Doulas

What does Doula mean?

• The most favored female slave in the Greek household of yesteryear.
• A servant to meet your needs and your partner’s in labor and birth and the time just after the birth.

Who is a Doula?

• A companion who knows the road you are about to travel in pregnancy, labor, birth and in the journey of bringing home the new baby to your family.
• A friend who is there to provide continuity of care- by your side throughout labor, no matter how long.
• A “birth guru” of sorts who knows what your options are for pain management and relaxation methods, well versed in these ideas.
• A support person who is there to help you have the birth of your choice without any hidden agendas on how your birth should be.
• A reminder of the goals you originally set out to achieve and help you in determining if your path needs to veer off of that and do the next best thing.
• A guide for when you venture off your path and need to be redirected.
• A massager, encourager and whisperer of the gentle things you want to hear in the midst of the storm.
• A photographer and story teller of the journey.
• A woman who helps you with learning how to be a new mother or parent.
• A guide in nursing and caring for a newborn in the transitional path of parenthood.

What does a Doula NOT do?

• She does not do any clinical treatment- no exams, no heart tones, nothing that is in the medical realm. She is not a midwife or doctor or nurse when she is acting in the role of doula.
• She does not give you medical advice but may remind you or your original goals.
• She does not decide what type of treatment you need but may help you in determining what questions you need answered before you make an informed decision.
• She does not speak for you; she instead encourages you to speak for yourself.
• She does not take the place of a partner who wants to remain involved in the process of labor and birth.
• She does not run interference between you and the medical staff. But she does help you in ways to ask questions prior to your birth to get the information you need.
• In the postpartum period she is not a housekeeper but will tidy up and do some light chores as well as prepare meals.

Who needs a Doula?

• Women who want a medicated birth.
• Women who want an unmedicated birth.
• Women who may have surgical birth.
• Women who have a midwife or doctor.
• First time moms and seasoned moms.
• Women who are having a baby at the hospital, birth center or home.
• Women who are induced and those whose labor begins spontaneously.
• Women who want to decrease the use of Pitocin, epidurals, forceps and cesarean birth*
• Partners who want an additional team member in the support of labor, birth and just after the birth of a baby

A doula is an additional member of the labor and birth team as well as a helper to the new mother and family. Although doulas do not require any special training to call themselves a doula, many have found it helpful in knowing more about how to help a woman by taking training and choosing certification with one of the many international organizations such as Childbirth and Postpartum Professionals Association (CAPPA) or DONA (Formerly Doulas of North America) or Association of Labor and Childbirth Educators (ALACE).** The training usually consists of required reading, a workshop of several days, essays or tests, and evaluations by professionals.

Besides certification there are other differences in doulas. All doulas do not offer the same services. It is important to ask what services are covered by the fee that is charged. Some offer prenatal meetings to review your birth ideals and options. Some offer unlimited labor support no matter the length of labor, others charge extra for longer labors. Many have a back up doula in case of the unexpected events that could occur. Most offer continuity of care and come to you when you need them. Some come to your home and then attend you where you plan to birth while others only meet you at the hospital. Some based their fees on experience and others are based on what the market will bear. Some offer a sliding scale or payment plan if it is needed. Some offer their services both for labor and birth as well as the postpartum period.

The most important thing in hiring a doula may not be experience or certification but instead who do you feel like you can be most vulnerable with in your labor and birth? Her heart and hands and how you feel when you are with her is paramount. It is this relationship that will help you the most in your labor and birth. Does she listen? Do you find her words and wisdom comforting? Is she relatable? It is not how much she knows that is important but knowing how much she cares. Does she help you find your intuitive voice and your power within?

Some things that have been said about our group of doulas by first time and seasoned parents when asked why they hired a doula were, “ I felt lost in my wife’s first labor and jumped at the opportunity to have someone there who knew more than I know,” Andy, a second time expectant dad. Regarding a doula this couple selected, Donnie a dad who has hired this doula for both of their babies writes, “You can see it in her eyes, you hear it in her voice, and you just know that you are in good hands. Not only do you get the benefit of her knowledge, she somehow empowers you to believe in yourself.”

A new mom, Liz, when asked, What were the most helpful things about having her doula present for your labor and birth said, “ Where do I begin? Peace of mind that someone was ‘in my corner’ and knew how I wanted to labor are top of my list. It was also helpful to have you reminding me and Rob about what was going to come next and how we might be feeling at the next step/stage. You ensured that we got to experience our son’s beautiful birth! “ and another when asked, Overall, did having professional labor support meet your expectations and was the experience what you expected? Tonya said, “ It was everything I needed!” She went on to hire the same doula for her next birth experience.

So, if you want to help have a more memorable and gentle birth experience, consider hiring a doula! It may well be worth more than you would even expect.

Woman Affecting Change In Birth

The 60’s and 70’s birth experience for a woman was going to the hospital, separated from her partner, laboring virtually alone and medicated. Times gave way to a surge of women seeking an unmedicated birth. But the 90’s brought the epidural epidemic, climbing to 80% or even upwards of 90% of Atlanta women giving birth this way. What has happened to women’s bodies – why do they no longer feel able to birth without the use of medications that numb their bodies and for many, their birth experience?

When a woman asks can wear her own clothing in labor, or if she can choose her birth position, she has fallen prey to the idea that once entering the birthplace, she gives up rights that are not medically indicated. Choices are available.

Location for a birth is a paramount decision- home or hospital. With no birthing centers in the Atlanta area, there are limitations. Homebirth is alegal in Georgia. This means if all goes well, no one cares, turning a blind eye. If anything goes wrong, the midwife can be prosecuted. There’s fear and lack of information regarding home birth. Home birth costs substantially less, but is rarely covered by insurance plans. Therefore most women will choose a hospital birth. This insurance company determines the prearranged contracts with the hospitals. Location may be something a woman feels she has little control over.

There is choice of provider. Choosing a midwife rather than a doctor may open up options for birth. Midwives, in this state work under the supervision of physicians. The provider book may not state if a practice offers midwifery care, so research is essential. Midwives tend to look at birth as a natural occurrence providing care for most normal pregnancies. Many doctors’ perspective is one of a medical emergency about to happen, being quicker to intervene.

Who will be your primary support person- only her partner, or mother or sister or friend? Many like the idea of being with just their partner. Others will want to include a woman to “mother” her in labor. Surrounding the mom with those who are fully supportive of her choices is important.

Doulas are professionals who specialize in mothering the mother in labor. They are trained and experienced in supporting birthing women, knowledgeable regarding birth options; pain management techniques and positions. Studies show a remarkable difference in birth outcomes- less medication and interventions, and also the mother’s perception of her baby and herself as a mother. The doula and partner join together insuring a smooth working team helping the mom achieve the birth of her choice.

Having her other children in labor and present at the birth is an option. If so, it is advisable to have someone solely as his or her care provider. The child can come and go as their needs arise. The mom may need help controlling the visitors. Calling a few friends at the onset of labor can mean a party begins to take place in her room. The mom should be allowed to limit or control who is part of her birth environment.

What to wear in labor becomes a concern. The stiff, impersonal gown opening in the back, leaving you feeling vulnerable and exposed is not the only option. Women find big t-shirts, their partner’s shirt or a loose fitting gown is more comfortable, offering security. Making her feel more relaxed will help her to allow her body to release and open.

Women are bringing music, sound machines, aromatherapy and birth art to their labor rooms. Physical therapy “birth” balls provide a comfortable seat in which to keep their pelvis open and moving. The environment should be one in which a woman feels safe and is able to let go and let her labor unfold gently.

