Monday, June 20, 2016

Doula Fees

Our fee is a fair reflection of our extensive experience and depth of skills and knowledge.  If our rates for full doula care seems too high, you can still access some of our service to help be prepared and supported through your birth (see below). 

If you can afford our fees but don't understand why we charge this fee, please see http://www.cordmama.com/blog/2015/3/23/why-doulas-are-expensive-and-why-youre-glad-they-are

If you have a lovely partner who doesn't understand why you would pay for extra support, please see http://goodmenproject.com/families/new-dads-advice-just-hire-a-damn-doula-jrmk/

We have services that help prepare you for your birth and postpartum:
Labour Prep Class for Couples (this can be dads or anyone who is planning to attend your birth as your companion such as a friend or relative)
Birth Plan Prep
Prenatal Classes (see list at http://angelikaevans.blogspot.ca/p/birth-preparation-classes.html)
Placenta Encapsulation http://angelikaevans.blogspot.ca/p/placenta-encapsulation.html 

We are willing to work with a payment plan.
We offer gift cards for people who would like to contribute to help you  hire a doula.
It's possible to raise funds e.g. have a collection-box for those who attend your shower or Blessingway, or ask people to contribute to your doula rather than buying other gifts.
Less experienced doulas have lower fees.  See www.DoulasofRegina.ca for a listing of local doulas and also information about the Relief Fund.

Sunday, May 17, 2015

Avoiding Postdates, Induction



Post-term or post-date pregnancy is one that exceeds 42 weeks gestation.  Post term refers only to dates and has nothing to do with fetal condition.  If a woman is healthy and well nourished then her placenta almost always continues to thrive and nourish the baby at any gestation. 

Post-term is not the same as postmaturity, which refers to fetal condition.   Postmaturity symptoms include loose skin suggesting weight loss, decreased ability for the skull bones to mold during labour, fetal distress in labour, and presence of meconium.  These babies are compromised as they receive insufficient nutrients through the placenta.  Therefore continuing the pregnancy is not safe.     
Studies vary on outcomes of post-date pregnancies.  Common belief is that post term leads to large, compromised babies, and that the placenta stops working.   Macrosomia (large baby:  >4000g / 8.8lb) occurs in 10% of post term births; 1% are > 4500g (9.9lb) (Fraser, Cooper, & Fletcher, 2003).  SOGC reports current studies regarding pregnancy past 40 weeks don’t differentiate between healthy and complicated pregnancies and are too small to be accurate (Delaney & Roggensack, 2008).   Canadian guidelines are to offer induction during the 41st week of pregnancy.    By far the number one reason for induction is post-term pregnancy.   Women have the right to accept or refuse this intervention and are encouraged to ask enough questions to partake in shared decision making with their care-provider.

Reasons Your Pregnancy May Last Longer than 40 Weeks
·         Inaccurate dates
·         That’s just normal for you
·         Malpositioned foetus e.g. facing the wrong way or head not flexed well
·         Anything that interferes with optimal release of labour hormones e.g. fear, lack of privacy, conflict, lack of support
·         Not being “ready” to receive the baby – birth-supplies, home, work responsibilities, too many friends or family around, calendar too full, waiting for someone
·         Emotional issues – fear, needing to hold on

Ensuring Placenta Develops Normally and Remains Healthy – Avoiding Postmaturity Syndrome
All the things that contribute to a healthy pregnancy and baby, including:
·         Good nutrition, including healthy salt and fat intake, minimizing or avoiding sugar and junk / processed foods
·         Proper hydration
·         Pregnancy tea (see handout)
·         Avoid smoking (including second-hand smoke), alcohol and drugs
·         Avoid antacids, cheap or poor-quality vitamins and calcium supplements as these all contain calcium that humans don’t assimilate.  This calcium builds up in placenta, decreasing function.
·         Discuss any health issues with care-provider.  Some conditions lead to inadequate hormone activity, circulation problems or malnutrition.  
·         Good prenatal care, including monitoring blood pressure and health of mother, foetus, placenta
·         Time for relaxation and some light to moderate exercise daily
·         Manage stress
·         Surroundings – healthy environment including the people with whom you interact

Is Your “Due Date” Accurate for You and Your Baby? 
·         Review your estimated due date (EDD) with your practitioner and how it was determined
·         Obstetrical history – some women tend to gestate longer than others
·         Your mother’s obstetrical history – does it include “late” babies
·         SOGC recommendations for determining accurate EDD (Delaney & Roggensack, 2008):
o   Ultrasound (u/s) between 11-14 weeks
o   If dates determined by 1st trimester u/s and LMP vary more than 5 days then u/s is used as EDD
o   If dates determined by 2nd trimester u/s and LMP vary by more than 10 days then u/s should be used as EDD
o   If u/s was done in 1st and 2nd trimester, then EDD is determined by earlier u/s
·         Ultrasound accuracy for estimating EDD decreases as gestation increases.  Accuracy is within 3-5 days in the first trimester, within 7-10 days in the second trimester, and decreases to within 2-3 weeks after 26 weeks (Varney, Kriebs, & Gegor, 2004)

