Update on book about "Homebirth Cesareans"

Guest post by Courtney Jarecki and Laurie Perron Mednick

The Homebirth Cesarean book shines light on homebirth women who transport to the hospital for a cesarean, and the midwives and others who care for them.

Homebirth Cesarean (HBC) began as a conversation between us: a homebirth midwife, and a mom who went from the dream of having a homebirth to the reality of a cesarean. Eight months after the birth experience we shared, we reconnected to process the birth and postpartum care. Although our experiences of the same birth were different, we felt immense relief in realizing that we still maintained a powerful connection as midwife and mother that hadn’t been broken through the HBC. We also realized that mothers require more support and resources following these births, and midwives and birth professionals were open to learning more about how they can best serve these families.

Natural Hospital Birth

Natural childbirth is not easy to achieve in hospitals, which may come as a surprise to pregnant women and couples who assume this option will be readily available, if they so choose.  Doula and medical anthropologist Cynthia Gabriel, PhD, has a lot to say on the topic, and offers parents her guidance for how to maximize their chances in her book, Natural Hospital Birth.  One of her tips that I love best is this strategy for active labor:  when the hospital staff has questions for the laboring woman, her spouse or support person can be the one to answer, so the mother can maintain her concentration and momentum in strong labor.  I have noticed how this technique can work beautifully in a hospital setting, where frequent interruptions are common and appear to slow down labor for many women.  Below, Cynthia Gabriel sheds light on the paradox of "natural hospital birth," and offers an inspirational viewpoint on what it can mean for families and those who care for them.

Birthing Project USA is saving lives

Birthing Project USA connects volunteers and pregnant women within the African American community and other underserved communities, with the goal of reducing infant mortality and strengthening at-risk families.  Volunteers are known as "Sister Friends" who provide support during pregnancy, childbirth, and the first year postpartum.  Chapters exist in cities across the USA and internationally.  The project's founder, Kathryn Hall-Trujillo, has been recognized as a CNN Hero.  Birthing Project USA has supported mothers affected by Hurrican Katrina, provided scholarships to adolescent mothers pursuing a college education, reduced infant mortality rates in high-risk communities, and mentored thousands of young families.  Donations and volunteers are needed to help this important work continue -- visit www.birthingprojectusa.org/intro.html to get involved.  Below, Birthing Project USA describes their accomplishments over the past 25 years and their goals for the future.

How to Avoid Overfeeding a Baby by Bottle

Overfeeding can be a consequence of bottle-feeding, whether a baby receives breastmilk or formula in the bottle.  A simple technique known as "paced bottle-feeding" can be used to help avoid overfeeding with a bottle.  Postpartum doulas, who are often involved in helping new mothers feed their babies, can share this technique with their clients.  Doula and lactation consultant Jessica Barton, IBCLC, demonstrates the technique in the video below.  For printed instructions on how to do paced bottle-feeding, click here to visit Jessica's Web site .  Be sure to explore her Web site for excellent articles on a range of other topics such as galactagogues (herbs and drugs that may increase milk supply), babies with "tongue tie," and more.  Here is what Jessica has to say about paced bottle-feeding:

Paced bottle feeding is a method of bottle feeding that is designed to mimic breastfeeding. There are many reasons families might decide to try it.

Some mothers find that when they return to work and their babies are receiving breastmilk or formula from a bottle in childcare, their babies become less interested in breastfeeding at home and some may even refuse the breast.  [For the complete text of this article, see http://santabarbaralactation.com/blog/paced-bottle-feeding-breastfed-baby.]

Supporting the Births of Plus-Size Mothers

A wonderful Web site titled Plus Size Birth aims to empower plus-size mothers in many ways.  The site offers articles on topics ranging from finding a size-friendly midwife or OB, to locating good-fitting baby carriers; links to many resources; an inspiring pregnancy photo gallery; and a directory of doulas in the U.S. and around the world who have experience working with mothers 200 pounds or more (doulas who would like to be listed, or mothers who would like to find a doula, can click here).  I encourage everyone to spend time exploring the Plus Size Birth site, and to be enlightened by its message of embracing a positive body image for all mothers regardless of size.  Founder of the site Jen McLellan shares her birth story, and her experience laboring as a plus-size mother, below.

