Monday, February 8, 2010

Mothering the mother in ALL circumstances: doulas and cesareans

I recently had the opportunity to do a consultation with a mother who is considering hiring a doula for her medically necessary scheduled C-section. Being me, I fear that I might have barraged her with a garrulous deluge of overinformation, but the interest was definitely there, and a good connection was made. (It would be a new experience for me, too, so my eager enthusiasm may have added to the overload.) Hopefully she'll be able to process what we talked about in her own time, along with the folder full of printouts I gave her.

So, what ARE the advantages of having a doula present at a cesarean, especially a planned one? As I wrote in the previous post on cesareans and birth plans, isn't the whole idea to use them (plans and doulas) to avoid having cesareans in the first place?

Yes and no. It's true that a woman seeking a natural or minimally interventive childbirth is doing herself a great favor by seeking out doula support. But A) There are, of course, rare times when complications can arise, even in a well-supported normal birth, and a cesarean truly is a lifesaving situation. Should the doula pack her bags and take off at that point? Of course not. She probably will not be allowed in the OR if the father is present, but there are other ways she can continue to be of great service, as I'll discuss in a moment.

And B) On a broader note, doulas are there to enhance ALL birth experiences for all women, and priority one is to support mom's own choices, helping her to achieve her own goals. The mission statement for doulas is often summarized as, simply, "mothering the mother". Yes, of course we do everything we can, within reason and within mom's parameters, to help her avoid a cesarean if she doesn't want one (and most women hiring doulas obviously don't), but we are not just vaginal-exit-only cheerleaders. This seems more obviously logical if the need for a c-section arises out of a spontaneous labor, but though it's rarer, there's no reason a doula would not be valuable, in some different ways as well as some very much identical ways.

So, then, what are some of the specific things a doula can provide to a mother having a cesarean? Let's say for the sake of argument that this needs to be a scheduled event (though much of it applies regardless). I would say there are three primary advantages to having a doula in this situation.

First of all, a doula can help the mother develop a birth plan that makes the absolute most out of the situation. The choices will have to be approved by the doctor and hospital, of course, but as I wrote in my post on c-section birth plans, there are actually a multitude of choices to be made. Some of those choices may be brought up by your doctor, but many others may not - they might even be new to him or her, and there are good doctors out there who are willing to try new things and learn and grow in their practice. Check out that post for a detailed discussion of the options available. The same doula can educate the parents about the whole overall process as well, if their doctor isn't able to take as much time explaining things as they'd like.

Secondly, it is a truth that more babies born via cesarean may have to spend some time in the NICU. Should that happen, typically the father will go with the baby - leaving mom alone and unsupported. The delivery of the baby, once everyone is prepped and ready, only takes a few minutes (5-15, depending on circumstances), but putting mom back together again takes significantly longer, generally 45 minutes to an hour, and that's assuming there are no complications. This can be a very difficult time for mom if her baby has been taken away, and having the doula step in for emotional support and companionship can make a huge difference.

The third major advantage is helping to get breastfeeding established. This is more challenging for moms in terms of positioning, even for experienced mothers with existing children, and can be particularly confounding for a first-time mom who is learning to nurse for the first time. Milk can also take a bit longer to come in (remember, though, 3 to 5 days is perfectly normal), and sometimes cesarean babies can be sleepy due to medication. If the baby is having to stay in the NICU, a doula can help mom to get pumping right away, establishing her supply and providing the baby with the best possible nourishment for him or her. All of these extra challenges are much easier to face with doula support.

Now, there are definitely some L&D nurses who are very good with breastfeeding, but, it must be said, there are sadly some who are not. Many a breastfeeding relationship has been sabotaged by hospital practices, even with an uncomplicated vaginal birth. And even the nurses who are good can be in short supply if you happen to be there on a particularly busy day. Same goes for actual lactation consultants. Some hospitals have them, but availability (and quality, too) can be limited.

Those, as I said, are the big ones. There are a lot of other little things that a doula can help with along the way - guiding both mom and dad through the admissions process; helping mom relax during the prep for surgery, including the epidural or spinal (a big fear for a lot of women); taking pictures as much as is desired and possible; keeping communication going between parents if they are separated by a NICU stay, and keeping mom up-to-date on baby's status; establishing skin-to-skin contact as soon as possible, which can be difficult if mom is having trouble with uncontrollable shaking from the anesthesia; running interference with relatives if needed, even running errands for the parents.

But hold on here, are you even allowed to have a doula in the operating room? In some cases, no. If the need for one arises during labor, it's true that it is very unlikely that a second support person will be allowed, though the doula can be standing by should dad have a hard time with the procedure or become ill or pass out - rare, but it does happen. (The other advantages of doula support still remain.) But if it is a scheduled cesarean, it is possible that special arrangements can be made in advance. As doula Rachel Wickersham explains:
Though it is possible your caregiver may initially be resistant to the idea of a doula in surgery with you and your partner, you may be able to convince him or her of the possible benefits to you - especially if you work with a doula who attended at least a few. And this may not be as far fetched as it may seem. I know of at least one practice in which there are doulas who specialize in cesarean.
I came across one mother's story of how invaluable her doula Shelly was for her own cesarean birth at Fort Wayne Doula Network. After attempts to turn Alison's breech baby via external version were unsuccessful, the family reluctantly decided to proceed with a C-section.
Shelly was very sympathetic and reassuring to us both. Mostly without words. Which we appreciated. She and Doug left the room while they prepped me for surgery. When they came back we made sure Shelly had her camera. Although we cried through the c-section a little it was very exciting too.

