Burning Questions #6: What is a Doula's Role in High Risk Birth?

tulsa doula high risk

Last week, I asked people on my Facebook page to choose which of three post topics I should write about next. Other than a vote for all three, the resounding winner was this question from Katherine Ferranti, LMT of Be Free Massage Therapy. And with good reason, because her question is just so good.

Do doulas experience resistance from doctors when the patient is “high risk” (whether because of age or medically related). Or maybe [...] does a doula have different responsibilities or a different approach when a patient is high risk vs not high risk?
— Katherine Ferranti

So let me step back for a minute and be really clear about what the role of a doula is...

1) To offer emotional and informational support during pregnancy. This can mean helping clients gather the information they need to weigh their options and determine their own preferences for their birth. This can include encouraging  conversations with the care provider to discover what options are available with that care provider or in that care setting.

2) To offer continuous emotional, physical, and informational support during labor, birth, and the immediate postpartum period. 

And what the role of a doula is not!

1) To provide any clinical care, such as blood pressure monitoring, internal exams/cervical dilation checks, or diagnosis.

2) To make any decisions for the client, speak on behalf of the client, or give medical advice.

A doula's approach to fulfilling the role depends on the client's situation and needs, but follows a general pattern.

For many low risk clients, especially those who desire an unmedicated birth, the doula will help prenatally with determining a birth plan or preferences, providing guidance on discussing these preferences with the care provider if needed, and discussing how the doula, the partner, and the laboring parent can all work together towards the clients' goals.

Then during labor, the doula will provide emotional and physical support to her clients, facilitate cooperation with the care provider and other staff, and remind the clients of their goals if circumstances are changing. Ultimately, a doula understands that birth rarely goes as planned, so she is balancing the need to provide unconditional support for her client, who is making the best choices for her situation in any given set of circumstances, while still keeping in mind the client's prenatally-stated desires and goals to do whatever can be done to fulfill them.

But guess what?

With clients in high risk situations, things aren't that different. 

Prenatally, a doula would still help you gather information about what options are available in your situation, and help you to determine your birth plan or preferences. With these goals identified, the clients and doula would discuss how they could all work together as a team to meet the physical and emotional needs of the birthing parent during labor and/or birth.

During the labor and birth (be it surgical or vaginal), the doula would provide emotional and physical support, facilitate cooperation and communication with care providers, and keep the client's goals or birth plan in mind. (Maybe physical support looks more like hand holding, head massage, or grounding touch instead of supporting a squat, providing counterpressure to the sacrum during contractions, or back massage, depending on the circumstances.)

It's been said before, but it bears repeating: doulas are not just for people who desire an unmedicated birth. (In fact, some doulas specialize in high risk birth or even specialize in working with clients planning cesarean births.)

There are more and more families, for example, that are desiring family-centered or gentle cesareans, and having a doula help to figure out the details of this, think through what needs to be requested and who needs to be consulted, and provide another layer of support during surgery can be amazingly helpful.

A pregnancy may be considered high risk for any number of reasons, including multiples pregnancy, maternal age, development of various conditions of pregnancy including Gestational Diabetes and Choleostasis, or pre-existing maternal health issues. The relative risk of each of these factors varies, and you may find that you have different options with different care providers or in different settings. Even if a pregnancy is considered very high risk and will likely require a high degree of medicalization, informed consent is still important, and continuous emotional and physical support can be extremely beneficial to the whole family.

So what do doctors think of doulas for their high risk patients?

I can't say that I've experienced any particular resistance from a doctor or midwife solely due to my client being considered high risk. But as for what doctors think of their high risk patients having doulas? It might be better to ask the doctors!

I've worked with a number of clients who were over 35, developed Choleostasis, had pre-existing health issues such as high blood pressure, or who had babies presenting breech at term. I've had clients whose labors were induced for medical reasons, and who gave birth via cesarean section. In all of these cases, the care provider's attitude towards my role as my client's doula seemed more indicative of their overall comfort with working alongside doulas than anything about the particular situation.

For example, in New York, I found that most hospitals would not allow a doula to be present in the operating room during cesarean delivery; because of this, two clients who ended up needing to schedule a cesarean were advised by their doctors to terminate their contract with me. I also had a client report to me that her nurse suggested that the client not call me to come to her birth when she went in for her induction. The nurse suggested that, since she would probably want an epidural now, she didn't really need a doula to help her. (My client did choose to have me present for her labor and birth, and was happy with my many hours of foot rubs, fetching ice chips, and emotional support while she labored with an epidural!) I think all these care providers had the misconception that doulas are only for "natural" birth.

On the other hand, clients going in for inductions, dealing with illnesses of pregnancy, and with pre-existing health conditions all started looking for a doula at the suggestion of their care providers who understood the unconditional supportive nature of doula work and the way that doulas increase patient satisfaction in their birth outcomes.

Some things to consider if you are pregnant and have been classified as "high risk"

  • How do you feel about being classified as high-risk?
  • Do you understand what about your situation puts you into a higher risk category?
  • What options are available to you with the care provider you have now? Do you feel good about these options? Do you want help figuring out if other providers or other hospitals may have a different opinion or policy surrounding your circumstances?
  • Do you (and your partner) want the additional support - emotional, informational, and physical - that a doula can provide prenatally, during the birth, and into the postpartum period? If you do want doula support, is there a doula in your area who has experience with your circumstances?

If you are looking for a doula in the Tulsa area that has experience in helping families plan for cesarean birth and recovery, induction of labor, continuous monitoring during labor, and other high-risk/highly-medicalized birth scenarios, please be in touch to see if I would be a good match for your birth team!