Choices of birth positions are available. Many midwives and some doctors are open to positions in which to give birth. Squatting, dangling, kneeling, leaning, and standing are available to many women. (Most of these positions are available for only unmedicated births.) The studies show that if you allow a mother to choose the position to birth in, the birth will go easier and faster.

There are a number of ways to manage pain during labor. Movement-rocking, walking, bathing, swaying and even dancing are good coping measures in labor. There is hypnobirthing, guided imagery, non-focused awareness and other techniques that allow a woman to let go and labor. Informed decisions about her choices in medication if she should choose, should begin before her labor.. Her decisions should be based on information that she has acquired from unbiased sources.

Moms may choose to touch their baby’s crowning head or reach down and lift their baby onto their own abdomen. The days of dad just cutting the cord have also changed. Dads many times can assist in the actual birth as well.

If she needs to have a cesarean birth, who does she wish to accompany her? Only in rare situations are there the restrictions of no one accompanying her. Does she want her partner, mother, sister or doula? Would the hospital allow two to attend her? Each hospital has it owns policies. Asking brings about change. To fail to ask for a change in policy changes nothing.

Once the baby is born, couples have options as well. Does the mom want the baby placed directly on her skin after the birth? Do they want the new born procedures done on the mom’s belly, or in the room? Does the mom want to nurse right away? Do they want to be a part of the first bath? Do they want to delay medications such as erythromycin and vitamin K or do they want to forgo those all together? These are all the parents’ decisions unless there is a medical reason to do so. Does the mom want to avoid any artificial feeding? Does she want to breastfeed on demand? Has this couple decided to leave their son intact instead of a routine circumcision? Possibilities are endless.

In the 70’s and 80’s we fought to ban those things that made birth more pristine and proper for the doctor but had no medical bearing to birth- routine enemas, pubic hair shaving and episiotomies and birthing in the supine position. What has made the change? Women. This is a consumer driven industry. Women are taking back their birth experience. The use of medication, where you birth, who is your provider, who accompanies you, what you wear, how your room is decorated, what position you birth in, what happens to the baby after the birth; these should be your choices.

You can affect change in the birthing environment by asking for what you want. Question protocols. In teaching I use the anagram BRAIN: B is the benefits, R is the risks, A is the alternatives, I is the instinctive and intuitive voice that is within you- listen to it, N is for the “now what”- or what needs to happen now- how will this affect me and my choices? So, women use your brain in making your childbirth decisions. Women can effect change by asking more questions and questioning more answers.

What Are Some Important Things To Know Before the Birth of Your Baby?

So, you have taken childbirth classes, read a ton of books and now you think you are ready for the birth of your baby. Well, let me share some things you need to know before you give birth. I share these things because recently I have encounted clients who have realized some difficulties that could have been avoided if a few more questions had been asked before the birth of their babies.

About your care provider:

Do they understand your birth desires? Sometimes there is no planned time to share what your desires for your birth are with your doctor or midwife. If it is not a scheduled appointment, then ask for a longer appointment time so that you can discuss your desires. Sometimes this is done really late in the pregnancy and it becomes apparent that they may not agree with your desires. But early in pregnancy you may not have formulated your desires yet. So, changing providers, although an option, is not one many people want to do. But don't be afraid to share your desires and your plans expecting them to honor your wishes even if it is not what they would normally do. This is a consumer driven industry and you do have a say in your birth process. The law says they must give you informed consent. Ask questions, you have to live with the repercussions of the decisions.

What is the induction protocol at your provider's office? There are many doctors and midwives that don't even start doing vaginal exams until the 41st week. Then others do them at 36 weeks and arbitrarily do stripping of the membranes each exam thereafter. While others will schedule your induction date after you have gone 40 weeks. You are due between 38 weeks and 42 weeks- that is when you are "late." So, ask ahead of time or before an exam is done what they plan to do. Even better, ask in mid to early pregnancy what their normal protocol is.

What about malpresentations? Does your doctor perform external versions if the baby is breech? Will he let you have a trial of labor for a vaginal breech if you have had a previous baby and have a "proven" pelvis?

If he or she is a solo practioner, who is the back up care provider? Many times you select a solo practitioner and then you find out that he shares weekend call with some other solo practitioner. So much for knowing who will be at your birth. Ask ahead of time about this and set up a time to at least meet the back up, just in case.

About breastfeeding preparation:

What shape are your nipples? If you plan to breastfeed you can overcome problems ahead of time if you make sure you do not have flat or inverted nipples. There are preparation techniques that will help to make it easier to breastfeed. Don't wait until the baby is born to address those issues. Go to La Leche League meetings while you are still pregnant. I can't stress the importance of meeting with other women who are nursing before your baby is born. A pound of prevention is worth a ton of cure!

Do they expect a large or small baby? There are weight limits that cause certain protocols at different hospitals. If so, having a lactaid or SNS system in your labor bag would help to assure if the baby needs supplement due to low blood sugar, you can do so while having the baby at the breast, not a bottle. The best thing to do is not have the baby weighed until you have had a chance to nurse the baby at both breasts. The colostrum goes a long way to raise blood sugars.

What is your pediatrician's stand on breastfeeding? Will he come to the room while you are still hospitalized so that the exams can be done there and your baby can avoid going to the nursery? Did she breastfeed, or did his wife? How long? Even if you do not know how long you plan to do so, it is helpful to find out how positive the environment will be beforehand.

About baby separation:

What is the hospital's protocol regarding baby procedures? Have a baby plan- tell them what you want. Again, they respond to consumer demand. Write a letter to the head of nursery staff and have a copy of it upon arrival. Let them know what you need- a delay in the bath, or eye ointment, or Vitamin K, no circumcision, no immunizations, etc. This is your baby. You decide what you want to have done if the baby is healthy. Routine procedures don't have to be so routine. Room your baby in so that you know what is being done and so you can have bonding time with your baby.

If you want a lactation consultant, ask as soon as the baby is born to have your name on the list. Do they have 24/7 lacatation consulting? Doubt it. Do they have weekend help? Doubtful as well. All the more reason to go beyond the lactation class or books you have read to the attendance of LLL meetings.

Read my article on using your BRAIN. Ask more questions so that you are an informed consumer taking a proactive role now in the outcome of your birth and your bonding experience with your baby.

Using Your Brain

When making a decision, we need to ask the right questions so that we can see our options clearly. This is a little acronym to remind you to use your brain when making decisions. It is useful in labor, but can be used for making all kinds of decisions along life's journey!

Benefits-- what are the benefits of doing this?

Risks-- what are the risks involved in doing this?

Alternatives-- what are the alternatives to doing this? Are there other options?

Instinct or intuition-- what is my intuition telling me to do?

Now what will happen?-- what will change if I do this?

Using your brain will help you to gather the information needed to make good decisions!

When Should Your Doula Arrive In Your Labor?

A doula is a professional birth guide. Her role is one of non-intervention and non-clinical in nature. She gently guides through her words, suggestions, and knowledge of birth to assist a couple in having a birth that is in line with their birth desires. Many doulas will come to your home in labor to assist before you leave to go to the hospital, for hospital-planned births. The question that arises in labor is when should I have my doula come.

The idea of coaching the woman in labor is one I am uncomfortable with. The birth guide and partner should be there to support the woman but not direct her. If a woman is walking the path of her labor and doing well, I do not think someone should tell her how to do things differently. If she begins to fall off the path and needs assistance- encouragements, affirmations, suggestions, that is when the birth guide should offer to gently guide her back onto the path. Listening to her body and what it tells her to do is paramount.

