An Epiphany... I am a high-risk doula
This client has Nitrous Oxide ready as she uses Pitocin to nudge her labor induction along
Ya know when something is so under your nose you fail to see it? I was traveling to Lexington, KY at the end of August for an Evidence Based Birth® (EBB®) Retreat with Dr. Rebecca Dekker, her hard-working and dedicated support team, and about 18 other instructors from around the country. I cherish these special events as they only come up every few years and to get this sort of intimate, face-to-face time with Rebecca is something I’ll grab every chance I get.
I was reviewing in my head some of the demographics of my clientele and how they have benefitted from the research that EBB® has made accessible to all of us, including the many disease processes and unanticipated events that can challenge us in pregnancy and birth. Pregnancy over the age of 35, and for my client base, many over the age of 40. Cholestasis. Hypertensive disorders such as Gestational Hypertension and Preeclampsia. Gestational Diabetes. Plus-sized pregnancies. IVF. Give me a “hell yeah” if this was you and I’ve taught to you or have cared for you as your doula in my 10+ years of doing this. Yup, I can hear you all now. There are a lot of you and your voices carry.
I work closely with my “birth bestie”, Shalin Butterworth. Like me, she is also a doula and EBB® Instructor and teaches the EBB® Childbirth Class. She runs a doula mentorship program in which I participate and bring my perspective as an RN and experienced doula. One of her mentor doulas was dealing with a difficult induction on my way to Lexington. With airplane WiFi and a long layover in Atlanta, I was able to chime in and support this newer doula in our private chat group while I helped her understand the pros/cons of various induction methods being presented to her client.
This client was 41 years old and was induced for her 2nd birth for post dates. She went on to have an unmedicated water birth
Another doula in the mentor group, who just LOVES to do home births (what doula doesn’t), was frustrated at what her cohort was dealing with at the hospital and stated “This is why I hate inductions”. I can’t say as I love them so I get her point. She gets the privilege to do many home births that I do not. Not that I wouldn’t, but those are simply not the clients that are attracted to someone like me. I theorize that the RN after my name represents (for many, I think) the type of influence you’re trying to get away from with an out-of-hospital birth. Little do they know I was their best friend when they got me as their RN at the hospital where I used to work. Little do they know that I had a home birth myself and would do it a million times over.
It’s okay. I don’t lose sleep over it much because as I thought about that doula’s comment and her understandable distain for inductions, I thought about of the beautiful babies I’ve seen enter this world after a well-informed induction and feel blessed to have been a part of each one of their birth stories.
However, to know me is to know that I am a fierce advocate for inductions being the last resort and right decision for my clients. My years as a nurse at an evidence-based facility, learning from midwives and physicians collaborating to achieve one of the lowest cesarean birth rates in CA, provide me with a unique perspective as a doula.
Simply put, we have a Plan B, C, D… because birth = life. No one knows how this is gonna go. I educate for all contingencies while hoping you’ll never need them. And when my clients do need them, we’re ready. We’ve discussed this. We’ve explored our values. We don’t have to like it, and sometimes we choose to challenge it, which I will always support when “I know you know everything there is to know” - a mantra many of my clients have heard me say before.
This client was diagnosed with Gestational Diabetes (GDM) in her pregnancy. She was then diagnosed with Preeclampsia later in her pregnancy requiring an induction. Hypertensive disorders are more common in people with GDM. She was induced in her 37th week and went on to labor/birth without pain meds or an epidural.
I’ll admit that my heart sings when a client goes into labor spontaneously and I get to labor with them at home. It happens, but I also realize it doesn’t happen for me as often as it happens for other doulas. This hit me as I reflected upon my ease and confidence in sharing with this new doula a quick-and-dirty education about Misoprostil (aka Cytotec) and it’s indications, and contraindications, in her client’s labor. I was also helping her understand why starting Pitocin as early as they did may have skipped some crucial steps. I didn’t think anything about helping this doula help her client. I had no guttural response to the fact that she was being induced because I’m kinda used to it. Not because my clients are not educated or because their providers coerced them into consenting to something they didn’t want. It was because their health, or their baby’s health, and their values made it the right decision for them. I was thorough about educating this doula while passionate about making sure she had the right information to support her client and give them options.
As this other doula had a more basal response to inductions, I first waved it off and thought, “Well, she’s just getting started and she’ll see her fair share of inductions as she continues this work”. But then I thought… maybe she won’t. She is a beautiful soul and a stark contrast from my style, and I love her for it. Diversity is what makes us all unicorns in the birth world and we need more 🦄and less 🐑. Maybe her distain for inductions is what attracts mostly healthy pregnant couples to her who are perfect candidates for home births - the type of birth for which she has chosen to specialize. That’s when I realized, as I went through the Roladex of former clients (dating myself here, but not to my 40yo+ clients 😉), that I likely have a vastly greater number of high-risk clients who, more frequently than low-risk clients, need an induction. I am a high-risk doula, and I’m actually pretty damned good in this space.