Will You Make a Good Doula?

Kristen Oganowski publishes the fantastic blog Birthing Beautiful Ideas, and has written the essay below which will inspire novice and veteran doulas alike.  (For information on how to become a doula in North America, visit the major doula organizations at www.cappa.net, www.dona.org, www.ictcmidwives.org, and www.tolabor.com.  For a list of doula organizations around the world, see pages 80-81 of The Doula Guide to Birth.)

New doulas–or people just considering whether or not to become a doula–often wonder if they’re cut out for the job.

Can I fit it into my lifestyle?  My work life?  My family life?

Will I be able to handle being on call?

Can I stomach the sight of blood, mucous, feces, and vomit?

Will I be able to withstand the unpredictable hours, and the unpredictably long hours?

But people asking themselves these questions might also be wondering if they have the “right” personality traits for doula work.  They might wonder if they are “too this” or “too that,” “enough of this” or “enough of that,” “not enough this” or “not enough that.”

Cervical Scar Tissue – A Cause of Preventable Cesareans

Dawn Thompson is a doula and the founder of ImprovingBirth.org.  She has spent the past eight years on a mission to understand how scar tissue on the cervix affects women in labor, and to let the public know about it.  In her article below, she identifies a variety of gynecological procedures that can potentially cause Cervical Scar Tissue, such as treatments for abnormal Pap smears.  (I also discuss the topic on pages 132-133 of my book, which includes a list of additional medical procedures that may be the cause of CST.)  Other resources on CST include: 

• an excellent article by O'Nell Starkey, doula and founder of The Beautiful Cervix Project
• photographs of the cervix from The Singapore Family Physician (images are graphic but informative -- see Figures 24a and 24b for scarring of the cervix); and
• an article by Dr. Fred Licciardi of New York University, with drawings that demonstrate how gynecological procedures may cause scarring 

Below, Dawn Thompson describes her investigation of the topic of CST, and the ways she has helped mothers with this condition avoid complications in labor.

Teaching Parents About Doulas in Birthing Classes

by Ananda Lowe

Over the years, I have attended numerous childbirth classes – as a doula accompanying my clients, as a childbirth educator-in-training, and as a pregnant woman myself.  These included natural childbirth, prepared childbirth, twins birth, hypnosis-based birth, hospital-affiliated, privately-run, paid and free classes.

What struck me is this:  although the evidence is clear that doulas may be the most important intervention to utilize for parents desiring natural childbirth, even doulas themselves tend to undervalue their role when teaching childbirth classes — which is unfortunate, I believe.

The last time I observed a natural childbirth class, I timed the portion of the class on the topic of epidurals, and it totaled over 30 minutes, while there was no formal time dedicated to the topic of doulas.   (To be fair, some of my educator colleagues have reported to me that they do provide instruction on the topic of doulas in their classes.)

Imagine the impact childbirth instructors could have if every family leaving their classes had a clear understanding of the medical benefits of doula care, how to find a doula, and how to afford the expense.  Here is an array of suggestions childbirth educators can use to make sure the topic of doulas is central to their classes:

The Natural Cesarean?

While talking with my friend Dr. William Camann, director of obstetric anesthesiology at Brigham and Women's hospital in Boston, I was surprised and excited to learn that he recently helped the hospital adopt components of what is being called "the natural cesarean" technique.  Bill is co-author of the book Easy Labor: Every Woman’s Guide to Choosing Less Pain and More Joy During Childbirth, and the Brigham is Boston’s largest maternity hospital, so its adoption of these methods is good news.  In the past, some mothers reported feeling “a disconnection from their cesarean baby because they did not actually see or feel the baby born,” according to the International Cesarean Awareness Network (ICAN).  The natural cesarean technique offers parents the option of viewing the emergence of the baby if they wish.  (For years, ICAN has been a pioneer in proposing guidelines for family-centered cesareans, as well as advocating for other reforms related to the use of cesarean sections—I encourage everyone to support their work!)  Below, Dr. Camann explains the concept of the natural cesarean.