Marsden Wagner has said, “I feel the most important thing the birthing woman does is to listen to her own body and find out what her body is telling her she needs to do. And that neither the partner, or the doula, or whomever, should be giving orders, ‘Now do this’ or ‘Now do that’ because that interferes with what she is really trying to get from her body. The coach image is the guy who’ standing there telling the player what to do- the coach is up her ea the player down there somewhere.”

Sometimes when I have arrived too early in a labor, I notice that labor seems to stall or slow down. It makes me wonder if the woman is relying too much on my guidance, and me, rather than her own instinctive voice. Pam England in the book Birthing From Within writes, “Well-intentioned, but excessive, support in early labor (as when a birth companion hovers solicitously) can make you feel helpless, weak and dependent.”

Begin a labor project. Some labor projects may surround areas of cleaning or nesting for the baby. Perhaps washing and drying the clothes you have bought for the baby. Sorting items in the nursery. Working on the birth announcements or thank you cards for baby gifts. Putting together photos of the family. Painting the belly cast. Journaling a pre-birth story for the baby. Reading a book on breastfeeding or parenting. Exploring the area of birth art and fantasizing on what the baby will look like. Doing things that will enhance the bond you have with your baby will help you to connect and begin to unfold.

When your doula arrives too early she interferes with the natural process of letting labor unfold. She may be close to you, but she is still an outsider of sorts. This is the time to start allowing your mind to totally trust your body’s ability to give birth. It is essential that a woman start to see how her body can manage through the early stages of labor, building confidence in her ability to handle the ever-increasing intensity of labor. Having access to her doula for conversations regarding anxieties or fears that may arise is helpful. But having a doula there in early labor causes some women to feel pressured to perform and she feels her labor is being watched. This can be an empowering time of self-discovery.

I don’t believe in trying to force labor to begin. If it is early in the day, a normal routine of daily activities should be attempted. Until labor demands your attention, you should go about as normally as possible. If it is late in the day, a restful walk followed by a warm bath will help the mom achieve rest before labor becomes more active. The most important thing is for her to mentally prepare and have a mindset that will help her to let go and unfold for the upcoming birth. Eating, drinking and resting are essential for any impending labor.

As your labor begins, I suggest you call and let your doula know that things may be starting. If it is in the middle of the night, don’t wake your doula. You will benefit more from having a doula that is well rested if this is truly your labor beginning. And if you can go back to sleep, do so- waking to find her number and call her often sets adrenaline into motion and getting more sleep becomes impossible. But call her if you need her no matter the time of day. If it is during the day, stay in touch with your doula, keeping her abreast of any changes or concerns that she may be able to help you with.

As your labor progresses, you may want your doula to come to your home. She can help you with pain coping techniques, positioning and ideas that may help labor progress. At the point in your labor that you want to move to the location for the birth, she will accompany you. This will help the transition from home to the birthplace be smoother.

Your doula will stay with you throughout the labor. She will be the continual support that is needed and welcomed by moms no matter if the labor is a long one or a short one. Most doulas are able to help with the initial bonding time with the new baby. Skilled in breastfeeding, she can help you with the initial time of getting a baby latched on properly, insuring a more successful breastfeeding experience.

Your doula is there to help, not impede your labor. Calling too early might slow things down. As Pam England says, “Relax, breathe, feel the earth; and do nothing extra.” Rely on your doula when you need her, but rely on your instinctive voice beforehand and along the way.

"Relax, Breathe, Feel the Earth; Do nothing Extra"

Pam England

How are due dates calculated?

In the 1850's, a Dr. Naegele determined the average length of human gestation was 266 days from conception, or 280 days (40 weeks) from last menstrual period. He assumed that the average woman had cycles that lasted 28 days and that she ovulated on Day 14 of her cycle. He used his data to come up with a mathematical calculation for due dates:

((1st day of your last menstrural period -LMP + 7 days) - 3 months) = Due Date. EX: ((January 1, 1996 + 7 days) - 3 months) = October 8, 1996

This is still the standard method used to calculate due date, despite the fact that it doesn't take into account: that many women are uncertain of the date of their last menstrual period and not all women ovulate on day 14. Other factors which affect term are: mother's age, ethnicity, prenatal care, prenatal nutrition, number of prior pregnancies.

Another Calculation

A more recent study (Mittendorf, 1990) indicates that term for uncomplicated pregnancies in first-time, Caucasian mothers, averages 274 days from ovulation. It averages 269 days for mothers who've given birth before. The abstract says non-Caucasian pregnancies are shorter than Caucasian, but doesn't give statistics.

*To calculate a due date: Take starting date of last menstrual period. Subtract 3 months. Add 15 days. (10 days if you're non-white, or this is not your first baby.)

What else can be done to determine fetal age?

If ultrasound is performed in the first half of pregnancy, it can indicate fetal age within a range of 7 - 10 days.

Fetal heart tones can be heard through Doppler starting at 9-12 weeks and by stethoscope at 18-20 weeks.

Some believe the baby will come five months after quickening, the first time the mother feels the baby move. This is hard to evaluate, as women can be more or less sensitive to these sensations, and may notice them at different times in their pregnancies. (First time mothers typically notice movement around 18-20 weeks. Mothers who have been pregnant before notice it as early as 16 weeks.)

Fundal height, the measurement of the uterus done throughout pregnancy, can indicate the size of the baby, which can give insight about fetal age.

When will my baby be born?

Only 4% of babies are actually born on their "due dates". 6-10% of babies are born early - prior to 37 weeks; 4-14% of pregnancies last more then 42 weeks.

If this leaves you very confused, just realize that predicting due dates is a very inexact science, and it's probably best to plan ahead of time for the baby to come anywhere between 2 weeks before and 2 weeks after your due date.

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For more on due dates, read: Calculating Due Dates and the Impact of Mistaken Estimates of Gestational Age

Sources: "How long is too long?" by Penny Simkin, Childbirth Forum, Spring 1993. Abstract for "The Length of Uncomplicated Human Gestation" by Mittendorf et al
Obstetrics & Gynecology, V.75, N.6, June 1990. "When will my baby be born?" found at http://pregnancy.about.com/library/weekly/aa042197.htm "Pregnancy past your due date" by Terri Isidro-Cloudas on www.americanbaby.com

Let Labor Happen

The increase in cesareans today is linked to the increase in inductions. but there is certainly a seduction to induction today. The reason for inductions being so prevalent today is multifaceted. There are reasons to medically induce a labor. The signs of preeclampsia is one reason. There are some conditions that make the pregnancy threatening to the mom's health as well as the baby's. But many inductions are not medically indicated.

When a mom has had a fast birth the first time, sometimes there is concern about a precipitous labor with the second. I have accompanied moms in just such an induction. Many times the induction is easy, but it can also cause the labor to be more painful and longer than it would have normally been if not interfered with by the induction.

Sometimes childcare arrangements for the couple with one or more children, makes an induction seductive. Knowing the exact day the birth will occur helps some couples decide to have an induction. The element of the baby not being ready, or the body not responding to the induction in a favorable way is always a risk.

Sometimes an induction is decided upon due to fear that the baby is getting too big. I have witnessed births where the ultrasound confirmed a baby that was estimated to be over 8 pounds, actually to be born only weighing 7 pounds. The accuracy of a late ultrasound for judging size falls under scrutiny. There is as much as a 40% inaccuracy rate of these ultrasounds.

Medical induction methods can vary. Pitocin is often used- given either in large amounts quickly (active management) to being given slowly over a slower period of time. Cytotec, although under a lot of scrutiny for inductions, can be given to either orally or vaginally. Although this drug was not determined to be used for inductions, but is a gastro ulcer medication, it is a cheap alternative with good results if used properly and with discretion.