I was 39 when I had my son at home while my 22 month old daughter bounced on a trampoline and watched her “aby brother” enter this crazy world.
Why do I see a higher number of inductions and higer-risk births?
Is it the RN after my name? Most likely a huge part of it. I’ve heard it said often “I liked that you’re an RN”.
Is it because I’ve been doing this a long time? No doubt. I’ve seen a lot. I’ve seen rarer diagnoses more often because of how long I’ve been doing this as both an RN and doula. The bigger the n, the broader the perspective.
Is it because I was a former NICU and pediatric OR nurse? I’m sure some people see that in my bio and appreciate it.
Is it because I’m an EBB® Instructor well-versed in current research? Hell YES! Just because we have a disease process or complication in our birth doesn’t mean we toss it over to our provider with our hands up and say, “Whatever you say, Doc”. We don’t give up advocating for ourselves just because we need medical intervention. That’s exactly when we need advocacy the most!
Is it because I had the diagnosis of Advanced Maternal Age (AMA) with both of my pregnancies and understand the mindset of those who didn’t begin to start their family until later in life? After world travel? After achieving educational or career goals? After trying for such a long time that we landed this category, not by our own choosing? After not finding that soul mate till we were meant to find them? I fit a number of these categories and simply put - it takes one to know one.
And what comes with this diagnosis of “AMA” or a pregnancy in people 35 and older? Well, there’s a lot. EBB® has a great updated Signature Article and a Free Public Webinar on this very topic. I have also embedded the podcast below if you want to review the evidence that way. I’m knowledgable in navigating/educating/supporting all of it. I help scores of clients have empowering births with this diagnosis - both spontaneous and induced - by really digging into your values and what’s most important to you. Couples in my EBB® Childbirth Class learn this too and because I teach this class 100% online, I’ve helped couples from all over the county find confidence in their decision-making.
Because clients over the age 35 makes up a sizable portion of my demographic (37% of doula clients at the time of this writing), I happen to be rather knowledgeable in the diagnoses that tend to attach themselves to this age-group - gestational hypertensive disorders, IVF, history of miscarriage, VBAC, birth trauma, gestational diabetes - to name a few. These diagnoses often carry with them an indication to induce. In considering inductions and when to induce, the topics of antenatal testing, biophysical profiles (BPP), Bishop scores, cervical ripening, arrested labors, postpartum hemorrhages, and more have to be a part of your knowledge base to make informed decisions.
This perfect baby arrived on the scene after 41 week induction for post dates. They knew their options and chose the induction method that felt right for them. They went on to birth their baby with no medical pain relief about 24 hours after their induction began.
Diversity is the spice of life and 63% of my clients are under the age of 35 and many do not require an induction for a medical reason but let us not forget other reasons inductions are recommended like going postdates. I went to 42 weeks with my first baby and needed to be induced when my waters broke with particulate meconium (pea-soup looking amniotic fluid). I had Prelabor Rupture of Membranes (PROM) which is a common indication for induction at most facilities, even without meconium. In the EBB® Childbirth Class, we review the evidence on inducing for due dates and PROM. Many are surprised to hear there is more to the story. Induction isn’t always the answer. Hospital policy has no connection with our personal situations. I’m a fierce advocate for informed choice in this space. I provide the information and you choose.
Sometimes we need medicine in life. One of our advocacy tools to help our births belong to us is support and education. We teach about these crucial advocacy skills in the EBB® Childbirth Class because understanding when an induction is indicated is the first step. At the time of this writing, 27% of my clients had their labors induced. Did you hear that? You probably thought I’d see more given the demographics I explained above, but that’s where education comes in.
If my clients didn’t know their options, that number would be much higher.
If my clients didn’t know when to ask for alternatives, that number would be much higher.
If my clients just said, “Whatever you say, doc”, that number would be much higher.
As a doula and educator with a demographic of higher-risk clients, I shout from the roof-tops that support and education are imperative to helping us navigate this crazy journey, including the unanticipated forks in the road, with agency and determination. Oh, and I’ll just throw out there that my cesarean birth rate for my first time parents with a single, head-down baby at term (37+ weeks) is 10%. Do I have your attention now?
With support and education, pregnancy diagnoses do not have to equal inductions.
With support and education, inductions do not have to equal cesareans.
With support and education, anything is possible.
Without support and education, no decisions are ours.
I am an RN. I am a high-risk doula. I am an Evidence Based Birth® Instructor. I am a mother at the age of 37 and 39 and had an induced birth and a home birth. I am good at helping you understand your options and the evidence behind them. I’m good at helping you apply said options to your values. I’m good at helping you shift when your low risk pregnancy turns into a high risk pregnancy. I am good at helping you shift when your low-risk labor turns into a high-risk labor (we never see that one coming). I’m good at leaving normal birth alone. And lastly, I’m a damned good educator on all of it.