doula

This article, written by Sophie Brigstocke, first appeared in the Journal of Holistic Healthcare, Summer 2017

How many lightbulb moments can you remember in your life?  Those moments when suddenly everything slots in to place, those jigsaw pieces re-arrange themselves and you see the whole picture for the first time. I see the same “eureka” moment happening time and time again – with the individual women and families I work with as a doula, to the groups of new doulas I teach. I am both excited to see the moment happening and saddened that the awareness wasn’t there before.  The moment I am talking about is around birth physiology: The understanding of how hormones work in labour and how they can be disturbed – or protected.

If I were to ask a random group of people to describe what happens during birth, the most common responses involve contractions, waters breaking, dilation and pushing out a baby. With the amount of fear-mongering stories that people like to tell, and our media’s obsession with drama, there will often be vivid and horrifying descriptions of women screaming, lying on their backs with their feet in stirrups, begging for pain relief, of torture-like instruments being wielded by white-clad strangers, lots of blood, a rush to the operating theatre, of life and death situations.  Just writing about it makes me feel nauseous and fearful.  However, it is incredibly rare in these conversations that anyone ever considers what is behind the physical sensations of birth. So, if we take a moment to look at what a woman’s body is doing during labour we can gain enormous clarity.    

The prime hormone of labour is Oxytocin.  The hormone of love.  Produced in the hypothalamus, the mammalian part of the human brain, it produces strong, effective contractions of the uterus. In the earlier part of labour these contractions pull the muscles of the uterus upwards to draw open the cervix. In the later stages they cause effective downward surges, helping to push the baby down and out of the birth canal.  Endorphins, also produced in the same area of the brain, are released alongside oxytocin and are responsible for providing natural pain relief. These are nature’s friends working side by side – oxytocin generating strong physical feelings, endorphins providing necessary relief from them.  So, in theory, all should be well.  A labouring woman or person will feel strong sensations but her body will provide a natural antidote. However, many people report feeling overwhelmed, in pain and/or out of control during their labour. So, what is happening and why is the body not able to deal more effectively with “pain”?

French Obstetrician and midwife Michel Odent describes oxytocin as a “shy” hormone.  And this is where a lot of the problems lie.  Oxytocin requires certain conditions to be produced, and it is very easy to switch off.  If we consider one of the other instances in our lives when we produce oxytocin, it is perhaps easier to see how impactful a change of situation can be.  Picture yourself staying with your loved one in a beautiful hotel – a romantic setting where you have perhaps just eaten a delicious meal by candlelight, maybe enjoying a glass of champagne, and have moved from dining room to bedroom where you and your partner are alone to caress one another, undress and start to make love.  The atmosphere is loving, warm and intimate.  Suddenly, the fire alarm goes off – really loud sirens sounding, bright lights come on in the room and hotel staff rush in to shepherd you out to safety in the cold street.  It’s not surprising that those warm, loving, pre-orgasmic feelings instantly disappear!!! It would also be surprising if the mood could be recreated in a hurry!  Adrenalin, an oxytocin-killer, flooded the body when the fire alarm went off. It caused the levels of oxytocin to plummet, and endorphins too.  During birth, adrenalin has a place, but only in the later stages – usually a hit of adrenalin is released just prior to the pushing phase, giving the mother an energy surge and impetus to clear the final hurdle!  Any adrenalin released in the earlier stages of labour is generally detrimental.  

So, what are the main factors that impact oxytocin production and release?  If we consider a mammal birthing – a cat bringing her kittens in to the world for example – the likelihood is that she will choose a nesting place which is somewhere dark, warm and quiet.  In my childhood home it was always the back of my Mum’s wardrobe, and once we realised that was where she wanted to be we would put a box which was lined with old towels for her to feel cosy and settled.  In our hotel scenario the environmental factors that changed were light, noise and temperature.  Birthing people need that same sense of a nesting place – somewhere comfortable and private, warm and dimly lit.  In addition to those environmental factors, which affect all birthing mammals, the human female has a couple of additional challenges.  The human brain has a significantly larger neo-cortex than other mammals – the thinking part of the brain, the part that helps us to develop language skills, rationalise, discuss and debate, appreciate the arts etc. During labour if the neo-cortex is stimulated it draws the focus away from the mammalian part of the brain, the hypothalamus, which is where those all-important birthing hormones are produced.  We need birthing women and people to be able to let go, shut off the world around them and access their primal state – the instinctive mammalian part of themselves.  Fielding questions, having people talking to them, worrying about who is going to win the next general election is all an unnecessary distraction, which can have an impact on those crucial birthing hormones and stimulate the neo-cortex. Similarly, the feeling of being observed can cause a birthing woman or person to switch off because birth is generally a private event.  If we return to our labouring cat, she is likely to stall birthing her kittens until she feels unobserved, safe and private, which is very disappointing for an excited child wanting to witness her first birth!  But, observation is more than being watched by people.  In the hospital setting it can also include physical examinations – having your tummy palpated or a vaginal examination to establish dilation – or foetal monitoring.  Labouring women and people generally want to be mobile, active, able to get in to whatever position feels comfortable for them without being told what to do or being limited in any way. 