Prostaglandin gels can be used to help ripen a firm cervix. Sometimes the gel itself is enough to cause labor to begin. Artificially rupturing the membranes is also a method used to get labor started. Although there is no assurance that labor will occur in a timely fashion and usually means augmenting the labor with Pitocin after it has occurred.

Unfortunately women will often follow an induction suggestion made by the caregiver without regard to all the options available to them. And sometimes all the risks are not discussed. The increase of cesarean births is definitely one of the risks that needs to be discussed. Sometimes when drugs are augmenting a labor, it causes the baby to not choose it's own position and timing to enter the birth canal. Malpositioned bodies are certainly a cause in having to have surgery for arrest of labor. Increase of infection and bad reactions to the drugs used can also increase the risk of cesarean births.

Often times a mom comes to me and asks how she can get her labor going. God provides a great source of natural prostaglandin by way of semen. Certainly the same sensuality that got the mom pregnant can and will help the baby begin the labor process if the cervix and the baby is ready. Oxytocin, the natural form of Pitocin is also manufactured in the woman's body naturally by way of nipple stimulation and orgasm. So. intimacy and cuddling is certainly a natural way to let your body get ready for labor.

Many times when I am with a woman who is in early labor and she asks what she can do to get things going. This is my response, let labor happen. There is no need to make things happen. If you are in early labor, a warm bath will often slow things down and allow more rest if it is late. If early in the day, staying upright will facilitate both the decent of the baby as well as the movement helps the mom deal with the pain of labor. A warm tub will often accelerate labor in the active stages. But, taking a power walk before your labor kicks in could prove to be detrimental if your labor is a longer one.

New studies show that labors for first time mothers can average 19 hours. So, resting, keeping yourself distracted with labor activities, eating and drinking lots of fluids remains the advice I give moms in labor. Just let your labor unfold. Don't do too much, but don't do too little. Focusing on your labor and each contraction is not the way to help the time pass either. Do what you can do to stay as normal as possible in early labor.

Confidence in her body and the absence of fear will help her labor unfold more than anything else. So, learning to trust her body, learning techniques to help her relax and dealing with the fears she has ahead of time will help her to let go and open up her body to birth her baby.

Doing the Next Best Thing

When someone asks if Birthing From Within is natural childbirth preparation, I have a hard time answering that. Certainly most of my students plan to attempt a medication free birth experience. But BFW is birthing in awareness. If you are making an informed decision, and are choosing your next approach based on what is the next best thing to do in our situation, then you are making a decision in awareness and thus birthing in awareness.

Each birth is different and you have not idea what may be truly needed in that particular birth. That is why birth planning is difficult if not impossible. Certainly you can fantasize about your birth and make your wishes known, but to truly plan it is not conceivable having no idea how it may unfold.

In a birthing in awareness childbirth class you will learn to develop a pain coping mindset. You will learn at least 20 things that will help with pain coping. For instance think in terms of a few you already know that work when you have pain now. In class you will learn how to decide what things to choose and when the timing may be more beneficial. But here is a list of 20 things to try in labor :

1. Bath or shower
2. Walking or movement
3. Birth ball
4. Encouragement
5. Co-chanting
6. Rice Sock for heat therapy
7. Ice hands for cold therapy
8. Aromatherapy
9. Non focused Awareness
10. Breath Awareness
11. Coyote Howling or vocalizations
12. Quaker listening
13. Massage
14. Edges, Centering, Spiraling
15. Candle Gazing
16. Bellydancing
17. Reflexology
18. Doula support
19. Narcotics
20. Epidural

Fear & Fatigue

the Two Big Factors in Labor and Birth

As a labor doula there are two factors that I think make the most difference in labors. The first one is fear. Pam England says that the work of pregnancy is worry. We need to get all our fears out on the table and address them one by one. That way when labor begins, we have gotten the fear factor out of the way and we can labor. When a woman is holding onto some hidden fears she does not allow her body to unfold and birth. This truly inhibits the mind-body connection that is so essential for birth to flow more easily.

Some of the greatest fears are not unique to most women. There is a fear of loosing control. The concern about pooping when they are pushing out their baby. There is concern that their behavior will be such that they will be embarrassed by it later. There is the issue of trust for their provider and the location where they will birth. Will their partner be supportive enough? Will this experience enhance their relationship or hurt it? Will their body "fail" them- not opening properly or not being able to withstand the pain? Will they have to fight for what they want? Will they allow something to happen that they will later regret? These are just a few of the concerns most women share with me. The answers or solutions are as varied and individual as the concerns. I do know that these concerns need to be addressed long before labor begins so that these same concerns won't inhibit the natural process of labor.

You mind has a lot of control over your body. Sometimes we don't even know some fears are lying just under the surface of our conscious mind. Some people find the use of journaling to help then get in touch with what they are feeling. Some use birth art to help them discover what is going on inside their heart. When you feel something don't squish it down, open it up and let it out. It is essential for you to have your mind and heart open to your birth experience. You can't plan it but you need to allow it to happen without fear being a controlling factor.

I think one way of addressing fears is to begin to talk about them. You need to talk about them to your partner. You need to talk to your provider about them. If you feel like you are having to defend or fight now with your provider on some issues, then you may want to consider if this is a relationship that needs to change now. If you don't feel comfortable addressing your concerns with the person who will be your care provider in labor before your labor begins, perhaps you need to consider if you will be able to once labor makes you feel even more vunerable.

The other factor that I see play a huge role in the way labor happens is fatigue.It is essential in the last weeks before birth that you stay active and fit. But it is also essential that you rest when you are tired. Going to bed earlier than normal after a soothing bath is a good ritural to begin. If you are having problems sleeping talk to your care provider about some homeopathic or natural remedies that they can suggest. A warm bath with lavendar scents and a soothing massage will do the trick for many moms. But creating the ability to at least rest even if sleep is hard, is important.

When labor begins, if it is late in the evening, try to rest. Stay in bed if you can. Cuddle on the sofa in front of a good chick flick. Don't feel the need to go out for a power walk if you are tired. If it begins after you have had a good nights sleep, then go about your day, but don't over do it. Women who have lost a lot of sleep or try to work themselves into a good labor pattern find that they usually don't have the stamina for a long labor. Labor can be exhausting. Save your energy. Stay upright and active but only if you have rested. Listen to your body. If it says lie down and rest, then do it!

My suggestion to women in early labor is to rest and keep themselves well hydrated. Go about doing what you would naturally do at that hour. If it is 2 am- then crawl back in bed. You won't have a baby while you are sleeping. If it is 2 pm, go about doing what you need to do- but don't over do and rest when you need to. I believe if you listen to your heart and body and address your fears and take care to not over do in prelabor and early labor, two factors that can cause labor to not flow smoothly will be taken out of the equation!

Bishop Scores... and warning about Cytotec

The Bishop Score is a method to help determine how favorable your body is for an induction. The less favorable, the more likely your induction will fail and thus lead to a cesarean birth. The more favorable your score is the more likely your induction will lead to a vaginal outcome. There are several reasons to induce. This is a question for you and your care provider. But determining how favorable you are is something you should know so you can make an informed decision regarding the likely outcome.

Points you earn / 0 / 1 / 2 / 3 /

Dilation (cm) / 0 / 1-2 / 3-4 / 5-6 /

Effacement (%) / 0-30 / 40-50 / 60-70 / 80 /

Station / -3 / -2 / -1/0 / +1/+2 /

Cervix / firm / medium / soft / /

Cervix Position /posterior/ meidan / anterior/ /

Ask the care provider these questions: How far dilated am i? How effaced? What station is the baby located? How does my cervix feel? Is it soft or firm? Did the provider upon the exam have to reach way back, making it uncomfortable to do the exam? Ask if your cervix is posterior or anterior. Then take that information and give each item a value based on the chart above. The add up your score. This gives you a predictive value for your inductions success.

