people's couches with no hurry, and let's just go there and break myths. Also, I think the other piece to this is, a culture that stays very surface level, that Instagram feed that everything is beautiful and perfect. I'm fine, I'm fine, I'm fine, but in the back end, there is a lot of fear, there is a lot of confusion. When a doula and a pregnant person sit together, those barriers are broken, and they can actually talk about, like, hey, what's the deal with this? What's the deal with all those things that they hear that are trendy?
Yes, I think what I have done is perhaps one of the things that I can say that I have seen a shift is I became a doula in 2002. Back then, you think about a Saturday Night Live skit of a stereotype of a doula. That's exactly what doulas looked like back then, right? Most doulas were white. Most doulas were middle class. Most doulas had given birth at home. Most doulas were more earthy, environmentally connected earth mamas, which there is absolutely nothing wrong with it, but that was more the demographic of doulas.
Even though I have a side of that, I was raised in a metropolitan area. I studied fashion. It really did not fit my personality to just go full on. I had never given birth at home. I was not born at home myself. My mom did not even breastfeed me. My background was very mainstream. I think what was very important to me was to be a doula just like myself. I remember when I was a newer doula, many times when people would open the door, they would take a second look like, you're the doula? Because back then they couldn't go on social media to check me out. When I was at their door, it's the first time they would see me, and a lot of times they were probably expecting the stereotypical doula.
I think I really worked very hard to bridge this mainstream aspect of doula world, that doulas are for everybody. One, everybody can be a doula. Two, everybody can have a doula. That doulas don't have to look one certain way or support one kind of birth. That has been all along my mission in all of this is that it doesn't matter how you want to do this, you deserve a doula. You not only deserve a doula, but you deserve a doula that looks like you, that speaks like you, that you can connect with, either that is culturally, racially, in whatever aspects that feels right to a pregnant person. Regardless if they can afford or not, that's another very big piece to this conversation.
Sarah: Over the course of your career, you said 2001?
Ana Paula: 2002.
Sarah: From 2002 to now, what have you seen happen from that outsiders not working in the hospital, outside the hospital, looking in on birth? What have you seen happen? Where did you fit? Where were you involved along the way?
Ana Paula: Explosion. I think that doula trainings are huge. They are happening everywhere from all different kinds of trainings, all different aspects of birth work being involved in doula trainings. When I was trained as a doula, we didn't get any training in regards to starting a business or running a business or racial inequities, all of those topics that are extremely relevant today. I think that organizations, not just DONA, but other people that train doulas have become much better and much more current in regards to what's happening, what are the main issues, and how can doulas be better prepared to fit this role.
I think that will never stop. It's just like this is always changing, both in the hospital or for birth work. In both ends, it's constantly changing. I think organizations like DONA International have done a really good job in changing with the times. There's always new leadership that is bringing new vision and changing curriculums and all of that. I think that brings a lot of great things. It also brings some challenges.
I think the fact that doulas are not yet a standard curriculum in regards to what doulas learn, how they're trained, if they need to be certified or not. There is some value in that, that anybody can put a curriculum and teach a doula workshop, but there is also discrepancy in regards to what doulas really do and how can we really help. I think at some point, we're going to have to have a standard curriculum. A very unified code of ethics and standard of practice, and it is going that way.
Yes, I've been part of all of these conversations. I've been a volunteer with DONA International in the past. I've been part of their leadership for eight years of my life. That has taught me so much in regards to the movement from inside out. As you know, I've also been involved with the hospital side of it, which also has opened my eyes so much. It's very easy for a doula to criticize an institution from outside. I think working very close with labor and delivery nurses from within has taught me so much valuable information in regards to what nurses go through, what life in the hospital is like, the administration part of a hospital that has really helped me to prepare doulas with that vision of collaboration. I hope that that's a very long answer to your question.
Sarah: No, it's great. Going there, what don't doulas understand about the hospital that you maybe have been exposed to that you wish they knew?