From the moment they got the baby's little bottom out Shelly started snapping pictures and showing them to me so I felt more a part of what was going on instead of so disconnected. It was great to have Doug and Shelly there so one person could be with me and one with the baby at all times until I joined him in the recovery room. She also unlatched my arm to touch the baby better after my pitiful attempts to stroke his little head while restrained for the surgery.

Shelly was intregal in getting me nursing the baby within 40 minutes of birth (not bad for a c-section!) She continued "nursing" Doug back to health a little bit by getting him what he needed and also helping out so he could get to the post partem room to rest for a bit. I was wheeled to my room with my sweet baby latched on and nursing like a pro!

Once we were settled in our room for a little bit Shelly asked if it would be ok timing for her to slip out for a bite to eat and to develop the pictures. When she returned she had an album of all the pictures she'd taken. I cried as I flipped through them... I would continue flipping through them MANY times over the next few weeks until I had memorized them so it actually felt like my memories instead of the actual memories I had of trying so hard to see everything and be a part of it while my baby was so far away at the little bassinet as they measured and treated him (the whole time he's just wailing for Mama)

I can't describe how much it meant having Shelly there. I am trying to in this email, and I tried to when I wrote her a thank you note after coming home from the hospital. But she was much more than a doula to me that day. She was a mother figure that I so needed. She filled that role when I needed it most. She was concerned for me and excited for me and I felt as if I'd always known her. She was truly the only advocate I really felt I had that day with me. My midwife was not able to be there during the c-section, and Doug was still kind of coming around and trying to get to feeling better himself. It was a very emotional day- but thanks to Shelly and her support the deliriously joyful emotions outweighed the negative. I had a happy, healthy (Big) boy and was well cared for with my medical needs.

Shelly helped give me memories by taking pictures of what I otherwise would not have seen. I can't tell you the value of that. It's priceless. I wonder if a doula isn't maybe even more needed w/ a c-section than a normal labor/birth- for the emotional side of it anyway. Even though it's such a shorter period of time. I guess everyone's experience is different. Shelly helped make the overtones of the day very happy. I just don't know how many different ways I can say it.
Two other great pieces I've found online do a great job of explaining the value of doulas with C-sections: Doula for a Cesarean Birth, by Robin Elise Weiss and the aforementioned "Is it worth hiring a doula if I'm going to have a C-section? by Rachel Wickersham.

Did a doula help you during your C-section? Have you been a doula at cesarean births? Please share your stories!

UPDATE: Make sure you check out the video about the "Natural Cesarean", a piece that began circulating after this post was originally published. The demand for this approach definitely seems to be growing!


  1. I didn't have a doula present at my emergency cesarean, but I made sure my midwife told everyone not to announce the baby's gender. I really wanted to see for myself first since I had planned to have my daughter at home and had that on my birth plan. It was a small thing but was the only thing that happened that followed my birth plan. And it made all the difference.

  2. I had a doula for my first labor, however when the doctor said "cesarean" she split. It was very disappointing. Now that I am a doula, if a client has to have a cesarean, I make every effort to go back with her (which over the last 6 years, I have been back for all but 3). I also stay with my clients for as long as they need/want me after the baby is born. ~ Caroline, The "Columbus Doula"

  3. Rachel is in my ICAN chapter! ;) She's one of the more popular doulas in my area. She is also a midwife in training.

    If I ever had to have a cesarean, I'm sure I'd have a doula. Though, I have to say, if I were a doula (being who I am) I would probably have a really hard time attending a cesarean. Too many PTSD triggers.

  4. Out of the 20+ births I have attended 3 have been cesareans. One was scheduled due to the position of the baby and other factors. She was very fearful and considering they kept pushing her back-due to "emergencies" my presence was invaluable. Her water had broken a few days before her scheduled surgery and they left her in triage for hours without allowing her anything to eat or drink. going into it I was nervous about my role-I was soon to learn my support was needed just as much as during any other birth. I also found I hung around postpartum longer than I had ever done in the past. :)

  5. Melodie, I was just thinking about that very thing, a few hours after I posted this! There are details like this that can mean the world to the parents, especially when their plans have otherwise changed so dramatically. Announcing the gender, making sure dad gets to cut the cord, requesting that baby not be scrubbed squeaky clean before being brought to mom, all these things are very much negotiable and can be facilitated by a doula's presence.

    Along with the above, for myself, I would also personally insist that the nurses refrain from holding the shocked newborn up in the air and making him "wave" to the mother, squealing "HI MOMMY! HI!" Just a pet peeve stemming from watching too many Discovery Channel birth 'reality' shows.

  6. Anonymous, that is SO disappointing! Urgh. I'm upset on your behalf. Way to make mom feel abandoned. I'm glad your own clients will be that much better cared for. It's good to know you've been able to be in the OR so many times, too.

    TFB, that makes perfect sense on the triggering. And tell Rachel she rocks! That was a very helpful piece.

    Simone, I'm sure your presence was hugely beneficial! And the extra postpartum care makes a big, big difference.

  7. So nice to see this! I just had a bunch of twin families in a recent class ask about the benefits of having a birth doula for their cesarean births. I gave them many of the above points, but there were several others I think were valuable that I didn't even think of!
    Thanks for sharing.

  8. Great post! I am really excited about having a doula for my 2nd birth (whenever that is), mainly b/c of the talk I had with you. I know my experience will be a little diff. from the one mentioned here, since I'll be under general anesthesia. Any doulas out there who have been a doula to someone who had a planned C under GA? When I think back on my birth experience I really regret not having had a doula there.

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  10. I wish I had a doula at my cesarean. I felt SO alone while I was in recovery and my DH was with my baby in the nursery. It was a scary lonely time for me. The nurse sat on the other side of the room and ignored me.

    I wanted to let you know about a great resource for moms with a planned cesarean.

    Hypnobabies has a set for cesarean moms.