Cutting the Cord at the Right Time: It's Not Delayed, It's Optimal

I will always feel gratitude for the fact that when our baby was born, my boyfriend's one request was that we not cut her umbilical cord too soon.  At the time, it was a topic I was unfamiliar with.  However, researchers, childbirth advocates, and doulas have been discussing the benefits of optimal cord cutting--sometimes referred to as "delayed" cord cutting--for decades, a technique that can be used with vaginal or cesarean birth.  (I believe one of the benefits for my daughter was that at age 12 months, her blood iron levels were normal even though she never had iron supplementation, on a diet that still consisted almost entirely of breastmilk.)  Over the past year, I have been excited to see this topic emerge more prominently in the mainstream news.  One of its spokespersons is pediatrician and author Dr. Alan Greene, who founded the TICC TOCC campaign to promote optimal cord cutting globally.  Other excellent resources include doula leader Penny Simkin's video that beautifully illustrates the concept, as well as a longer, well-referenced lecture by obstetrician Nicholas Fogelson.  I had the pleasure of meeting Dr. Greene and am happy to share a link to his compelling TEDx Talk about the TICC TOCC campaign, which he also explains below:

Mothers Sharing Breastmilk: What's It All About?

I have often mused that there are thousands of ounces of pumped breastmilk in the freezers of mothers in my city alone, some of which they might not ever need.  What if it could be offered to babies whose mothers were not able to provide a full milk supply?  I became a Certified Lactation Counselor in 2001 and heard of milk sharing over the years; I knew it had its supporters and its critics, but I did not know the details of how it was actually being practiced in real life.  A few years ago, Emma Kwasnica and I met as childbirth advocates on Facebook, and recently I had the chance to learn more about her organization, Human Milk 4 Human Babies.  I was moved by the mission of the project and the reach it has had in just a few years -- mothers from 52 countries have participated in "informed milk sharing" through HM4HB.  Below, Emma explains the history of the organization.

How Dilated Am I? Estimating Dilation in Labor WITHOUT a Vaginal Exam

In 2008 I visited Israel and lectured to a wonderful group of doulas on the topic of alternatives to using vaginal exams (VEs) in labor, and that is when I met Sarah Vine.  Sarah later wrote a post about this topic on her blog, which I've reprinted below.  When I published my book, my favorite chapter was titled "Labor is Not About Dilation," where I explain that although vaginal exams in labor are widely and heavily used, scientific studies have not proven routine VEs in childbirth to be beneficial or medically necessary.  VEs have their downsides, including an increased risk of serious infection such as Group B Strep, as well as potentially disturbing a mother's comfort and concentration in labor (imagine how other mammals would respond to this intervention?).  Click here to visit Sarah Vine's blog, and continue reading below to see what she has written about estimating dilation without a VE.

Your "Postpartum Plan" Is As Important As Your Birth Plan

Many people have heard of writing a birth plan--and a postpartum plan can be just as important.  Mara Acel-Green, a psychotherapist specializing in postpartum depression and other perinatal mood disorders, has created the form below for families to use when choosing who will help them through the enormous changes of the postpartum time.  Some other resources I love are the sample postpartum plan at Dona.org, a post from That Wife which touches on the importance of planning who will help you with breastfeeding, and Molly Remer's account of pushing herself too hard during her postpartum.  Also see pages 220-221 of The Doula Guide to Birth for more information on postpartum plans.  I encourage all expectant parents to be able to answer the questions below provided by Mara Acel-Green, and be clear in advance who you will ask for help postpartum.