Ana Paula: Well, one, I think that the hospital needs to change. The hospital just needs to get rid of this policy or start a new policy. It's just like, oh, yes. It's just like you're running your doula business with your three friends, and you put out an email, and you change something. Change something inside a hospital. I remember when we tried to put together that birth plan for the hospital. I remember from the time that committee--
Sarah: Oh, [unintelligible 00:16:00]
Ana Paula: Yes, from the time that committee sat down, discussed that birth plan, and keep in mind that committee had labor and delivery nurses, had postpartum nurses, had anesthesia, had doctors, so it was a robust committee that met for a significant amount of time to come out with a sample of a birth plan. By the time we submitted that to the hospital, to the time that it was published in the hospital website, it took about two years and it was changed about 15 times because every department that the birth plan had to go through, somebody had an edit to make.
That was my first time going like, oh my goodness. This is a hospital that is willing to do something. We have a manager that is willing to change things. It did change. That was a very big awakening. That you have to celebrate the wins, even when they're small and slow. The larger the hospital, the slower the change. I think that is a big myth. Also, how important relationships are. I think like-
Sarah: Amen.
Ana Paula: -getting an in, in the hospital, being invited to be part of these committees, to have that golden ticket to get me that table, was all because of relationships. It was all because of nurses like you, that you work once and you love, and then you work again and you work again. Before you know, you're talking in the corridor. Before you know, you're exchanging numbers. Before you know, you're going out for coffee. That's when bridges start to be built. Yes, relationship is truly everything.
Sarah: I think that that is part of the issue between doulas and nurses. In my opinion, there's so much misunderstanding between what a doula's vantage point is and the nurse's vantage point. Then when you look at the hospital system, even that alone, it's like what I find with the doula world is that a lot of people get into doula work because they're either had a terrible experience in the hospital, and then they had a positive experience at home, and therefore home birth is the answer, or they're looking to fulfill a desire to lead the change in birth. Therefore, what a lot of times that becomes is this aggression against the system that then it feels like we're opposed.
When we look at the evidence, we'll pause on that for a second because I've taught now on the evidence on continuous labor support. As nurses, we're half tired of hearing about it because you hear continuous labor support, and then as nurses, you're like provide continuous labor support, rolling your eyes like good freaking luck. We look at the evidence on continuous labor support. By the way, this is one of the most evidence-based things that we can do. By evidence-based, what I define that as, and let's be clear, I don't define it as, when we look at the definition of evidence-based care, it's using the least invasive, least risky, intervention first with the highest reward before you start layering on more and more risky things.
You look at the risk of continuous labor support, the risk of continuous labor, the biggest risk, I would say, is the relationship dynamic that messes with the physiology of labor when the doula and the team don't agree, when they don't get along, when they decide that they are enemies and that they are working against each other instead of with each other. Other than that, who doesn't want to feel not alone during their labor?
What we know about continuous labor support is that it leads to evidence-based decreased need for intervention, doubles the likelihood of spontaneous vaginal birth, shorter labors, lower cortisol levels, which is maternal stress, which, by the way, if you've taken Physiologic Birth or Physiologic Coping, impacts the physiology of labor and their chance of a vaginal birth, decreased cesarean birth, decreased instrumental vaginal birth, decreased use of anesthesia, decreased use of regional analgesia, higher 5-minute Apgar scores, more positive birth experiences, and better postpartum recovery, both recommended by A1 and ACOG. Why wouldn't we be doing this everywhere?
I will say the internal conversations, AP, that I'm hearing on these hospital calls are the doulas are buzzing. There's buzz in the hospital. What do we do with doulas? How do we work this in? Because what's happened over the last years is that, and I will say from a nurse's perspective, you have a good doula-- I hear it on stories. I hear it from our team. I hear it from myself of like, you have a good doula, and you're like, thank God. This is amazing. Yes. Then you have a "bad doula," and it is the bane of your existence. It makes your job so much harder, and you're looking at it where the doula's screaming outside the OR saying, "No, you can't have a C-section," when you're like, you don't even know what you're talking about.
