31 Mar Working Together: The Struggle Between the Nurse and the Doula
Writing this blog entry is extremely challenging for me. The comparison between nurses and doulas creates heated debates. There are varying opinions regarding the two professions and the Internet fosters even more opportunities for open debates. Often when I explain my business and list my qualifications to parents, they ask, “Are you a doula?” That got me thinking: exactly what do people know about nurses and doulas? Do they understand the credentials behind these professions? Are doula’s appealing because they are non-medical individuals advocating for patients in the delivery room? All these questions have lead me here, writing this blog to provide any needed clarification.
When you say the word nurse, people immediately envision someone working in a hospital, wearing scrubs, grabbing medications and charting information for their patients. In reality, there is so much that goes into becoming a nurse, it’s hard for someone outside of the profession to truly understand the intensity of the job. The definition of a registered nurse is “a graduate nurse who has passed a state board examination and been registered and licensed to practice nursing (Dictionary.com).” Registered nurses can graduate from nursing school with an associate’s degree or a bachelor’s degree. Studying as a student nurse involves years of extensive work in the classroom and with patients. Upon graduation, a registered nurse who moves forward to specialize in a particular area of medicine, in my case in labor and delivery, continues their training with the protocols set in place by their hospital. They are further educated on how to understand and meet the needs of the laboring woman and the unborn child. This requires comprehension of the fetal monitors, how to read decelerations and accelerations in the fetal heart rate, ways to improve outcomes for their patients, and strategies to provide necessary medical and emotional support. Also, nurses work alongside the medical team, including doctors and fellow nurses, to implement a plan of care for each individual patient. She must be aware of possible complications that arise and know how to respond accordingly. The delivery room is an ever-evolving setting, where things can go from good to bad in the matter of seconds. A nurse treats patients holistically and must be ready to adapt at the drop of a hat.
In addition to the extensive medical training that comes along with earning a nursing degree, registered nurses are highly trained to meet the emotional needs of the patient and their family members. We, as nurses, have empathy for our patients and the emotional toll laboring entails. Nurses are there to answer questions from loved ones and patients, help them understand the process, and give proper guidance when things move forward towards delivery. At the same time, nurses get orders from doctors to ensure the labor is progressing in the manner it should to deliver a healthy baby and maintain a healthy mother. It’s a balancing act, but this does not negate the fact their role is also to serve their patients on an emotional level. Generally, nurses enter the profession with a desire to provide one-on-one care for their patients. Specifically, a labor nurse is meant to be a significant source of comfort and knowledge for families.
There is a newer support person that can be found in the delivery room, called a birth doula. A doula is defined as “…a trained and experienced professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth (DONA International, 2016).” As stated by Doulas of North America (DONA) International, “[a] doula acts as an advocate for the mother, encouraging and helping her fulfill specific desires she might have for her birth.” It should be pointed out that there are many different doula certification programs available. Further, the requirements to become certified as a doula are at the discretion of the program chosen, with no state licensing program or exam issued. The process of certification includes attendance of live births (specifically for a birth doula) along with reading requirements chosen by the particular doula certification program. Essays may also be required, as well as video interviews. Many programs have online certifications, where the entries are turned in through the website and graded by designated appointees. Once certified, doulas are able to start their professions, either with their own company or as an employee of a company that assigns them to families.
It seems that these two professions should compliment each other quite naturally; however, working together has served as a challenge for many nurses and doulas. Overall, the goal of the nurse and the doula is a safe and healthy outcome for both mother and baby, but it seems throughout the years, conflict has arisen. Nurses have been described as defensive when it comes to the care they provide their clients, making doulas feel like they are an imposition (Ballen & Flucher, 2006). There have also been cases where doulas attempted to practice outside of their scope of training. Doulas are not educated, for instance, on fetal deceleration patterns or other medical complications during labor. Although they may be aware of specific instances such as this, they are not allowed to legally give any medical advice. There have been documented cases in which a doula has overstepped and given advice beyond their knowledge. In certain instances, “[d]octors complained that birth doulas sometimes persuade laboring mothers to reject Caesarean sections, medication and other treatments deemed medically necessary (Hwang, p. 1).” This poses a danger to the patient’s wellbeing. There have been complaints by medical staff that doulas sometimes impose their own beliefs onto their patients, causing the patients to reject certain medical care that may benefit them in order to deliver a healthy baby (Hwang, 2004). Specifically, Hwang (2004) states that on the advice of the doula, a patient rejected the doctor’s request to use the drug Pitocin to speed the process of labor due to the patient’s water being broken. When the patient finally consented to the medication and ultimately delivered, the infant had an infection and needed to stay in the neonatal intensive care unit. However, a doula can also be helpful to patients and medical staff during labor. According to The American College of Obstetricians and Gynecologists “…in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor (p.3).” Although doulas are not medically trained, their support is beneficial as it helps the patient to feel their voice is being heard. Some patients feel their needs are being met on a more personal level with a doula. Emotional and physical support are part of a nurse’s role as well, but due to charting demands and increased patient ratios, they may be less available. In this way, the presence of a doula, serving in their proper capacity, should function as a benefit instead of detriment.
As the use of doulas increases each year, it’s important that the two professions find a way to work positively together (Ballen and Fulcher, 2006). Proper communication between the nurse and the doula in the delivery room is key. Patients should be aware of the role of doulas and their limitations when it comes to the level of knowledge they possess. Patients have expressed the desire to have a non-medical person by their side throughout labor (“Approaches to Limit Intervention During Labor and Birth”, 2017). I can’t help but wonder why that is. If you are looking for extra support, wouldn’t you want that person to have the most knowledge possible to help you achieve your goal of a great birthing experience? That’s why I became a certified doula in addition to already being a registered nurse. I want to make sure people know I can provide knowledge and understanding of the delivery room, along with the emotional support they are seeking during their labor experience. The interaction that occurs between the doula and the medical staff cannot be denied as an important factor to creating a positive experience. I work hard to make sure that my patient’s wishes are well known by the staff, but also that the medical personnel know I am on their side as well. Just like the nurse, I want the best possible outcome for my client and her safety is my top priority. My goal is to have my client and her family looks back on their laboring experience with fond memories, knowing her support people were teammates and not opponents.
References
Ballen, L. E. (2006). Nurses and doulas: complementary roles to provide optimal
maternaty care. The Association of Women’s Health, Obstetric and Neonatal Nurses. 35 (2), pp. 304-311, Retrieved from www.jognn.org
Approaches to limit intervention during labor and birth. Committee
Opinion No. 687. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2017;129:e20–8. Retrieved from www.acog.org
Hwang, S. (2004, January 19). As ‘doulas’ enter delivery rooms, conflicts arise.
The Wallstreet Journal, Retrieved from www.wsj.com
Registered Nurse (2017, March 28). Dictionary.com. Retrieved from
What is a Doula? (2016, January 18). DONA International. Retrieved from www.dona.org
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