Home Births That End in Cesareans

Doula and mother Courtney Jarecki, along with her midwife Laurie Perron Mednick, are working on an important new book about home births that result in cesareans.  While we wait for the book to be available, the authors are publishing an excellent blog of their own which gives us a preview.  Some of you may have experienced an unexpectedly difficult birth, and may be able to relate to the stressful impact these births can have on the relationship between a mother and her midwife (or her doula).  I am very moved by the goals of the Homebirth Cesarean book, and I also invite you to read the chapter "When Epidurals and Cesareans are Unplanned" in my own book, which addresses related issues.  Here is what Ms. Jarecki has to say:

Advice for Twin Births

I am happy to present this information written by Kimberly Amato, a doula with expertise in twin births, as well as the mother of twins and a singleton.  Kim has been a fantastic resource for me when I’ve been a doula for twins, as well as when I wrote about twin births on pages 211-214 of my book.  Depending on the care provider or hospital, mothers of twins may be expected to:  use an epidural even if they prefer natural childbirth, because of a small increase in the chance of a stat cesarean; have an induction as a routine protocol, or because complications develop that are more likely with twin pregnancies; and/or move into an Operating Room during the pushing phase of a vaginal birth, as a precaution in case of emergency.  Kim has written an excellent guide that mothers and doulas can use to help them have a dialogue with care providers about birth options with twins.  To correspond with Kim for more information, email her at kjpdoula@gmail.com.

Everyone can support African American doulas and mothers

I want to let everyone know about the International Center for Traditional Childbearing, an organization that trains doulas and midwives throughout the USA, with a special emphasis on preventing infant mortality and promoting breastfeeding in the African American community, where infant mortality rates are the highest in the nation.  Any person is welcome to attend an ICTC doula training or conference, locate a doula trained by ICTC, apply for membership in the organization, and make donations to support their work.  (For more information about the role of doulas in reducing prematurity and infant mortality, see pages 9-11 of my book, The Doula Guide to Birth.)

When Mothers Don't Make Enough Milk

Nature's design is for mothers to have a slight oversupply of milk during the first couple months of breastfeeding.  In spite of this, one of the top concerns new mothers report is a worry that they are not producing enough milk.  Sometimes this is an incorrect assumption; other times it is an actual problem--caused by a lack of support and information about how to create a normal milk supply, or because of a possible underlying medical issue.  Lactation consultant and doula Jessica Lang Kosa, PhD, IBCLC, shares a post here reprinted from her blog at MotherFeeding.com, explaining this phenomenon and what a lactation consultant would do to help turn the situation around.

DoulaMatch.net has great doula referrals

One of the best resources I know of for referrals to doulas across North America is the Web site DoulaMatch.net created by Kim James, who explains the service below.  (For further information on finding a doula, including community doulas available at no charge to low-income mothers, doulas outside North America, and how to interview a doula, see chapter 5, "Find Your Doula!" in my book The Doula Guide to Birth.)

Childcare tips for doulas

A while back I surveyed doulas to find out how they arrange care for their own children while attending births.  If you are a doula who has struggled with how to handle this, you are not alone!  I received a range of incredibly creative responses which I will post here -- please feel free to post a comment and let us know what your strategy for childcare is, too.