I think we're missing each other when we're looking at this world of opportunity in front of us to go, we can change the game of birth if we were to just collaborate and understand each other better. Where I want to take the conversation is, what can we understand about each other, and especially in this case, for nurses to understand about the doula vantage point? I just have to speak it out that the most annoying thing for nurses is when doulas act like they know, and they're the knowledge base, whatever, and they're giving medical advice when you have no medical background.
Now, I can speak to that side because I've been functioning as a doula for the last eight years and taking those clients and now have that vantage point. I very much can speak to that, and this is where this could be our entire season of the podcast at some point. We can start our own. What are your thoughts on all of that? Particularly, I know it's like, where do we even go with this, but what do nurses need to know about the vantage point so that we can work better together? You can take this wherever you want.
Ana Paula: Okay. I'm going to start with the third thing that I have learned from working with nurses and closer to the hospital is that nurses become nurses for very similar reasons that doulas become doulas. It's a vocation. Even though it's a highly recognized and not enough recognized profession, it is a vocation. Nurses become nurses because there is a deep desire to soothe, to improve, to care. I have learned that in many situations when there is a doula family relationship, and they have now entered the hospital, many times they leave the nurse out. I think they come in this love bubble that is just like they have the inside jokes and they have the history background because the nurse is just meeting this family now when the doula has met with this family for sometimes 10 months before.
The importance of inviting the nurse into that optimism bubble. It's just like if there is an inside joke, share with the nurse. If there is a bet going around about the baby's weight, ask the nurse to weigh in. If you go to Starbucks, ask the nurse if they need something. Again, it's just like relationship and collaboration. It's basic, but it's really important for all the reasons that you mentioned in regards to improving physiological birth. Because in the end of the day, it's not about schmoozing, it's really about making the birthing person have the best experience, and the best way for that birthing person to have the best experience is, like you said, when there is collaboration, because we know that's how oxytocin works. Oxytocin is a bonding, trusting hormone. If it's not present in the room, it would be heartbreaking to think the doula was responsible for--
Now, we are our experiences. You mentioned the good doula and the bad doula. I remember hearing from nurses that there was a black doula list. It's just like all this stuff. Yes, of course. If a nurse is just coming out of an experience where they had a "bad doula," they are coming into this experience a little bit more reserved, but so could the doula. We are talking about your audience. If you are a nurse and you're listening to this podcast, you are interested in change. You are interested in physiological birth. You are interested in collaboration, but you also know those nurses in your floor that are not interested in change, that resist change, that resist doulas.
A doula may be coming from an experience that they had a "bad nurse" that mistreated a client or that shared bad information. I just saw this video that was going viral on Instagram about this doctor trying to coerce somebody into a medical intervention. Again, we see that all the time. We also have to understand that nurses, for the majority of the time, work in one hospital. As doulas, we see birth in a variety of hospitals in a variety of studies. We attend home births, birth centers. If you are a nurse that is super progressive, but you are working in a conservative hospital, that is limited. We also work in a system that is racist. If a doula is working with a family that is of color or there is a minority in whatever way that doesn't speak good English, they will have their guards up because they are fighting a system that doesn't treat everybody the same. Those are difficult conversations that we do need to have.
Now, we always talk about worst-case scenario, best-case scenario. There's where the opportunity is. It's just understanding as a doula. I think it's really important for a doula to understand that we are always advocates. It is part of our code of ethics to advocate for the family's wishes, not the doula's wishes, for the family's wishes. We are there to advocate. We can advocate by helping them to understand, making sure that if there is medical terminology being used, that they understand what that means. Getting somebody that can answer a question for them, making sure that they get their answers. It doesn't matter if they have to ask the same question five times. That's advocacy.
