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DONA%International%Birth%Doula%Manual/2012©%%%%%%%%%%%%%%%%%%% 1.2

Labor#Support#by#Doulas,#Midwives,#Nurses,#Physicians#and#Loved#Ones#

by$Penny$Simkin$

A%laboring%woman%is%cared%for%by%a%variety%of%people,%each%of%whom%has%a%defined%role%to%play.%Clinical%or%

medical%aspects%of%care%are%the%top%priority%of%physicians,%nurses,%and%midwives.%Doulas,%fathers%and%loved%

ones%focus%on%psychosocial%or%non?medical%aspects%of%care.%The%baby’s%father%and%loved%ones%also%have%a%

great%emotional%investment%in%both%the%woman%and%baby%and%may%need%emotional%support%and%guidance%at%

times%during%labor.%%Below%is%a%brief%description%of%the%roles%played%by%each%member%of%the%team:%%%

• Physician:$$responsible%for%clinical%well?being%of%mother%and%baby;%present%occasionally%during%labor$• Midwife:%responsible%for%clinical%care;%gives%intermittent%support%and%comfort;%present%when%possible%in%

active%labor%

• Nurse:% clinical% care% as% dictated% by% caregiver’s% orders% and% hospital% policies;% intermittent% support% and%

comfort;%keeps%caregiver%apprised%of%situation%

• Baby’s$father/loved$one:%continuous%or%intermittent%presence,%varying%amounts%of%support%and%comfort,%

witnesses%and%shares%birth%with%the%woman%

• Doula:% continuous% presence% for% emotional% support,% physical% comfort,% non?clinical% advice,% guidance% for%

partner%

The%table%below%lists%specific%components%that%contribute%to%the%emotional%well?being%of%the%laboring%woman,%and%

indicates%which%team%members%supply%each%component.%As%can%be%seen,%everyone,%even%those%whose%role%is%

primarily%medical,%provide%some%emotional%care.%Obviously,%the%doula,%whose%role%is%defined%as%a%support%role,%

offers%the%most%emotional%care.%Only%with%a%doula’s%presence%can%women%be%assured%of%continuous,%unadulterated,%

emotional%support.%%

Comparison%of%providers’%ability%to%furnish%emotional%care%to%laboring%women%

Components$of$emotional$care$ MD$ Midwife$ Nurse$ Baby's$Father/$Loved$One$

Trained$Doula$

Continuous%uninterrupted%presence% —% ?% —% +% +%

Knowledge/understanding%of%woman% —% ?% —% +% ?%

Love%for%mother%and%baby% —% —% —% +% —%

Knowledge/understanding%of%emotions%and%

physiology%of%labor%

?% +% +% ?% +%

Experience%with%other%laboring%women% +% +% +% —% +%

Ability%to%remain%calm/objective% +% +% +% —% +%

Knowledge%of%MD,%midwife,%hospital%policies% +% +% +% —% ?%

Perspective%on%problems/options% +% +% +% —% +%

Advocacy%of%mother's%wishes/goals% —% +% ?% +% +%

Freedom%from%other%obligations,%other%patients,%

tasks,%clinical%management,%hospital/MD%policies%

—% —% —% +% +%

Knowledge%of%comfort%measures% ?% +% ?% ?% +%

Key:%+%=%provides%this%component;%—%=%does%not%provide%this%component;%?%=%varies%


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Best#Research#Evidence#on#Labor#Support!