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Childcare tips for doulas

1. Last summer I hired a teenaged babysitter and guaranteed her 80 hours a month at $10/hr.   That was enough money for her that she didn't have to work anywhere else, so I had her on call 24/7.  I was able to pay for it easily by doing 2 births a month.
2. My husband is a firefighter and works 24 hour shifts.  On the times that I've needed childcare at night and he was working I've called my backup doula.  I partner with 2-3 other doulas that I know and trust and rather than taking each other's clients when we don't have childcare readily available we just take each other's kids. 
3. I have been fortunate to have the help of my partner to be there during births as well as a fellow doula/friend that has helped get my baby to and from sitter when I had a birth. 
4. I have an "on-call" babysitter who is almost always home, because she homeschools her four children.  She had a doula herself, so she understands the nature of the job.  For payment, we actually do a trade--for every three hours she watches my daughter, I give her 10-year-old a one hour throwing lesson (ceramics).  It works out great!  I love trading services like that :)
5. I think the idea of paying a premium for off hours is a good idea.  By off hours I mean late nights, weekends, or any time that it really would interfere with regular life. I think that you would have the best luck with a fellow mom.  I've done childcare before, and while it is not something I would ever want to do again full time, I would love the opportunity to earn a little bit of money here or there.  I would even be open to trading childcare hours sometimes – i.e., I'll watch your little one for a few hours and bank those hours with you and you watch my little one at a later date when I have a Dr.'s appointment.  I think the biggest thing is to let your provider know you appreciate them. Round up not down when paying for fractional hours, or if it's $48, just give $50, etc..... it sounds small but it doesn't go unnoticed.  If you're going to be later then expected, a call goes a long way.  Basic stuff really, but it adds up to a better relationship.
6. I'm a single mom to three, and have 3 babysitters that I call on when I need to attend a birth.  I actually pay less for overnight hours since they are basically getting paid to sleep (my kids are 12, 8, 5, so they all sleep through the night).  I don't have a "regular" offering or bonus for coming over last minute, but have occasionally given them bonuses of $20. 
7. I have a great Nanny that already comes 2 days a week.  She keeps me posted on the rest of her availability, and when/if she cannot come, my husband will fill in the rest.
8. I've been a single mom/doula for 7 years.  For a few years I had a roommate. In exchange for food and very reduced rent she took care of my daughter when I had to go to a birth in the evening or middle of the night but it got more complicated when she went back to school and my daughter only had preschool 3 half days a week (that was all I could afford). For the past year and a half I’ve been to around 30 births while living alone with her (she's almost 10 now). The good news is that I have an amazing community of friends and family that will help me out when needed. The bad news is that there are times when I have to wake her up in the middle of the night and drive her to my mom or a friend's house so I can go to a birth. This sucks for all involved...including the laboring mom who has to wait for me to get my child situated before I can go to her. I'm reducing my birth load greatly now and focusing more on postpartum. Starting soon I'll be working with 3 other doulas. We'll share call and have all group prenatals so my schedule won't be so chaotic and and I'll only be on call one 24 hour day a week and every 4th weekend.  I don't want to stop doing births so I had to figure out a way to make it work for my family.
9. I didn't attend births while my children were very young. I chose to wait until they were all school age. While they were little, I did things like leading LLL meetings and attend workshops so I could have set times when I knew I'd need help with them.  After they were older and I started attending births, I hired a local homeschool, high school-aged teen girl to be on call and she was awesome! I paid her by the hour plus mileage since she drove herself here and back. Now the boys are older and for short trips I leave them alone but for longer, I leave them with their grandmother. I'd strongly suggest looking into your local homeschool association if you have one. Those families are mostly flexible about school work and the girls that I knew were emotionally mature for their ages as well as many come from big families so they're used to working with young children.
10. I had two babysitters and my family on call. It always seemed like a constant juggle. Now my oldest son is the default baby sitter and he likes the responsibility, thank goodness! I always felt like I was imposing and I paid my sitters $10 per hour at first and gradually increased to $15 per hour b/c it can be a strain on their family. I offered the $50 retainer but my sitter would not accept it.
11. Not typical, I know, but for the first two years of my son's life, he came with me each and every time...usually, if not always, in the wrap.  This was discussed with the birthing mamas ahead of times, and they never had any objections.