The other piece to this that you mentioned is medical advice. I think that is why it's important that doulas have some form of understanding of what we do and what we don't do. Doulas are not medical providers. Therefore, we do not give medical advice. It doesn't mean that I don't help my client to get the answer that they need. I think that is the confusion that sometimes people have and why some doulas resist certification because they think that if they become certified, they're just going to sit there and do nothing. That's not it at all. That is the role of advocacy. Can you please say that again? Are you clear? Do you have more questions? Would you like for your provider to explain one more time? All of those things that nurses do as well.
As doulas, we advocate always and all the time, but we are activists sometimes. Inside the labor room is not the place to be an activist. Being an activist inside the labor room will break that oxytocin bond. I always say this in doula training, like day one, if you are not an activist, you either become one or you have to quit. Because you cannot be part of a system that is racist, that mistreats people, that is not always honest and be okay with it. You see one person being mistreated in labor, you're like, oops, how can I change this? All doulas end up becoming activists one way or another, but we need to understand how to exercise that.
That's when committees and relationships and understanding laws, lobbying, being part of organizations, attending conferences, whatever. There's so many different ways to change things. I think that's an important conversation. They're both equally important, the role of activism and the role of advocacy, but where and how, that's really something that we all need to finesse a little bit. I'm constantly learning ways to do better.
Then the last thing is in regards to the buzz word of doulas inside a hospital, and that makes me very happy. It makes me very happy because everybody wins. I think that if hospitals are invested in doulas, then families will have more access to doula work. Doulas will have more work. Perhaps there will be a little bit of more understanding in regards to what a doula does and doesn't do inside a hospital setting and all of that, and doulas being seen as part of the care team. It's like, good money for the hospital, saves on intervention from all the evidence that you just mentioned. Again, I think there is an opportunity for everybody to win there. I hope that helps a little bit.
Sarah: Yes. I think when I'm thinking about the system, because what I think nurses need to understand as well, I agree with everything you're saying, I think it's so wise. I think the difference between the nurse's vantage point, and now I'm speaking from my own experience, is that as a nurse, advocate-- we also, you say you're an advocate. I'm like, well, we're an advocate. I think that can become triggering for the nurse because it's like, well, you're doing my job. I'm the advocate. Yet, what we don't understand, and yet I say we don't understand, but we also do understand that when you pull back and you look at the hospital's system, and I realize every hospital's its own microcosm, its own culture, its own values, and its own way, it's like working with different doctors.
You have a certain doctor, and you know that you're like, oh boy, this is going to be a wild ride. You have another doctor, and you're like, oh, thank God, because the doctor also paves the way. It's that same way, I think, with doulas, and yet we're forced to work with our doctors because of the hierarchy of the hospital system, and yet the doula's at the absolute bottom, least valued player from a hospital perspective, if I'm just calling it out, and yet we're missing the opportunity there.
I think what's triggering is that it's like, well, that's my job to advocate. From a nurse's perspective, then we're also like, well, but you can't offer medical advice, which I have a follow-up question for that in a second. It gets frustrating and triggering because they are offering medical advice. I realize you're the ideal doula that we all love working with, but they are offering medical advice, but what happens is we write their story, y'all. How many times do I say that on every single podcast episode?
This is going to be my book. I have another book that I'm trying to write, but this will be my first book because I think what when we see that, it's like, oh, well, they're just trying to overstep or we start deciding that they're trying to exercise their power or they're trying to have more say in the room when we all have the same collective goal. We're all trying to help this patient, and so if we can remove the ego, we can remove the one-upping each other or whatever it is and realize we're all here for the patient. Why can't we both advocate for the patient? Why can't we both help speak up, but all of a sudden, that becomes really messy?