A predictive value:

0-4 45-50% failure

5-9 10% failure

10-13 1% failure

Understanding your rate of success for induction is just gathering information in order for you to make an informed decision.

Doctors can improve your bishop score chemically. They can insert Cervidil into your cervix and it can often bring your dilation to 3 cm and increase your effacement. There are other methods like using a bulb syringe from a catheter to stretch the cervix to prepare you for an induction. There is another method that is considered quite controversial- misoprostil of Cytotec. I do not feel a women should consider this method until she read what the manufacturers say about its use for induction, "

Misoprostol , given as a 1/4 of a small tablet placed in the vagina.
Misoprostol is an ulcer drug that is contra-indicated in pregnant women, not approved for induction of labor, associated with increased uterine rupture and maternal/fetal/neonatal death.

Known complications include:

Uterine hyperstimulation / tetonic contractions -- less than 2 1/2 minutes between contractions or lasting longer than 75 seconds, can occur up to 12 hours later;

fetal distress or amniotic embolism due to prolonged hyperstim;

uterine rupture, hemorrhage, emergency hysterectomy, maternal or fetal death/disability,

neonatal brain damage at birth, admission to NICU, cerebral palsy.

And another authortiy on birth, Marsden Wagner writes, "

The June 1999 issue of the American Journal of Obstetrics and Gynecology published the article "Uterine rupture associated with the use of misoprostol in the gravid patient with a previous cesarean section." The data in this article are truly frightening. "Uterine rupture occurred in 5 of 89 patients with previous cesarean delivery who had labor induced with misoprostol. The uterine rupture rate for patients attempting vaginal birth after cesarean was significantly higher in those who received misoprostol, 5.6 percent, than in those who did not, 0.2 percent or 1 in 423, p=0.0001)." Furthermore, a medical records review turned up several more cases of uterine rupture associated with using Cytotec with VBAC not included in their calculations.

Be clear on what this says. Over five percent of women given Cytotec for VBAC had a ruptured uterus, a 28-fold increase over those who did not have Cytotec induction for VBAC. This is a truly shocking rate of uterine rupture. And one of the five women with uterine rupture ended up with a dead baby as a result of the rupture. Just in case you think this paper reports an aberration, the same issue of this journal has a second paper in which three of eighty-one women receiving Cytotec for a VBAC had uterine rupture--a still shocking rate of 3.7 percent. And one of the three babies died in the NICU after the rupture. Both these papers were retrospective which means that none of the women given Cytotec were part of a research project. Thus, none had received the protection of research subjects, including information on the experimental nature of the drug given to them.

So in these two papers, of 170 women given Cytotec for induction with VBAC, eight have lost their uterus and two lost a baby as well. It is my educated guess that to this day none of them has been told that they were given a drug for a purpose not approved by the FDA nor has been told their case is described in published papers saying this drug should not be used in this way. These women and babies paid a very big price because their practitioners were willing to use a very powerful drug before it has been approved by the FDA for this purpose and before it was adequately evaluated by prospective, controlled research.

Marsden Wagner MD, MSPH

Do I Need a Doula if I Plan to get an Epidural?

Sometimes women think if they are considering an epidural they don't need a doula.

As doulas it is not about us and what type of birth we want. Or what kind of birth we had personally. We are there to support women and help them to make informed decisions that are right for them as individuals. But, I tell moms if they would be sorely disappointed if they don't get an epidural then I am probably not a good doula choice for them. The reason I say that is that many women who have considered an epidural an option, find that they don't need one once I am there offering many other options in pain relief. It is not the doula's roll to insure you get your epidural if you are not asking for pain relief and are coping well with the contractions. Many moms are wonderfully surprised when they find that they can manage without an epidural after all. Much of the pain experienced in childbirth is related to fear. The doulas support and presence can enable a mom to let go of her fears and enter a safe haven to birth.

If you have a doula, does that insure that your labor will be one that an epidural won't be used?

Definately not, although the statistics state that it decreases the request for epidurals by 60%. But there may a time and a place for an epidural in some births. Are they overused today? Yes. Are there negative aspects to an epidural that you need to know about before deciding on using one? Yes. But if your labor is excessively long and fatigue sets in, or if you have a labor where you are failing to progress, sometimes it can be useful. If you have a non-natural labor, where you have to be induced, many times epidurals become neccessary. If you have to have a cesarean birth, you most likely would prefer an epidual over general anesthesia. For some women who have experienced abuse in their background, epidurals can ease the pain of labor. A doula is there to support the informed decisions you make.

What can a doula do once you have an epidural?

A doula may have arrived earlier in your home or met you at the hospital in earlier labor. She could have offered pain coping techniques that helped you get to the active stage of labor. This is the best time to wait to get the epidural if that is your plan. She can offer support in your decision. Many times women are disappointed if they had not planned on getting an epidural and end up making the next best thing decision and decide to have one. And yet by having a doula there you have knowledge that you have exhausted other alternatives before choosing to have one. There is the ability to delay the epidural until you are in active labor and therefore limit some of the negative side effects that epidurals can offer. She can assure that you get turned frequently so that malposition of the baby is limited. She can offer some massage techniques to help keep your contractions regular and not slow down after getting an epidural and therefore limit the need for pitocin. She is there to offer information and companionship during what can be a scary time. She can help when it comes time to push by offering some techniques for helping the mom to push more effectively. She is still there for photo taking and help with breastfeeding afterwards. And for the moms who have negative reactions to the anesthesia, shaking, nausea, windows of pain that the epidural missed, and itching, she is there to help.

So remember this is your birth experience.

But before making some of your decisions set in stone before the first contraction, know what other options are for pain coping methods, delay the use of an epidural until you are in active labor, and have a companion that is knowledgeable about birth there to act as a birthguide. Learn about labor and what to expect in labor. And understand that there are many unknowns in any labor. Having a doula by your side can decrease the use of forceps and vacuum by 40%, decrease cesarean births by 50%, decrease Pitocin use by 40% and shorten your labor by 25% as well as decrease the requests for an epidural by 60%.

Here is an article by another doula that explains why that is a misconception.

Doulas and Epidurals

By Kelli Way, ICCE, CD(DONA)

Your doula’s role is to assist you during birth. With or without pain medications, you are giving birth, and your doula will be there to comfort and support you.

Giving birth to your baby is much more than a medical procedure. It is an emotional as well as a physical journey, and having a doula with you can help smooth the crucial transition from pregnancy into parenthood. Both parents will benefit from the nurturing care a doula provides.

Epidurals do not usually take all the pain away. You will still be required to use some other forms of comfort measures at times.

Although good to excellent pain relief is obtained in 90% of epidurals, few epidurals take away all the pain. Some hospitals advertise "painless childbirth," but few women experience it that way. There are several reasons why an expectation of "painless childbirth" may be unrealistic. Often you must wait for the anesthesiologist to become available. You may need to wait while you receive 1-2 liters of i.v. fluid. The procedure itself can take up to 30 minutes, and you may not have complete pain relief for another 20 minutes. Once you are close to complete dilation, the epidural may need to wear off, or you may experience breakthrough pain. Rarely, the epidural gives only patchy pain relief, or doesn’t give pain relief at all.

If you experience any of these situations, or if you prefer to avoid using the epidural until you are 5cm to reduce your chances of needing a cesarean, your doula will be invaluable in helping you use breathing and relaxation techniques, suggesting position changes, and using non-medical forms of comfort measures.

