Friday, October 1, 2010

Anatomy and Physiology: a Birth Doula Training

Best training EVER. (Okay, it was my ONLY birth doula training so far, but I can't imagine a training being more awesome than this. This was our group, and I'm second from the right, perched on the birth ball.)

I'm fortunate to have now had the opportunity to "sample" three of the most significant doula & childbirth education organizations out there. My postpartum doula training was with the big guns, DONA International. I've been doing the distance learning program for childbirth education through CAPPA. And it's now been five days since I finished the toLabor (formerly ALACE) Birth Doula Workshop in Chicago.

I genuinely have enjoyed aspects of all three. DONA's postpartum training was thorough, enjoyable and efficient, run by wonderful veteran Susan Martenson. The CAPPA training is a little tricky to get a feel for since I'm doing the work independently, but based on the written materials included as well as the video portion of the distance learning (consisting of footage from an actual workshop), I think this is a very worthwhile program as well; quite challenging, as it should be, but well-structured. And I was lucky enough to convince The Feminist Breeder to be my study buddy as we worked through the manual and videos, Skyping once a week to talk about our progress and bounce stuff off each other. (Yo Gina, have you gotten to those essay questions yet? Ay caramba! Buzz me to vent when you do.)

But this has been the zenith of my experiences so far. First, it was the culmination of a process I began about a year ago, in fact, when I applied and was approved to sponsor this workshop in my own area; in exchange for coordinating, promoting and otherwise acting as local contact people for the training, sponsors are then able to take the workshop for free. I was thrilled and enthused, and set about doing everything I could to make this happen. Alas, after months and months, the deadline drew nigh and in this arid birth climate (more on that in a moment) we only had two - TWO - people signed up (there was a minimum of 12), and toLabor had to make the difficult decision to pull the plug. Fortunately for me, they were generous enough to invite me to attend a workshop in another area. As I have a few friends in the Chicago area and it was a reasonable drive away (well, moreso without a toddler, but such is life), I signed on with the Chicago group.

My arrival at the location of the workshop itself was like walking into an oasis from two years of wandering the desert. It was held at Mother Me, a collective space where doulas, childbirth educators and other birth professionals pool their resources to serve the needs of pregnant women - birth preparation classes, massages, prenatal yoga, and more; it all happens here. What really blew my mind? This isn't even the only place like it in the area. There were even other collectives like it IN THE SAME BUILDING. And this is just one area in Chicago proper. It's all over the place - travel a bit outside the metro area and you can also find places like Birthing Babes (which happens to be TFB's latest gig, but it's just one example).

You must understand where I'm coming from. In my area, there is ONE independent childbirth education teacher - a truly excellent teacher (I sat in on her class and had a ball), but still. One. The only other options are the hospital's own class or the 4 week series taught by a "crisis pregnancy center", where for ten dollars people can take the series and get (I am not making this up) a free car seat. What's truly amazing about that $10 plus a car seat series? They are having trouble filling their classes.

There is a small but dedicated local chapter of ICAN, comprised of fabulous women who I not only consider good friends, but care deeply about birth and do everything they can - but in this climate, where there are only a handful of active doulas and even those doulas are being challenged by some OB offices' policies, their battle is mighty indeed.

The local cesarean rate, you ask? 37.6% as of 2008. Some L&D insiders estimate that it has easily risen beyond that in the last two years. I'm sure that's just a coincidence.

So yeah. To walk into this space was a glimpse of paradise, of the way the world CAN BE. Everything being relative, I am positive that the local birth pros could tell me quite a bit about the challenges they face in their own area, and I don't mean to discount that. But seriously, Chi guys, take just a moment to appreciate the fact that your community exists and thrives to ANY degree, because it could be so much worse.

So back to the training! Where to even begin with how amazing this was?

There was plenty of material that one would consider standard and expected; a thorough breakdown of the stages of labor, a risk/benefit analysis of every standard current intervention, discussion and practice of positions and techniques used to support laboring women, and much conversation of the way to walk in the world as a doula, supporting women's choices with information yet without judgment. All well-organized, all as thorough as can be in an 18 hour training; the time constraints were my only criticism, but it's an unavoidable given in this setting.

There are some features that are unique to toLabor's training, however, features which are controversial, and I'm going to address them and share my own feelings about them.