Best%evidence:%%When%making%important%maternity%decisions,%women%should%have%information%

from%the%best%available%research%about%the%safety%and%effectiveness%of%different%choices.%%In%

general,%we%can%be%most%confident%about%results%of%systematic)reviews)that)summarize)randomized)controlled)trials%(or%RCTs,%a%type%of%study).%%

What%is%the%bottom%line%about%labor%support?%

The%most%recent%and%largest%systematic%review%of%continuous%labor%support%summarizes%the%experiences%

of%over%15,000%women%who%participated%in%21%randomized%controlled%trials.%The%authors%conclude:%%

Continuous$support$during$labour$has$clinically$meaningful$benefits$for$women$and$infants$and$no$known$harm.$All$women$should$have$support$throughout$labour$and$birth%(Hodnett%and%colleagues%2011).%

%

What%is%the%best%evidence%about%the%benefits%of%continuous%support%during%labor?%

The%review%found%that,%in%comparison%with%women%who%had%continuous%support,%women%who%labored%

without%continuous%support%had%longer%labors%and%were%less%likely%to%have%a%“spontaneous”%birth%(with%neither%cesarean%section%nor%vacuum%extraction%nor%forceps).%Women%without%support%were%more%likely%

to:%%

• have%an%epidural%or%other%"regional"%analgesia%to%manage%pain%%

• use%any%type%of%pain%medication%(including%narcotics)%%

• give%birth%by%cesarean%section%%

• give%birth%with%vacuum%extraction%or%forceps%%

• give%birth%to%a%baby%with%a%low%Apgar%score%rating%of%well?being%5%minutes%after%birth%

• be%dissatisfied%with%or%negatively%rate%their%childbirth%experience%%

%

Does%it%matter%who%provides%continuous%support%in%labor?%

The%most%recent%systematic%review%looked%closely%at%how%effects%of%labor%support%varied%by%type%of%

person%providing%labor%support,%and%offers%new%knowledge.%%

%

Effects%were%strongest%when%the%person%was%neither%a%member%of%the%hospital%staff%nor%a%person%in%the%

woman’s%social%network,%and%was%present%solely%to%provide%one?to?one%supportive%care.%Compared%with%

women%who%had%no%continuous%support,%women%with%companions%(such%as%a%doula)%who%were%neither%

on%the%hospital%staff%nor%in%the%woman’s%social%network%were:%%

• 28%%less%likely%to%have%a%cesarean%section%%

• 31%%less%likely%to%use%synthetic%oxytocin%to%speed%up%labor%%

• 9%%less%likely%to%use%any%pain%medication%%

• 34%%less%like%to%rate%their%childbirth%experience%negatively%%

%

Support%provided%by%a%person%that%the%woman%selected%from%her%social%network%(for%example,%her%

partner,%husband,%other%family%member,%or%friend)%increased%her%satisfaction,%but%did%not%seem%to%

impact%her%use%of%obstetric%interventions.%%

%

%


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Support%provided%by%a%member%of%the%hospital%staff%(such%as%a%nurse)%did%not%seem%to%impact%a%woman’s%

likelihood%of%having%a%cesarean%or%her%satisfaction.%The%authors%note%that%hospital%employees%may%have%

divided%loyalties%and%other%duties,%and%may%be%influenced%by%hospital%policies,%which%could%limit%the%

impact%of%their%supportive%care.%%

%

Does%labor%support%have%the%same%impact%in%all%types%of%birth%settings?%

Hodnett%and%colleagues%(2011)%found%that%benefits%of%continuous%labor%support%appeared%to%be%greater%

when%women%received%it%in%settings:%%

• that%did%not%allow%them%to%bring%companions%of%choice%(versus%settings%that%do%allow%

husbands,%friends,%etc.)%%

• where%epidural%analgesia%was%not%routine%(versus%settings%where%epidural%is%routine)%%%

• that%allowed%intermittent%auscultation%(periodic%listening%to%the%fetal%heart%rate)%or%

intermittent%electronic%fetal%monitoring%(versus%settings%where%continuous%electronic%fetal%

monitoring%is%routine)%

%

What%factors%most%contribute%to%women's%satisfaction%in%childbirth?%

In%considering%whether%to%make%arrangements%for%labor%support,%it%may%be%helpful%to%consider%results%of%

research% about% satisfaction% in% childbirth.% A% systematic% review% of% the% best% available% research% (Hodnett%