Epidurals often (over 70%) come with mild side effects, which are unpleasant although not medically serious, such as itching, nausea, and shaking. Your doula will stay at your side, helping you cope with any side effects you have, and giving you information about your options.

While an epidural relieves most of the physical pain, it does not affect your need for reassurance.

You might expect that with pain relief, all your worries will go away. Interestingly, this does not seem to happen. Women experience the same emotions during labor whether they use epidurals or not. Many times, the medical staff feel that if a woman has pain relief, she doesn’t need the same type of gentle emotional support. Women often feel even more frightened and worried when they sense this emotional withdrawal. Your doula will continue to focus on what you are feeling, and will give you the reassurance and comfort you need.

Help in coping with pain is only one small part of your doula’s role.

Epidurals do not hold your hand, rub your shoulders, explain what is happening or help you make decisions. Epidurals do not get you ice chips or remind you to urinate. Epidurals cannot suggest position changes to help labor progress. Epidurals will never advocate for you or help you get what you need from the hospital staff.

Epidural or doula?

You may want both. If you are considering using an epidural for pain relief, make sure that you choose a doula who will support that decision. Talking about your options and feelings in advance will make your labor much smoother, leaving you free to concentrate on the birth of your baby.

Benefit of labor- even for planned cesareans

Babies born by cesarean section before labor are more likely to have breathing problems and to need special care in the early days of life,compared to babies born after labor. Sometimes the obstetrician thinks the baby is older than he or she actually is, perhaps even ignoring the mother's opinion of when she conceived. Other cases seem to reflect the normal human variation which leads some babies to mature sooner than others, just as they roll over, sit and walk at different times. None of the tests are 100% accurate in dating a pregnancy or in assuring fetal maturity. However, even when the baby is definitely mature, a certain number of born before labor suffer from lung disease, particularly complications from excess fluid in the lungs.

A recent article in Scientific American documents why labor benefits,including their lung functioning. ("The 'Stress' of Being Born," Hugo Lagercrantz and Theodore A. Slotkin, Scientific American, April 1986, pp.100-107). Hormones called catecholamines are released in the baby in response to the stress of experiencing contractions, being pushed through the birth canal, and the intermittent oxygen deprivation which occurs in normal labor. Twenty years of research indicates that these hormones not only protect the baby from a lack of oxygen, but also prepare him or her to adapt to life outside the womb.

Adults also produce catecholamines in response to physical or emotional stress. The heart rate increases, while blood is redirected away from many organs and sent to the heart, brain, arms, and legs, all needed for the so-called "flight or flight" response. This is the reason for a mother's fear and anxiety can lead to prolonged labor and fetal distress. (See C/SEC Newsletter, Vol.12(2), 1986). With the immature nervous system of the fetus, however, catecholamines work somewhat differently. Blood is kept in the brain and heart rather than the limbs, and the heart rate shows rather than rises. This allows the brain to survive without damage at much lower oxygen levels, similar to the way people can survive for hours in very cold temperatures under ice or buried in snow. The discovery of this different response to stress in the fetus means two things: 1) Babies are well protected from reduced oxygen in labor; and 2) When the fetal heart rate slows in labor, rather than meaning the baby is in danger, it may mean the baby is being protected from damage. This process explains why over 50% of babies delivered by emergency cesarean after monitor tracings indicate fetal distress are in fact not short of oxygen at birth. The authors recommend that only when fetal scalp blood sampling shows the baby is truly short of oxygen should he or she be delivered quickly.

Catecholamines appear to help the baby adapt to life outside the womb in several ways. First, a surge of catecholamines in labor facilitates breathing by causing fluid to be absorbed from the lungs and surfactant to be released. (Surfactant allows the lungs to remain open once they are expanded with the first breaths.) Lung compliance, the ability of the lung to stretch and fill with air, is partially dependant on lung liquid absorption. In research at the Karolinska Institute in Sweden, lung compliance was correlated with catecholamine levels at birth. Two hours after birth, vaginally delivered babies had significantly better lung compliance compared to cesarean babies. This helps explain why even mature babies born by elective cesarean are more likely to have breathing problems.

A second benefit of catecholamine surge at birth is to speed up the baby's metabolism, so energy stores in the liver and fat cells are made available until the baby begins to nurse. Cesarean stored fuel, and were more likely to have low blood-sugar levels. The burning of stored fuel also helps the newborn maintain body temperature.

A third effect of catecholamines is to alter blood flow so more blood is sent to the vital organs. Blood flow in vaginally delivered babies was lower in the legs and higher through the lungs during the first two hours of life. This effect is particularly important for babies experiencing breathing difficulties right after birth. In general, the higher the catecholamine surge, the better the baby can withstand oxygen deprivation. Babies who were moderately deprived of oxygen during birth had good Apgar scores if they had high catecholamine levels and lower Apgar scores if they had low catecholamine levels.

Another effect of high catecholamine concentrations is to produce a state of alert arousal. It is possible that the catecholamine surge leads to the extended quite alert state which usually occurs in a healthy baby in the first hour of life, and which may contribute to the beginning of parent-infant bonding right after birth.

The Karolinjska Institute studies also found that babies born by elective cesarean without labor had markedly lower catecholamine levels compared to those born vaginally, while those born by cesarean after labor had begun had only slightly lower levels. The message seems clear: A mother who wants a VBAC is not putting her own experience ahead of her baby's well-being. Babies benefit from a vaginal birth whenever possible. When it is not possible, they benefit from experiencing labor before a cesarean birth. The authors conclude, "Taken together, the weight of the evidence indicates that the elevation of 'stress' hormones in the normally delivered newborn reflects not only a response to acute stress but also an attempt by the body to enhance the chances for survival at birth. Such findings suggest that infants delivered by elective cesarean section before the mother begins labor may be at some disadvantage."

How Labor Benefits Babies:
Adaptational Effects of a Catecholamine Surge

Improves Breathing
Increases lung surfactant
Increases lung-liquid absorption
Improves lung compliance
Dilates bronchioles

Protects Heart and Brain
Increases blood flow to vital organs

Mobilizes Fuel
Breaks down normal fat into fatty acids
Breaks down glycogen (in liver) to glucose
Stimulates new production of glucose by liver
Activates heart-producing brown fat in response to cold

Facilitates Bonding
Dilates pupils
Appears to increase alertness

(From "The 'Stress' of Being Born," by H. Lagercrantz and T.A. Slotkin, Scientific American, Apr.'86, p.106.)

The Value of Labor Support

Having a doula be with a mom in labor has many values. The initial value, if you are able to do so prior to the labor, begins during pregnancy with a relationship building that will encourage the mom's ability to relax with the doulas help based on a relationship of trust that has been built and established during this time .During this time, the doula can point the mother in the direction for obtaining more information in order to better educate herself as to what her options will be for this upcoming birth. I am available via the phone to answer questions that arise during the pregnancy. In labor the doula can act as an advocate for the couple. She can also be the clear mind that will help the couple achieve the birth that has been planned for, if at all possible. The woman will need mothering during labor and birth, a doula can act as this mother without the emotional entanglements that sometimes occur when it is actually your own mother. After the birth, a doula can assist in helping the bonding time to go smoothly and offer assistance with breastfeeding, if it is needed.

Women don't need to be "delivered" if they are allowed to give birth. Birth needs to be reconsidered as a natural process- not a medical procedure. A doula can support a woman in this, in a natural non- intervening way. She can support her ability to give birth, and thus helping to empower a woman in the process. Many times this medical interventions are the way that the medical community copes with attempting to meet this mom's needs. And many times she falls prey to interventions that will increase her chances of the unnecessary need for drugs and possibly a cesarean section. All she may need is comfort and reassurance.