Since its inception, toLabor has included two unique hands-on experiences in the workshop. The first is the palpation of actual pregnant bellies, provided by volunteer mothers-to-be on the second day of the workshop. We also used fetoscopes (not Dopplers) to listen for fetal heart tones. There were four women who graciously offered themselves, and we divided into four groups, each group getting to work with two of the mothers. It was amazing to really have a chance to take our time really sensing and feeling a baby in utero other than the quick, cautious feel of a friend's kicking action - typically the only experience we ever get outside our own bellies, if we're had them. We took turns locating each woman's fundus, at first gingerly and then with more confidence, then worked at identifying anatomical landmarks - not quite as formally as using strict Leopold's maneuvers, but as accurately as we could, with continuous feedback from the mother (and the occasional commentary from the baby, too) and help from our classmates.

The fetoscope was also a revelation, truly a shame that they are used less and less often. It IS much quieter than the blaring of a Doppler, true, but it is also so much clearer without the associated static (Rixa writes about this here), not to mention risk-free (exactly how much risk is associated with Doppler use is a matter of some debate, which I won't get into here). It looks like this, in case you haven't seen:

And you use it either like this:

Or like this:

Therese, our fantastic and intrepid instructor, explained that this was absolutely, positively NOT about learning to palpate pregnant abdomens in order to do so on our clients. She was crystal-clear about the limitations of our scope of practice all weekend long, on this and other matters. This was an experiential, well, experience, simple as that. She described it as learning to touch, and while I agree with this, I also saw it as an opportunity to get some practice communicating with and just plain being around pregnant women, period, getting more comfortable talking with them about their lives and bodies and babies. To an experienced birth pro, that probably sounds so basic as to defy a need for practice, but I would argue that some of us still have nerves about it, and want to make sure we're both confident and respectful.

The second experience is the one that triggers the most raised eyebrows, and understandably so. If you're a part of this birth pro community, you might have heard about it, and yes, it's true. In this workshop, under extremely careful guidance, we had the opportunity to give and receive a very brief vaginal exam. All volunteer, working as partners with one another - no one had to participate, and indeed, we did have a few women sit out (though I'm not even sure who did, as we were all just focused on what we were doing ourselves).

Let me make this clear as can be: This, like the palpation of the pregnant bellies, is a learning experience ONLY. This was not instruction on how to perform pelvic exams on our clients, EVER, and it could not have been made more clear that doing so was strictly prohibited (unless this is something that is already within one's professional scope of practice; if an RN were participating in the workshop in order to learn how to give better hands-on support - but even then, it couldn't be clearer that a vaginal exam would be done in his or her capacity as an RN, anyway, not as a doula). A pregnant pelvis would feel completely different anyway, as would a cervix that was in the process of dilating - the assessment of which is a different skill altogether.

Those participating paired up, donned sarongs and slipped off their underwear, grabbing gloves, chux pads and tissues. The women receiving first lay in a circle with their heads together, a configuration which preserved modesty completely. We had learned the sterile technique for donning gloves, and once they were in place, we sat with our dominant hand raised in a fist, awaiting a touch of lubricant from Therese. She then guided us through what was ultimately a very short exploration; not rushed, but not terribly lingering either, with lots of feedback from our recipients. We first felt for the cartilaginous tissue of the cervix itself, then upward for the pubic symphysis and on each side for the ischial spines, giving us a tactile understanding of what the pelvic outlet comprises. Finally we felt for the downward slope of the sacral curve, and we were done. (No speculums, by the way, just gloved fingers, straightforward verbal instruction, and respectful caution.) We efficiently switched off and repeated the process in opposite roles.

What was this about, for me? First and foremost, it was about context, about taking the discussion of the baby's journey out of descriptions, diagrams, vinyl models of the pelvis and even 3d animations, and just for a moment giving us live, real, conscious, flesh and blood experiences. It also (unexpectedly for me) demonstrated the subjective nature of what we're discussing. Sometimes I hear birth stories where there is a discrepancy about how dilated a mother is, or how a position was misread, and my initial reaction definitely included a bit of "What? How could they, the PROFESSIONALS, not get that right?" And it's so much clearer now. So increased understanding for the care provider's perspective was an added bonus.

A third and more nebulous purpose of this exercise has to do with our culture's vaginaphobia, as Therese aptly put it. Does participating in this solve the problem, does it instantly cure us? Probably not, but it sure goes a good way towards demystifying the area, which is certainly apropos for those of us who care enough about birth that we were in the room in the first place. Which leads into addressing the controversial-ness of this part of the workshop.