Tips to Help Avoid Post-Term Pregnancy
There may be nothing to be done about post-term pregnancy as some babies just take longer than others.  Like roses opening on a bush, they don’t all happen at the same time.  However the following can help prepare you and the baby for labour.  If they don’t bring your baby faster they will contribute to a healthier, more comfortable and efficient birth experience. 
·         Herbal “pregnancy-tea” blend through pregnancy as desired; 3 cups daily in last trimester
·         Homeopathic Actea racemosa Complex or a similar homeopathic labour-prep blend from your midwife or homeopath – 2 doses daily from 36 weeks on
·         Massage therapy by a practitioner who understands pregnancy and the female pelvis
·         Osteopathy to address any structural issues
·         Webster, a chiropractic technique to help prepare pelvis for labour and achieve optimal fetal positioning (Pistolese, 2002)
·         Acupuncture helps prepare the body for labour and decreases need for pharmaceutical induction; can be used to induce labour (Winder, 2012)
·         Hypnotherapy or other counselling techniques to help resolve fears or emotional issues that may be holding back progress
·         Ripen the cervix
o   Sexual activity – female orgasm produces oxytocin, semen contains prostaglandins which act on the cervix
o   Evening Primrose Oil capsules orally and/or vaginally beginning at 36 weeks: 1500 mg  daily orally, and/or insert 2 caps to the cervix before bed
·         In one practice guideline the SOGC  recommends membrane sweeping beginning at 38-41 weeks (Delaney & Roggensack, 2008), while in another they state the procedure doesn’t change neonatal or maternal outcomes (Crane, 2001)
o   Hill et al. (2008) found no benefit to membrane sweeping, and no decrease in induction rates.  In fact they found this procedure can lead to risk of membranes releasing before onset of labour. 
o   This invasive procedure ranges from uncomfortable to very painful for the client

Induction – Holistic / Natural Methods
If induction is necessary or unavoidable then there are a few methods possible.  Please contact your midwife before beginning any of these to facilitate a discussion for shared decision making.
·         Herbs such as black and blue cohosh – seek a qualified herbalist
·         Homeopathic remedies such as Caulophyllum, Actea racemosa, Pulsatilla - your midwife or homeopath will have strong dilutions
·         Castor oil drink with Lemon Verbena
·         Acupuncture helps prepare the body for labour and decreases need for pharmaceutical induction; can be used to induce labour (Winder, 2012)
·         Acupressure – see http://www.youtube.com/watch?v=wnEcLSHTI0s for excellent demonstration
·         Massage 2 drops of Clary Sage essential oil with any carrier oil – can be used for acupressure treatments; stimulates hormones

Induction – Medical Methods
·         Pharmaceutical induction with cervical ripening agents and/or drugs to stimulate contractions
·         Studies are mixed regarding outcomes with routine induction based on dates alone.  SOGC (Delaney & Roggensack, 2008) recommends offering induction at 41+0 to 42+0 weeks, claiming a decrease in perinatal mortality and no change in caesarean rates.  Many other studies such as (Grivell, Reilly, Oakey, Cahn, & Dodd, 2012) found increased rates of caesarean birth and complications with induction.  Menticoglou & Hall (2002) present evidence that the original research was flawed, and that routine induction based on dates does more harm than good.

References
Crane, D. J. (2001). SOGC Clinical Practice Guideline No. 107: Induction of labour at term. J Obstet Gynaecol Can , 23 (8), 717-28.
Delaney, M., & Roggensack, A. (2008). SOGC Clinical Practice Guideline #214: Guidelines for the management of pregnancy at at 41+0 to 42+0 weeks. J Obstet Gynaecol Can , 30 (9), 800-10.
Dudley, N. J. (2005). A systematic review of the ultrasound estimation of fetal weight. Ultrasound Obstet Gynecol , 25 (1), 80-89.
Fraser, D., Cooper, M., & Fletcher, G. (Eds.). (2003). Myles textbook for midwives (14th ed.). Toronto: Chruchill Livingstone.
Frye, A. (1998). Holistic midwifery vol 1; Care during pregnancy. Portland, OR: Labrys.
Grivell, R., Reilly, A., Oakey, H., Cahn, A., & Dodd, J. (2012). Maternal and neonatal outcomes following induction of labor: a cohort study. Acta Obstetricia et Gynecologica Scandinavica , 91 (2), 198-203.
Pistolese, R. (2002). The Webster Technique: A chiropractic technique with obstetril implications. Journal of Manipulative and Physiological Therapeutics , 25 (6), E1-E9.
Tayler, R. (2000). Homeopathy for Pregnancy and Childbirth. Ottawa: Ottawa School of Homeopathy.
Varney, H., Kriebs, J. M., & Gegor, C. L. (2004). Varney's Midwifery, 4th Ed. Toronto: Jones and Bartlett Publishers.
Winder, K. (2012). Naturally Inducing Labour – Natural Induction Methods. Retrieved from BellyBelly: http://www.bellybelly.com.au/birth/natural-induction-methods