Doulas act as the support a woman needs emotionally, assisting in carrying out the birth plan that the parents have selected to provide them with the "right" birth for them. She does not replace the role of the father, but enhances it. Many times a couple does not know all of their options. I initially meet with the mother or couple to offer assistance in determining the birth plan that best fits her needs and desires. A doula can point this couple in the right direction to gain this much needed additional information if they so desire. I try to educate and encourage everyone to take the responsibility for exploring their options for their birth experience, choosing the one that is right for them.

As a doula, I stay by a woman's side throughout labor, providing the emotional support, physical measures and an objective viewpoint to help her make the decisions that will enable her to have the birth experience she desires. Many times she can get caught up in the moment and not have the ability to make rational decisions. Having a doula can help to keep her grounded emotionally and a doula can be the stability to assure her the birth experience will go as she has planned, unless medical emergencies arise.

The role of a doula is multifaceted. I will attend a prenatal visit to meet the doctor or midwife you have selected. Sometimes a doula can assist the mom in planning out the questions to ask her provider. Many women feel intimidated by the medical community. A doula can be there to offer moral support. She can help give emotional support and aid in building the confidence the woman has in asking difficult questions to her provider. I can become a liaison between the medical staff and help with communication between mom and her partner. Although we do not speak for the mom, we can help her formulate the questions to find her answers needed before making a decision. A doula does not offer medical advice, but can help with the questions a couple may need to ask before complying with advice they may not understand facilitating a decision based on knowledge.

I stay with the laboring mother throughout labor offering comfort measures- encouragement, massage, relaxation techniques, making suggestions along the way to aid in helping the mother stay comfortable. Having a third party there- not he emotionally connected family member, but someone with knowledge of laboring techniques, can speed labor along and help the mom to stay more comfortable. Many times, a husband just needs some guidance in order to best meet his wife's needs during this time. A doula can provide that guidance and reassurance.

Certainly the results are in for the way that a doula can decrease the chance of a cesarean, decrease the length of labor, reduce the needs for pain medication, and facilitate a normal, natural, non-intervening birth experience. There is no other job as rewarding. I find being a doula both exhilarating and fascinating. It is hard work but the rewards outweigh the work every time! A doula is certainly an extra pair of hands and another heart, helping each birth be a labor of love!

I have been a doula for almost 17 years (first birth 5/6/92) and 380 babies ago. There is nothing like seeing a woman become empowered through the birthing experience.

I consider myself a birthguide--only there if she ventures from the path and needs help returning to it. I give her my heart, my ears to listen to her fears, my hands to touch, and my eyes to help her refocus.

I don't mind the long hours, the sleepless days and nights. The gift of the birth is what makes it so wonderful! Most of my clients stay in touch forever! I am beginning to really do a lot of repeat clients now--it's such a compliment to be invited back again!

I waited till my kids were all grown to become involved in this and that has been a blessing too--I am not splitting my attention. This is wonderfully rewarding work!

What influenced the way you have raised your children the most?

This is an article I wrote in 1997

---

When I give thought to this question, beyond the religious influences that have had a great deal of impact on my family, I believe it is the influence that La Leche League had on me. I became pregnant at the age of 19, just after I was married. The pregnancy was something that did not figure into my plans- a newlywed entering a sophomore year of college. After all, due to severe endometriosis, I was told children would probably not be a part of my future. But all of a sudden, I found my plans turned upside down. At one of my office visits to the OB, it was strongly suggested that I consider Breastfeeding. My family history included both my mother and maternal aunt having had breast cancer, so my doctor felt it favorable for me to breastfeed since evidence was showing the decrease of breast cancer having done so. So, since I had no friends who were pregnant and no background that would support me in this adventure, I sought out the local LLLeague group that was advertised in the brochures at his office.

I started attending meetings finding this whole attitude toward Breastfeeding very a la natural and therefore a little intriguing. But the idea of nursing past 6 months was something that I found distasteful. But as time wore on and the pregnancy came to a conclusion, I found myself excited about the aspect of doing something so intimate yet so earthy. I was not really excited about the aspect of being pregnant or having a baby as much as doing something new and different. Once Julie was born, I found myself quite adept at this new venture.

I had changed pediatricians when the previous one had not been supportive during a bout with a stomach disorder. I don't think I could've done this without the support of my LLL leader. The women in my league group became my friends and support peer group. The older moms were helpful in teaching me to listen to my instincts and inner voice.

The library was filled with information on child rearing and such novel concepts as the family bed. I would chatter away with women who had the same common interests and who were empowered by their instincts, having listened to their inner voices. I found this whole process of turning into a woman and a mother almost instantaneously exciting! I found inner strengths that I never knew I had. I found myself exploring options that I did not know I would've even considered. Not only did I nurse past 6 months, but I planned to nurse at least one year!

At the one year mark, my LLL leader asked me to consider becoming a leader too. I nursed Julie into the third month of my pregnancy with my son. She weaned at 22 months with little encouragement due to my sore nipples. When John was born, I planned to let him nurse till he weaned on his own. He was born with some birth anomalies that caused him to have numerous surgeries. There were battles with the anesthesiologist when NPO was required- encouraging him to understand that breast milk was digested more quickly than formula but after 20 months- and two surgeries, I gave birth to my third child, Jami.

John had been interested in nursing through out the pregnancy and continued to tandem nurse with his sister for a year and a half longer. Jami nursed till she was 3 ½ years old.

When I look back on the experiences I had through these years, I am sure without the support of the friends I had made in those early years, and continued to build, I would not have had the confidence to try new things. I would not have gone against the system of our society that encouraged bottle feeding and schedules. I would not have ever welcomed our children into our bed. And I certainly would not have ever nursed a toddler much less two non twins at the same time!

The library of books available to me within LLL, The women who would listen to my concerns and share theirs, but mostly the friendships shared influenced the way I continued to mother my children throughout their lives thus far.

My oldest daughter will be 21 soon, a senior in college and in love herself these days. My son entered his freshman year in college this year, John is 18. And Jami is my baby. The one who would empty one breast and twirl around in my lap and say"empty, oder side". She is almost 17 and is in her next to last year of high school. No, they are all weaned. They are normal, well adjusted kids. They don't sleep with us anymore. They can spend time away without negative repercussions!

Julie has traveled to Africa, to Soweto, to work in orphanages for AIDS babies. John had worked with children coming from main land China into Hong Kong and inner city kids in Philadelphia. And Jami plans to have a home birth for her future children and wants to teach special needs children, she works as a teachers aid now as part of her curriculum in high school.

Do I feel blessed. Indeed. But I do think I owe a great deal of appreciation to LLL for the way they influenced a young 19 year old girl who began her journey as a new mom.

(In the last ten years a lot has changed... Jami did have her home birth almost six years ago and nursed her son well into toddlerhood. Julie has also given birth to two (almost six and fours years old) and soon to her third child. She also allowed her children to gradually wean into their toddler years. Our son is an architect in St Louis and was married a year ago- no children yet!)

Only a nursling for a short while

I am amazed at the pressure women still feel today regarding nursing an older child. Twenty years ago it was a very hush hush thing, but somehow I thought with more time passing, it would become something that was considered more the norm. I wish people would view the breast as a natural element of comforting a child, as do many other cultures, rather than a sex object.

I guess everyone may have the fears running through their heads when they nurse a toddler. Will they go off to school still nursing?, will they ever wean?, will I make my child overly dependent on me?, will my child be normal- what we really mean is like every other child? I am not sure we come up with these questions on our own, or if these are the questions others place into our minds.