My follow-up to some of that, you can say whatever you want related to that, but I want to know when a doula is pushing into that medical advice, while the risk of Pitocin is blah, they're suggesting Pitocin and they jump in on the conversation, what is the nurse supposed to do there? Even as a nurse myself, that's really annoying, where you're like, that's not actually true, and you're just functioning out of your own bias, and yet their bias exists because we abuse Pitocin. It's not unreasonable to have a little bit of bias related to Pitocin, but you also don't totally understand what we understand about Pitocin. What would you say to that?
Ana Paula: I love that. Thank you for the question. It's an excellent question. I love the word bias in it, because one of the things that I believe that it's really important for doulas is also to know your bias. It's really important to know your bias. For example, I don't love narcotics for labor as pain management-
Sarah: Same.
Ana Paula: -so I know when that's being offered to my client that I have to work on my face. I know that I have to take a notch down because I don't like it. If it was just my friend, I would just be like, hmm, but it's not my friend, it's my client. If my client wants that option, my client deserves that option. I think that's really important that we all know our bias. It's really important that we know and we own it. I have this bias. It's even okay to disclaim that to a client sometimes, to say like, listen, I actually have some strong feelings about this. Because of it, instead of answering you, I'm going to ask you more questions, or perhaps we can hear from your nurse first.
I think it's important to know your bias. You're absolutely right. Bias comes from experiences that they've had. They probably have seen an overuse of things, or they have seen perhaps clients being-- I think one of the things that doulas see a lot-- Again, we all have been on a program, and especially a hospital, in a time that it was doing really amazing job in changing for the positive. We've seen the culture change for a better communication and transparency in this patient-institution-doula relationship. What doulas see a lot is manipulative consent that looks like informed consent.
Questions that can be presented like, okay, we're going to do informed consent, but then they present the question in a way that it's basically saying, you either want to be a responsible adult and put the health of your child first, or you want to risk the health of your child just because you want to have this birth. It is- they're still asking questions, but they are manipulating and setting up for- it can look like informed consent, but it's not. I think the more experienced the doula is, we become better like, oh my God, that's such bullshit. This is not informed consent.
For example, I have had a client that asked her doctor, what is Cytotec? His answer, "A small white pill we put in your cervix." He's not lying. He was super friendly and super nice about it, but that was his version of informed consent. It's like as a doula, what do you do in a moment like that? You are not supposed to give medical advice and there is your client there, "Okay, uh-huh." It's just like those are the moments that you- but again, we still have a standard of practice and a code of ethics that doesn't allow us to give medical advice.
What I tell doulas is you can say anything that ends on a question mark because that doesn't mean you are telling anybody what to do. You are just starting a conversation, right? "Oh, a small white pill that goes in the cervix. Does it have any side effects?" Again, you are not saying, "Oh my gosh, there is some really bad articles online. Let me just Google it for you and here you can read about all the women that have died." No, you can just ask the question and you don't have to be the person that answers. You just start the conversation and you keep going until-- and I think that by the time the doula asks two or three questions, the family then it's like, okay, this is a time that we should be having this conversation. I think just getting that conversation going and I think that is the best way for us to advocate in situations that we need to advocate any state within our code of ethics and standard of practice.
Now, what does a nurse do when a doula is like, no, you shouldn't do Pitocin because this or that? I think it is appropriate to say, okay, thanks for sharing that. As a medical provider, is it okay if I now share my view on this? Let's go through possible benefits, possible risks, and alternatives. I think, again, modeling something, but I do understand that sometimes things are happening fast and sometimes people are tired, and sometimes it all sounds very polite and posh and nice right now, but sometimes in the moment, it's just eyes rolling everywhere. I can totally see why that would be annoying.
I don't know. I went through an experience that we built a house and I don't know anything about building houses, but I was the project manager on the family side. This house was built, not only something that I had never done before, but in Brazil, which is completely different standards, ways to build it. I could see the face of the construction people when I would give opinion or ask my question because I don't understand anything about construction.