Monday, December 8, 2014

Birth-Doula Services: FAQ


What’s a doula?
A doula is a woman experienced in childbirth who provides continuous physical, emotional and informational support to the mother and partner during pregnancy, birth & early post-partum.  In much of the world today and throughout history, women support women through labour & birth. 

Where’s that name from?
In ancient Greece “doula” meant the highest female servant who helped the lady of the house through child-bearing.  Medical researchers Marshall Klaus and John Kennell, who conducted several randomized clinical trials on the medical outcomes of doula attended births, adopted the term to refer to labour support as well as prenatal and postpartum support.

What’s the difference between a midwife and a doula?
Doulas work as part of a team with doctors or midwives, but not instead of.  They provide non-medical support and comfort measures (e.g. encouragement, massage, positioning suggestions).  They do not perform clinical tasks such as heart rate, blood pressure, or internal exams. 

Midwives are highly trained in the medical aspects of birth.  The carry oxygen, medicines, resuscitation equipment and other gear, and are known as primary care-givers during birth.  In North America primary/medical birth care is offered by either a midwife or a physician. 

Why choose a doula over simply using a friend or family member as support?
Doulas are trained and experienced in childbirth support.  They know the sounds and behaviors of laboring women, and what that may indicate about progress.  Doulas are trained in pain-reducing comfort measures, natural methods to keep labor progressing, and to support both the laboring woman and her partner.  Doulas are familiar with local hospital policies & practices and have often built a rapport with the doctors, nurses and midwives.  See http://evidencebasedbirth.com/2012/06/26/why-wouldnt-you-hire-a-doula/

In most Canadian hospitals, women are allowed 2 support persons – usually that’s her partner and a support person.  Some hospitals accommodate a 3rd support person.  Homebirths and birth centers encourage women to have all the support they wish.

How does the doula fit in with nursing staff?
Doulas do not replace nurses or other medical staff, but rather work as part of the team.  They are there to comfort and support the mother & her partner.  Nurses change shifts; doulas stay. 


How does a doula assist with communication in hospitals during labor & birth?
During prenatal meetings doulas learn what’s important to a couple and discuss how to make informed decisions.  A doula may remind or encourage a client to ask the questions necessary to understand a procedure and make informed decisions.  Doulas do not speak on a client’s behalf nor intervene in their clinical care.  They do not make decisions for clients, nor judge the decisions clients’ make, but are there to support those decisions.

What difference does the presence of a trained doula have on birth outcomes? 
The presence of a doula tends to result in shorter labours with fewer complications and less interventions.  When a doula is present during and after childbirth, women report greater satisfaction with their birth experience, make more positive assessments of their babies, have fewer caesareans and requests for medical intervention, and less postpartum depression. In case of unplanned circumstances, doula support helps reduce negative feelings about one’s childbirth experience. Studies [1],[2],[3],[4]   have shown that babies born with doulas present tend to have shorter hospital stays with fewer admissions to special care nurseries, breastfeed more easily and have more affectionate mothers in the postpartum period.

Analysis of six randomized trials1 demonstrates that lack of doula presence correlates with:
·       Double the overall caesarean rate
·       33% increase in length of labour
·       67% increase in oxytocin use
·       2 ½ times more requests for epidurals

Will a doula make my partner feel unnecessary?
A responsible doula compliments and enhances the father/partner in their supportive role rather than acting as a replacement.  (While I respect people’s individual circumstances, I will use “father” words for most of this paragraph.)  The presence of a doula allows the father to support his partner emotionally during labor & birth without the pressure to remember everything he learned in childbirth class!  The father typically has little-to-no actual experience with the birth process, yet is expected to act as a coach.  Some partners feel (accurately) that this is a huge expectation.  Many fathers experience the birth as an emotional journey of their own and find it hard to be objective.  A doula is supportive to both the mother and her partner, and plays a crucial role in helping a partner become involved in the birth to the extent he/she feels comfortable.  Studies have shown that fathers usually participate more actively during labor with the presence of a doula than without one.  