There is something very special about nursing an older child. when an infant nurses, they look very angelic. Nestled in to the breast and dozing on and off. But when there is a toddler sitting in your lap, holding a cookie with one hand and wanting to nurse with that mouth full of cookie, there is some unpleasantness. But with time and tenderness, these can be worked around with a few rules.

There is nothing so special as to have a child crawl into your lap and ask you if they could please nurse. And then at the completion of one breast let you know it is empty and they would like the other. There is nothing so satisfying as for that sweet child to then let you know how warm and good it tastes, how special they feel and how much they love your milk.

I wish that others could experience this without the haughty comments from others who have no clue what this relationship is like. Don't let others opinions rob you of the joy that having an older nursling can bring.

Remember what your grandmother told you, they only stay little for a little time! My children are all weaned now and only one is left at home for a short while longer. Hopefully I will have nursing grandchildren to cuddle in a few years. But I hope that my children will remember to let a little one be little for that short while. And also that the nursling will be off in running quicker than they think.

Sleeping Alone

The reason why we tucked a little baby into the bed with us... the motives were purely selfish. I was 20 years old and mothering was a completely new horizon for me. I had not babysat very much and I was the baby in my family. experience was certainly lacking! This new baby in the house was mixed up and slept all day and was wakeful at night. Now I know how this happens when you first bring them home, but his was happening into the 5th month. I was able to rest some during the day, as I was told to do. but in the morning when I would get up I was irritable and resentful for not having slept much the night before.

Benefits, rewards and challenges of experiencing the physical process of birth

Here are excerpts from the speech that Teresa gave at the La Leche League Annual Conference 2001 in Atlanta, GA

Labor of Love

A loving look at the benefits, rewards and challenges of experiencing the physical process of birth.

"The view of labour pain as an affliction seems most prevalent among western women. In many cultures pain in labor is accepted as necessary. Perhaps the fact that these women are usually cared for by other women, who understand birth and it’s mysterious benefits for the female psyche, is the central reason why pain is not feared but accepted.”- A. Robertson

“Pain in labor is seen as a blight, an unnecessary imposition, an affliction we must bear as the price for bearing children. This view bolstered by the perception that pain is a symptom of disease and illness has enabled men to convince us that pain is indispensable during birth and is of no value, an evil to be cured with modern treatments and technology.” –A. Robertson

“ Many western women have never been physically tested until we go through labor and birth …haven’t gone 18 or 24 hours without food or sleep…allowed ourselves to go a day or 2 without a bath or shower, without brushing our teeth and doing our hair and makeup. Even fewer of us would allow anyone else to see, smell or touch us, unwashed, sweat-soaked, naked, oozing mucus, blood, and feces from our nether regions. When faced with the forces of labor, we can’t hide the fear, the anxiety, the responses to pain…All the inhibitions and trappings of our social selves are peeled away as our bodies thrust and heave, vomit and grunt, cry and leak. The animal is there for everyone to see”- S. Diamond

Pain Coping Mindset

• No pain, no gain- why does this work in other areas of our life but not here, or does it?
• Preparation mentally, emotionally and physically is needed
• Surrounding yourself with examples- where do I find them today?
• Warriors stand up and fight- back up plans- doing the next best thing thinking
• Benefits to painTriggers the knowledge that labor has begun- time to find a safe place to retire while the process unfolds
• Feedback as to the stage of labor
• Alert mechanism for problems and special needs
• Releases endorphins
• Guides the mom in positions to choose
• Guides the feedback loops that tell nerves to transmit to other parts of the body

Endorphins

• Releases natural pain killers
• Creates a sense of well being and promotes positive feelings
• Link to mother baby attachment- increasing bonding ability
• Self esteem and confidence enhances with feelings of achievement and satisfaction
• Amnesic effect

Adrenalin

• Signals fight or flight mechanism
• Subconscious fears can trigger
• Raises blood pressure
• Causes a sense of panic
• Slows contractions
• Decreases oxytocin
• Increases pain
• Counteracts dilation of muscles

Why Natural or Unmedicated?

• Empowerment- labor is hard work, it hurts and you can do it – a willingness to try- I can do anything attitude
• Passing on a legacy to our daughters
• A rite of passage learned no other way

Rites of Passage

• Puberty
• Making Love
• Birthing
• Breastfeeding
• Menopause

Pros to Natural birth

• Less interventions mean less complications
• No catheter- less UTIs
• Let’s keep moving- a baby in a bad position- let’s move the mom
• No drug reactions
• No out of body experiences- birthing in awareness
• Recovery- ready to enjoy the new family

While pregnant we are told to avoid drug use and then in labor we are eagerly offered them. Many women will find that labor pain is bearable if it means better health for the baby. The desire to avoid drugs may necessitate women once again accepting that pain may be a necessary component to birth.

Advantages to Baby

• Alert and ready to nurse
• No drug reactions
• Less chance to have to go to NICU
• No sepsis workup for epidural fevers
• Less drugs mean less complications
• No delay in the labor/birth process
• Mom and baby alert together- bonding

Disadvantages of Natural

• An exception to the rule- what! - No drugs- why?
• It hurts and it is hard work- is there value to the pain?
• Do you have support?- Why do I feel so alone?
• My support can’t stand to see me in pain

What do you need to birth?

• To feel nurtured and protected
• To feel safe and have a safe place to birth

“The right place to give birth would be the right place to make love.” –Michel Odent

So How Do You Prepare?

• Books- how many and which ones?
• Birth plans- a help or a hindrance?
• A living birth plan
• Protecting your minds
• Learning to listen to your instinctive voice
• Childbirth classes- which ones?
• Pain coping techniques that work

Birthing Instinctively

• Trust your body
• Forget learned patterned breathing
• Follow instinctive behavior
• Get good labor support
• Avoid induction or augmentation

"Women are tricked into believing that a managed, predictable labour is not only desirable, but safer for themselves and their babies.” “Have we placed our faith in medical men when we should have had more faith in ourselves and found female companionship for labour and birth?” –A. Robertson

Protecting Your Birth Space

• Preparing the space- what makes me feel safe?
• Addressing the fears ahead of time
• Environmental controls, privacy
• Reduction of people, things and procedures
• No negative languages, behaviors or people with anxiety
• Avoid conversation- keep a woman in laborland

Virtually all women have the potential to give birth easily and safely and no special knowledge or learning is required.” –A. Robertson

Doulas

“Part of the increase (in using doulas) stems from the fact that the consumer is taking back birth into their own hands and wants to be a part of the decision process. Also, it is a natural instinct to gather the right kind of support around you.”-Ridd-Young

Doulas- Why do I need one?

Who can be my doula? Mothering the mother

Four women often unaccompanied by knowledgeable support people, and made vulnerable by their emotional and hormonal state are ripe for seductive messages conveyed by “experts? That labour pain has not benefit.”– A. Robertson

Doula Studies

Promises promises- what can she really do?

• 25% shorter labors
• 60% reduction in epidural requests
• 40% reduction in pitocin use
• 30% reduction in analgesic use
• 40% reduction in forceps use
• 50% reduction in cesarean births

“Your heart and hands are the most important. If someone’s not certified, they’re not necessarily less qualified.”-Guralnick

“Good doulas make fathers feel more involved and more useful at a stressful time.”-Guralnick

Dads- what help are they really?

Men have not experienced the innate birthing instincts since they don’t give birth- this may make them more uncomfortable with woman in labor.

What role do they feel comfortable with?

• The pitfalls of being a labor coach
• How do I help him to prepare?
• Find someone to help support him as well.

Doctors and midwives- are they really different?

Average doctor visit is 6 minutes- midwives on average are twice that.