Again, it's not that doulas don't understand anything. We understand by experience, and yet, it's like legally we are not supposed to do that. It's just not our lane. Now, it doesn't mean that our clients don't deserve the right answer, it's just who is giving it to them. I think, again, we are our experiences. I think doulas that tend to get more outspoken like that, it's probably because they've had bad experiences in the past or they have seen people not being given properly informed consent. It's coming from a good place in wanting to protect that, but you are absolutely right. I think a lot of it too is about ego. It's not just bias. It's about ego. I think--
Sarah: On both sides.
Ana Paula: On both sides. It's just that power play and I think that hierarchy of who is calling the shots.
Sarah: Yes.
Ana Paula: I think that some doulas value that power more than other doulas. Some nurses value that power more than other nurses. I mean, It's very clear when a nurse walks into the room, for me as a doula, when it's a nurse that is going to be collaborating or when it's a nurse that really walks in to tell us that it's their house and they call the shots. It's the same thing with providers, the same thing with doctors. There are some doctors that are really great in collaborating and some doctors that it's very clear that from the moment they walk in the room, that they are the top dog and they're going to be calling the shots. I think a lot about doulas stepping outside about their lane is probably from things that they have seen happen or perhaps not being properly trained or not. You never know. It could be so many different reasons.
Sarah: I'm having another aha because I'm thinking about this whole advocacy thing where doulas feel very empowered to advocate. I am your advocate. I am here with you to advocate. Nurses feel like I need to advocate. I'm here to advocate. Mind you, they may also feel morally injured by the system. They may also feel tired and burnt out and like, I don't have it in me, I don't care. I'm kind of apathetic. That's their own work, but my thought was, and I feel like I can say this because I've been on both sides, is that before I say this because it's going to bring some challenge, is that I think a lot of times with doulas, we tend to blame the doula for being annoying, for giving pushback, for being anti-hospital, like just be collaborative. That is true.
That is, and that I think is the massive gap that we have with doulas that we have to standardize training. We have to hold them accountable. There's zero accountability. You can report my license tomorrow, but you can't report a doula. There's these rogue doulas out there thinking that they're here to save the world with their egos flying high that are destroying this potential opportunity for families with the hospital system. I agree with you. I think it's so wise that birth room is not the time and place. There are so many other ways to be involved, but all you want to do is just fight the system. That's so annoying.
Yet, with that being said, that if nurses, let's be clear about the nurse's role. Actually, I was taking ferocious notes because I'm working this into our Move content, and we are going to talk about what this looks like. We are going to workshop this because it's not something that we're taught, and yet it's such a huge opportunity. If nurses did their job of ensuring adequate, let alone thorough patient education and informed consent through a shared decision-making model that was with an unbiased approach, let me teach you how to be unbiased.
I'm going to because I have so much to say about this, and I'm so excited about Move all of a sudden, and prepping that. If we were to do our job, and imagine a world in which, AP, that you have a client, and the nurse is there, and they pull up a seat, and they're physiologic, and they're like, talk to me about your preferences. Then they're like, what's important to you? How can I help with that?
Let's talk through Pitocin in a way that is non-coercive, non-manipulative, that gives you all the sides. How do you feel about it? You want some time, and doulas owned their own bias and said, I'm going to reserve myself. This is not my experience. This is their experience. Let me learn from you. How do you feel about it? Let's just make sure that you've thought through all sides. Then you want some pit, no problem. Even though I may, as a doula, I don't, by the way. I'm very open. I'm a nurse, let's be clear, but you want some pit, whatever. It's not that serious, so long as that you understand that you're making that confident decision.
If nurses were doing their job, and advocating, and educating, and ensuring shared decision-making, I don't think we'd have the same situation with doulas.
Ana Paula: Absolutely.
Sarah: Doulas would be able to just be able to show up and help facilitate the conversation, and be a part of it, and do comfort measures, and help with the vibe, and do all the things that nurses really want to be doing, but not all nurses want to be doing, but we can't because of the constraints of the unit.