Bearing all of this in mind the questions we all need to consider when preparing for birth are where and with whom?  Given that we know that oxytocin production is likely to be impacted both by our environment and the people around us, surely we need to think far more carefully about what we would like for our birth experience than which brand of buggy to choose!  As a doula I work with a wide range of families, all with unique circumstances impacting their choices and options.  For some, once we have discussed birth physiology, the idea of a home birth becomes hugely appealing.  Home is that person or couple’s most familiar environment – their safe space, somewhere the labouring woman or person knows well and can move about in without restriction.  Her bathtub is clean, her kitchen contains all the foodstuffs she finds most appealing, her bed is large, inviting, comfortable.   There are spaces for her partner, midwives, doula to retreat to if she wants solitude and peace.  For some, the idea of birthing at home doesn’t suit, so the challenge is to create a “nest” in a different setting – the hospital, birthing unit or maternity centre.  Medical issues may dictate a more interventionist approach, and whilst a woman or person may be more limited in what she can do we are reminded by the brilliant charity Birthrights, that pregnant and birthing women and people still have choices and that their experience of birth is most commonly affected by whether they felt they were given options and supported in deciding what happens to their own body.

Continuity of Care is a phrase being used a great deal in the birth world at the moment.  In Baroness Cumberledge’s National Maternity Review 2016 she identified lack of Continuity of Care as one of the key factors affecting women’s experience of birth in the UK.  It is certainly a huge challenge. More recent research done by the NCT and WI shows that 88% of women have not met the midwife who supports them during labour prior to the birth.  This is a distressingly high statistic when we consider that with familiarity comes reassurance and calm, and is therefore oxytocin-friendly! Pioneer sites across the UK are being encouraged to look at Baroness Cumberledge’s findings and tasking with coming up with innovative ways to address them. On a team that I am working on, Heads of Midwifery are combining forces to share knowledge and ideas so that the general experience of women can be improved. But, given the limitations of our NHS and the shortage of midwives across the UK, this is not going to be resolved quickly or entirely satisfactorily.  For me this is where the doula comes in to her element.  Hired independently by a woman or person during pregnancy, the birth doula can provide such support that there is a deeply established and positive relationship in place long before labour begins.  A doula becomes aware of her client’s individual needs, expectations, hopes and fears.  She is able to ask her clients those all important questions about where they feel most comfortable birthing, who they want to have there, what might have a positive or negative impact on them.  She can signpost evidence-based information and research to help them come to decisions that feel right for them.  She can empower, inform, challenge and nurture.  The doula works with the couple and for them, but is able to liaise with the health care providers in a positive way, acting as advocate if necessary, helping to alert midwives or others to essential information about the couple, and provide practical support to the midwifery team when applicable. The doula is non-medical – she certainly is not going to make decisions on behalf of the mother or birthing parent, nor give her judgement or opinion, but she is able to facilitate positive discussion and provide evidence.  But, ultimately, if we return to the original topic of this article, the doula understands, believes in and respects birth physiology!  She is able to hold the space for a labouring woman or person and their birth partners. She will help to create and maintain that essential birth nest, the environment that will help a mother or birthing person let go and enter her primal state.  She will be a calm presence, aware of what is going on around, gently giving reassurance to those at the birth to reduce any stress levels that may impact the labouring mother or person.  

A doula’s role doesn’t end with the birth.  There is a wealth of evidence to support how doulas reduce the number of interventions during labour, the need for pharmacological pain relief, caesareans, episiotomies, even duration of labour, but even after birth significantly more women who are doula-supported breastfeed successfully and for longer.  And these statistics are important because what happens during pregnancy and birth has a bearing on the future of that mother/person and baby.  A person’s mental wellbeing is impacted by the type of birth they have, and this, obviously, has a direct effect on the growing baby.  The human baby who is programmed for connection, and whose brain is still developing and growing.  If a baby’s parent is depressed, in pain, traumatised or unwell then he/she is less likely to get the necessary connection, feeding and bonding that he/she needs to develop into a healthy adult. It is challenging stuff.  It is my belief that doula support during pregnancy, birth and in the first few essential weeks of parenting is hugely and significantly beneficial to families and the wider community.  I feel excited about the positive impact that doulas can bring as awareness of the doula role increases, more women and families choose doula support and conversations happen to look at how doulas can support our challenged NHS, relationships develop, grow and build.  My long-term desire is that every woman, person and family should be able to access doula support regardless of financial circumstances.  There is plenty being done to encourage that, so let’s keep the ball rolling!