2002)% found%that% the% following% four% factors%made%the%greatest%contribution%to%women's%satisfaction% in%

childbirth:%%

• having%good%support%from%caregivers%%

• having%a%high?quality%relationship%with%caregivers%%

• being%involved%in%decision?making%about%care%%

• having%better?than?expected%experiences,%or%having%high%expectations%%

%

%

%

References%%

Hodnett%ED.%Pain%and%women's%satisfaction%with%the%experience%of%childbirth:%a%systematic%review.%Am$J$Obstet$Gynecol%2002;%186(5)%S160?72.%%%

Hodnett%ED,%Gates%S,%Hofmeyr%G%J,%Sakala%C,%Weston%J.%Continuous%support%for%women%during%childbirth%

[PDF].%Cochrane$Database$Syst$Rev%2011,%Issue%2.%%

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Reprinted%with%permission%from%Childbirth%Connection,%www.childbirthconnection.org%

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Checklist#of#Comfort#Measures#for#Labor))Relaxation/Tension)Release)% Relaxation%

% Roving%Body%Check%

% %

Rhythmic)Breathing)&)Vocalization)% Slow%full%breaths%

% Light%breathing%

% Vocalization%–%moaning,%sighing,%groaning%

% Encourage%her%to%express%herself%freely%

% %

Bearing)Down)% Help%to%avoid%bearing%down%

% Spontaneous—encouragement%

% Directed%("purple"%pushing)%

% %

Comforting)Touch)% Acupressure%

% Hand%&%foot%%rub%

% Light%stroking%

% Firm%pressure%

% Crisscross%on%back%

% Holding,%hugging,%resting%touch%

% Massage%tools%

% %

Hydrotherapy)% Bath/jetted%spa%tub%

% Shower%

% %

Attention]focusing)Strategies)% Visual%focal%point,%music,%voice,%touch%

% Visualization%

% Inward%focus%(reboot)%

% %

Mental)Activity)% Count%off%10%sec.%intervals%in%contractions%

% Count%breaths%

% Conducting%

% Chant,%mantra,%song,%counting,%prayer%

% Guided%imagery%

% Spontaneous%rhythmic%rituals%

% %

Body)Positions/Movements)% Standing,%leaning,%slow%dancing%

% Walking%

% The%lunge%

% Kneeling%leaning%forward,%beanbag%

% Kneeling%on%one%knee%

%

% Sitting%up%

% Sitting%straddling%a%chair%

% Birth%ball%(sitting,%leaning)%

% Lying%down%&%side?lying%

% Semi?reclining%

% Supine%with%tilt%to%side%

% Squatting%and/or%supported%squat%

% Lap%squatting%

%

Warm)Packs%% To%low%abdomen/groin%

% To%perineum%

%

Cold)Packs%% To%low%back%

% To%perineum%after%birth%

% To%forehead,%back%of%neck,%upper%chest%

%

Specific)Backache)Measures%% Counterpressure%

% Double%hip%squeeze%

% Knee?chest/open%knee?chest%position%

% Hands%&%knees%with/without%birth%ball%

% Pelvic%rocking%(rebozo)%

% Lunge,%asymmetrical%positions%

% Walking/movement%

% Slow%dancing%

% Abdominal%lifting%(rebozo)%

% Crisscross%on%back%

% Cold%or%hot%pack%

% Rolling%pressure%

% Shower%to%back%

% Bathtub%

%

Emotional)Support%% Feedback%&%verbal%reminders%

% Encouragement%&%reassurance%

% Give%unsolicited%praise%after%each%ctx%

% Patience%&%confidence%in%woman%

% Undivided%attention%

% Eye%contact%

% Take%Charge%Routine%

% Anticipatory%guidance%&%progress%reports%

% Firm%embrace,%“ground”%her%

% Match%her%mood%

% Take%contractions%one%at%a%time%

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