Ana Paula: 100%, Sarah. I think it's absolutely that. I think there's so many pieces to this, like the culture of the unit, the culture of the hospital, where was that nurse trained, how long ago, all of those things come into play. The situation that you described, that a nurse comes in the room, sits down. To us as doulas, it's like a heavenly experience because doulas don't become doulas because we want to advocate or play diplomats. We don't become doulas because we have a vein in politics. We become doulas because of the pleasure of watching somebody on their labor, and find their voice, and even make decisions.
I think there's a lot of power in somebody that, since we're using Pitocin as an example, somebody that perhaps was planning on a medicated birth, all of the sudden understand and embrace that it's not going the way that they thought it was going to be. All of the sudden, go through that process of like, okay, I'm going to let go of this idea of the birth that I have, and I'm going to embrace this new birth. I think all medications have its place in labor. I think it's like the overuse of it or the unfair use of it that leads doulas sometimes to have a bias, but you're absolutely right. I think nobody should have a bias about that birth besides the person giving birth.
It's like we all have different ideas of what is an ideal birth or what's an ideal, even in regards to medications, the non-medications. I think this conversation is so outdated. This is about 30 years ago that the Bradley method would keep track of how many people that took a childbirth class would have unmedicated labors or would have a vaginal birth. Who cares? Who cares if you had medication or not, if you had a vaginal birth or not? I think what's really important is how were you treated? Was it fair? What did you learn from it? Did you have an awesome experience? That's just life. Sometimes it goes as you planned. Sometimes it doesn't, and things that are completely outside of our control.
Yes, there are many things. Of course, everybody should take your physiological class so they can learn all the things that we can help for a birth to end vaginally. There is a lot in regards to position of the baby and what we can do to the birth in person in regards to position. I think that if you have a doula or a nurse that has a strong bias and is showing that all the time, it definitely affects the outcome.
Sarah: Yes.
Ana Paula: I think that as a doula, I can think of experience that even in a progressive hospital, I've been with clients that are having the not straightforward labor, the ones that has curved balls, like a posterior baby or is low dilation, but baby's okay, birthing person is okay, but then there is that nurse that is like, well, sometimes it just doesn't work, or sometimes the baby may just need to be born by cesarean. It's like, we're not there yet. The doctor's not even here. Nobody's talking. There is that nurse just setting the stage for a cesarean. Those are the moments that as doulas, just like you have the annoying doula, for us, it's like, oh my God, isn't it your lunchtime? Don't you have another patient? Because things are okay. It's taking a long time, it's not straightforward, but we're okay. We're going to keep going.
Then the shift changes. The next nurse comes in and it's like, hey, how about we try hands and knees? You're like, oh. Again, it's just preferences that people have. Perhaps the nurse really thinks that a cesarean is the best way to go and is just trying to help them by thinking that they would probably not be disappointed or whatever. Again, it's really important to, if we all focus on the birthing person, what their dreams or their fears or their goals, what's happening with this labor, and we all focus on that, then it's all good. It's probably not going to be exactly how the nurse thought it should go.
It's probably not going to be exactly how the doula thought it should go, but it was not our birth. It was somebody else's birth, somebody else's story, somebody else's lessons, somebody else's path into becoming a parent that at some point we have to accept and let go. I do believe we're going to see a time that nurses and doulas are going to--
Sarah: It's coming, but we have to fix a few things. That's where what I'm seeing here that I don't know that I was expecting is if we all just owned our role, and honestly, doulas are the way they are because of us. If we were perfect in the way that we gave care to patients, they could come in and they could do the eye contact and the environment and the soothing and the massage and the options and the, what do you think about this? Try this, partner. You know what to do. Yes, that's normal. Look at how beautiful. All the, like the gushy stuff, but yet it's become so much of it does, it becomes this pushback, which is triggering to us. because we're trying to do our best and we're trying to function within a broken system. Then you're coming into the broken system with an understanding of the broken system trying to help, but these human-to-human dynamics are tough. That's where I get so excited about being at a place like Bundle Birth where we have the freedom to give some resources and tools to help with that because we're taught this stuff.