The controversy DID come up, though not at length or with any specificity. We were not given details of debates past or identities of accusing parties, but it is clear that there are those out there who disapprove of this part of the workshop. I'm willing to listen to anyone's thoughts on this, if they take issue. Everyone has a right to their opinion, and I'm certainly willing to concede that there may be a POV that I have not considered.

But if the argument is (as it does seem to have been in the past) that toLabor/ALACE, by including the palpation and the vaginal exams in their workshop, is tacitly approving of doulas performing either one as part of their professional service, I wholeheartedly, emphatically disagree. I would even go so far as to say that suggesting that the inclusion of these exercises might be interpreted as permission to do so professionally is a bit of an insult to the intelligence of the participants. Anyone making this argument is simply not listening to the explanation and detailed description of the exercises, and has certainly never taken part in the workshop, since as I stated previously, it could not have been made more clear that this was never, EVER to be done on clients. Some toLabor participants are interested in becoming midwives in the future (i.e. me), as toLabor definitely appeals to the midwifery-minded (being explicitly based in the midwives model of care) so perhaps there's some legitimate confusion out there.

Is there a chance that some doula out there could go rogue and start doing so anyway? Sure, it's possible. But that is an irresponsible act by an individual, and in no way reflects on the training organization. It's just as likely that a CAPPA doula would turn off a fetal monitor, or a DONA doula would take it upon herself to start removing IVs, or turn down the Pit, or even simply start answering for the family regarding their decisions. ALL of which are terribly irresponsible, ALL of which reflect poorly on us as a community, ALL of which are repudiated by the major organizations. None of which means that the rogue doula's training organization has approved of their individual ethical breaches.

Now, on the flip side, none of that is to say that if you haven't been through these exercises at a toLabor training, you therefore aren't a good enough doula or that an organization's training isn't adequate without them. Not at all. It's not for everyone! It's not even for everyone who attends the toLabor training itself - I mean it when I said there was no sense of judgment at all. But let's please recognize, as a larger community, that there is a place for a variety of experiences, just as there is a place for a variety of doulas, and for some, this is going to appeal greatly to their learning style and if it does (not that it has to), it will only serve to enrich their work and thus their service to women.

There, I feel better.

Suffice it to say, I can't recommend this training highly enough. I would happily do the whole weekend over again, and in fact, I just may get to in the spring, if I'm lucky enough to be selected as a sponsor when I move to my new location in Portland (from a desert to an oasis to the freaking rainforest). In closing, here's a bad camera phone shot of my own workshop, followed by some quality shots from the toLabor site itself.


  1. Wow! That sounds awesome! Thanks for posting.

  2. The Collective sounds like my long-time dream of starting a center for Community Supported Parenting! Maybe we can get some ideas! Sounds like an incredible weekend :)

  3. Justine, I saved a flyer of theirs for you!

  4. Thank you so much for your reflections on these exams. I appreciate the thought you put into these write-ups and agree with you wholeheartedly. If we could only get the naysayers to calm down and process the actual scenario.

  5. love this-- Therese Hak-kuhn is an amazing woman, full of priceless wisdom and insights when it comes to childbirth (and life in general). She is a living treasure. She facilitates a fabulous birth circle in my community, as well as a post-partum circle,assists the midwife with whom I've worked with for 5 of my 6 births, and offers support and love to the entire birthing community nationwide in the training she offers. I am scheduled to take her toLabor course in January, and I can't wait. Thank you for posting this :)

  6. I took the training in March and it was fabulous. In response to your discussion of the vaginal exams, I will add that giving and receiving these to and from women who were conscious of being respectful, gentle, and present really highlighted how disrespectful, rough, and distant many doctors are when handling a woman's most intimate body parts.
    Glad you enjoyed the training. Best wishes on your journey.

  7. As a DONA-trained birth doula, my mouth dropped open at the Fetoscope on pregnant women part. But my chin is still on my chest from reading about vaginal exams! Torn between shock and awe or kinda jealous :) but maybe only b/c I am a mid-wife wannabe too. Aren't ALL doulas?
    so glad I found your blog from Birthing Beautiful Ideas. I am glad you enjoyed your training so much and will be checking back in to see how your births go. Oh, and moving to Portland? Yes, the rainforest of granola. Grew up in Oregon and finding anyone here that has even HEARD of a doula has been a long road! :)

  8. I'm so excited! I just signed up for this training in Feb, and it's only 1 hour away from my town. :) Thanks for your suggestion of it; I may not have found out that it was so close otherwise!