When a couple works well together during the birth process they’re better able to handle the challenges of early parenthood.  An incredible bond forms or is made stronger. 

How often and when do we meet?
We’ll meet 2-3 times before the birth.  The introductory meeting is any-time – it’s never too early.  The prenatal meetings are best done between 24-36 weeks.  After your baby is born there will be a minimum of one postpartum visit, more if needed or desired.

Are doulas only useful if planning an un-medicated birth?
The role of the doula is to help attain a safe and pleasant birth, not to choose the type of birth.  The presence of a doula is beneficial no matter what type of birth you are planning.  In fact, women who choose a medicated birth need as much support as those who choose a natural birth, but a different kind of support.  For women who know they want a medicated birth, the doula still provides emotional support, informational support and comfort measures to help the women through labor and the administration of medications.  Doulas can help a mom deal with possible side affects and by filling in the gap that medication may not cover; rarely does medication take all discomfort away.

For a mother who faces a cesarean, a doula provides comfort, support and encouragement.  Often a cesarean is an unexpected situation and moms are left feeling unprepared, disappointed and lonely.  In this case doula support is especially helpful during the early post-partum period. 

What if I planned a drug-free birth then change my mind during labour?
Doulas don’t make decisions for clients or intervene in clinical care, nor do they judge women’s choices.  They provide informational & emotional support while respecting a woman’s decisions.

What kind of comfort measures do you use during the labour & birth process?
While there are common comfort measures taught in doula training courses, each doula also brings her own tools and methods.  Ours include the following:
o  Positioning suggestions
o  Massage & various touch methods
o  Homeopathy & Bach Flowers (optional; no extra charge)
o  Aromatherapy
o  Encouragement & reassurance
o  Heat or cold as desired
o  Hydrotherapy (water for comfort in labour, and/or water-birth)
o  Create space for partner, and recommendations to help partner to offer support
o  A calm, reassuring presence who trusts the birth process

When do we call you in labour?
Please call at the first signs of suspected labour.  We’ll discuss what those are.  From then on you’ll keep us posted on your progress and what’s happening.

When and where do you join us in labour?
When depends on the woman, her partner, and the labour.  Early support often takes the form of checking in by phone and/or dropping by your place.   Your doula joins you either at your home or in hospital or birth center and remains with you until 1-2 hours after the birth.

How does shared-care work?
Doulas team up to provide enhanced service.  Clients benefit from combined experience, education, and availability.  Since doulas are on call for up to a month for each client, shared care allows them time for important life events and days off without having to turn clients away or rely on unfamiliar back-up.  Clients meet both doulas prenatally so they’re familiar with whichever one attends birth. 

What if you can’t be at the birth?
In the rare circumstance that one of your doulas can’t be there, you will be well supported.  We work with reliable back-ups who offer excellent care.  Fees remain the same.  If the back-up is likely to be part of care, some clients wish to meet her prenatally, which can be arranged. 

Do we pay more to work with 2 doulas?
No.  Fees are outlined in the contract.  The cost of working with both doulas is the same as hiring one of them individually. 

What kind of postpartum support do you offer?
Your birth doula usually stays for 1-2 hours after the birth, until you’re ready to be on your own with your baby.  We also visit in the first day or two postpartum, offering basic breastfeeding support, answering questions, and going over your birth.  We are available for questions and can offer resources (educational and community).  A second postpartum visit is offered.

What if I need extra help with breastfeeding or baby-care? 
The information above describes our work as birth-doulas.  Another kind of doula, a “postpartum doula”, specializes in extended care and breastfeeding support.  There are also breastfeeding counsellors and lactation consultants that can be arranged through public health or hired privately.  We can provide resources and contact info.   If you’re on the Mother-Baby Unit the nurses or unit Lactation Consultants can provide support. 


[1] Klaus, M.H.; Kennel, J.H.; Berkowitz, G.; Klaus, P.  “Maternal Assistance and Support in Labor:  Father, Nurse, Midwife or Doula?”  Clinical Consultations in Obstetrics and Gynecology 4 (December 1992).
[2] Sauls, DJ.  Effects of labor support on mothers, babies, and birth outcomes.  J Obstet Gynecol Neonatal Nurs. 2002 Nov-Dec; 31(6):733-41.
[3] O’Driscoll, K. and Meagher, D.  Active Management of Labor.  2d ed.  London:  Bailliere Tindall, 1986.
[4] Klaus, M.H. and Kennel, J.H.  Parent-Infant Bonding.  St. Louis:  C.V. Mosby, 1982.