Ana Paula: Totally. Also, I do have to say, as I get older and nurses get younger, I am very, very hopeful with the new generation of nurses. There's nothing wrong with the old guard. There is amazing nurses there, but a lot of the people that have been doing this for 20, 30 years, they may be a little more resistant to change. Every doula training, there's at least three to four labor and delivery nurses taking a doula training because they just are curious about it. I think, you know--
Sarah: Oh, and they want to be doulas. Let's be clear. I get stuff in my DMs all the time where they're like, how did you do it? What do you do? What's the legal stuff? How complicated is it? Because the bedside wears us out. Those of us that love labor from a physiologic birth standpoint with an epidural or without, I will say, remove the charting and then get to just have continuity of care to build a relationship, to see it from beginning to end, to get to do the back rubs and the eye contact and the education is the most fulfilling thing ever.
Then I can text them after and I can go to their house and see their baby grow up. That's what we want as nurses. We're all jealous of that component of it. Not everybody, but a lot of us are. I think for nurses, by the way, it's coming for you if we can get there and we have the baby. That's my dream.
Ana Paula: Yes. Why not? I think that is another really important point because I think the labor is one important piece of this experience, but there is the pregnancy part, and then there is the postpartum part. I think that even when we talk about maternal deaths and we talk about doulas, we are now focusing on birth doulas because that's what we are talking about today, but we also have to talk about the importance of postpartum doulas and how they can prevent these maternal deaths that can happen in postpartum, especially for families that don't have support at home and all of that.
There is so much that doulas do that is outside of the labor room, but I think that you're absolutely right. What that does, it's like it harvests this relationship in between the doula and the family that it's really precious. Yes, watch these babies grow and also help people to understand that labor begins really after you push the kid out. That's when you're going to need support and the drugs and all of that because that's when labor really begins. I think it is a continuation of all of that.
Sarah: AP, any last words of wisdom that you wish nurses in general, but our nurses specifically, knew about doulas or could take?
Ana Paula: I think that they need to keep taking their classes and having conversations with you and attend their conference because it's true. It's just like opening portals of communication and understanding and collaboration that we have to be bilingual. We have to be bilingual on both ends. I think for nurses is stay curious. Try to communicate with that doula and understand where that doula is coming from, just like doulas should do the same.
One of the things that I always tell doulas is in regards to nurses advocating, which I think it's really important, is that even how we advocate is different because nurses know who to ask, when to ask, and how to ask. Doulas would never know how to do that. So many times I have heard nurses come in the room and say, like, hey, I checked who is on tonight, so we better do that now.
Sarah: Yes.
Ana Paula: Those are things we would never, ever know. The more that the nurse is involved in that story, the more that that birth also becomes part of the nurse's birth that is just like a collaboration, then they will be advocating in ways that doulas will not be able to. I think it's like, thank you for what you do. Thank you for every labor and delivery nurse. You have a really hard job, but a really important job. These people will never forget you. They will never forget the words of kindness that you share with them, the advocacy that you do for them. The high touch and the emotions that you share with them. You will always be part of their birth story. Thank you for what you do. I know it's not easy. Thank you for having this conversation and this interest in what doulas do. I really do believe that we are going to a more collaborative relationship. Thank you for having me.
Sarah: Thank you for being here. Thanks for spending your time with us during this episode of Happy Hour with Bundle Birth Nurses. If you like what you heard, it helps us both if you subscribe, rate, leave a raving review, and share this episode with a friend. If you want more from us, head to bundlebirthnurses.com, subscribe to our newsletter, or follow us on Instagram.
Now it's your turn to take what you learned today, apply it to your life, and the next time you work with a doula, take a step back, slow everything down, and really choose one action item from today's podcast to make a micro- shift in your practice to better collaborate with that doula and center the patient. We'll see you next time.