12. I hire about 4-5 sitters through the local college job boards.  I have split my Monday thru Friday into 2 shifts per day -- 8AM-1PM, and then 1PM-6PM, which is basically the time frame that my husband is working. My sitters sign up for shifts for the entire month, as many as they wish but ideally 2 per week. I pay them at minimum a $50 monthly retainer; if they take 3 or more shifts per week, I'll pay $75. This is in exchange for their guaranteed availability during their shift. If they get called in, the retainer goes to what I pay per hour (which is obscene, but I think with 3 kids I'm getting it easy at $17/hr). If they don't get called in, they keep the retainer. The only downsides are that during academic breaks, my fleet of sitters gets scant, and I have to comb for people who are around. I always get a million responses when I post on the job board, and then when I explain very carefully that this is not steady work and that signing up is not a guarantee of work, I lose a few candidates. But the ones who I hire like being paid during their block of study time, or when they would be running errands, etc. The most important factor is that YOU MUST CHARGE ENOUGH FOR YOUR DOULA SERVICES IN ORDER TO PAY FOR YOUR CHILDCARE.
13. I have a husband who travels at least a 24 to 48 hour trip a week and I am also homeschooling a 9,11 and 15 yr. old. We moved my parents in last year to cover overnights, it has had its plus and minus for sure :)  Other than the travel my husband has a flexible job schedule BUT I try not to have him miss his regular work day so I have friends of the kids moms who I ask to be "on call" for a day long playdate, like my friend P. has Mondays, my friend S. Tuesdays etc.  I have to find care for each child’s activities also so that plays into it for our family, so I have to coordinate on call friends who have kids in my children’s activities. I have always been very generous in taking my on call friends’ children here for playdates and driving them places for their parents so that when I need help they dont feel taken advantage of.  For the most part it works but it is not easy at all and it is probably the biggest stress factor for me in doula work. 
14. When my children were very young, I partnered with another doula.  We would take turns with one of us supporting a family and the other caring for all the children; next birth we would switch roles. We took only one client a month so that we would be the one available to the mom who hired us.  Therefore we would only be on call for a birth every other month meaning that we could have a family life without interruption the alternate months (my doula colleague's children became a part of our family and went wherever we went without hesitation if their mother was at a birth so it never felt like an intrusion.)  We each taught a variety of prenatal, postpartum and childbirth classes and had other baby sitters for our own children (and the other doula's also) on those nights as well as back up for our classes.  This was a little extra money and limited intrusion in our family's lives.  Although this took some organization, we were not as overwhelmed about doing this work as I hear from so many of you out there.  It makes me sad to hear of your frustration when we felt joy and excitement about doing doula work.   It is great to hear how others are putting together systems that work in their individual situations. 
15. Have at least 5 babysitters on call each month a client is due and keep them on retainer, or barter for other services. Keep a primary that will be on call throughout high traffic times that you find to be very dependable and flexible. If at all possible retain interest in being on call with these babysitters by using them as well, whenever truly needed, as scheduled babysitters. Good resources for flexible babysitters are early child-education majors at local colleges. They normally are cheap, are really eager to make money, and are willing to be on call for a week at a time.
16. I have turned some clients down if it seemed my time away from my kids wouldn't be "worth it" – i.e. distance from birthplace, really annoying hospitals that would send me home to my kids in a bad mood, etc.  Childcare is the toughest part of the whole thing.  I would suggest that if you can have the luxury of having a mother's helper come the day after a birth, that can be a life saver so you can rest up a bit (presuming you're nursing that can be essential -- a "milk day" in bed with baby until s/he's ready to do something else and the mother's helper can take baby for a bit).  I have between 3-5 sitters and my spouse can come home for a quick break while waiting for sitter to arrive (because some of them are quite far -- it has been challenging to find reliable help locally).  At first I had folks lined up by day of the week -- Sitter A on Mondays and Thursdays, Sitter B on Tuesdays, Sitter C on Wednesdays and so forth.  I would check in with them once a week and I paid them retainers, if they felt it was important.  That system worked well, except for paying for two weeks of retainer for more than one sitter. Another thing I've done is had a sitter in non-winter months who would watch my kids until my mom drove over (an hour and a half). 
17. I advertised on Craigslist for an “on call” babysitter and found a few who were willing to be called on very short notice.
18. Care.com is a great website.  Some daycares offer drop in service and home provider that are monitored by the state are great resources because they have to have FBI checks.  I know because I am a state certified childcare provider.  You can acquire a list of home providers from either a childcare resource organizations in your area or your local county of family services. 

Welcome!

Welcome to THE DOULA GUIDE blog.

My name is Ananda Lowe and I am co-author of The Doula Guide to Birth:  Secrets Every Pregnant Woman Should Know, published by Bantam Books.  Since 1995, I have worked with childbirth professionals and new parents throughout North America and beyond.  My roles have included Assistant Director of a national doula training organization, pregnancy massage expert, Lamaze-trained childbirth instructor, college major in Maternal Child Health, mother, and of course, doula.