The Doula and Facilitating Consent

I recently listened to an episode of @birthallowedradio that broke my heart. A doula describes being a witness to an event that she said felt like witnessing a rape. What she saw was a doctor who followed a more patriarchal style of practice, performing a perineal massage on the woman’s vagina without any discussion before shoving his two massive hands inside her vagina.

This is a common practice, but there is actually no evidence for it. I once asked a doctor about it who said she does it “because she feels like it helps” to prevent a perineal tear. Perineal massage has been proven to be effective in preventing tearing when done during pregnancy*, but he effectiveness of its use during the second stage of labor, when it is most often performed by the doctor as a labor management technique, is questionable*. Some argue that it can cause inflammation in the soft tissues, making them more prone to breakage, and actually increasing the likelihood of a tear.

This doula couldn’t speak, and couldn’t do anything about it, but was a little more prepared the next time something happened. She had a client who chose a doctor who was known for performing routine episiotomies. When it came time to push, and she saw the doctor prepping the scissors, she said, “All I could think to do at the moment was to just repeat the statement that the woman had on her birth plan. ...I just kept repeating ‘she doesn’t want an episiotomy, she doesn’t want an episiotomy, she doesn’t want an episiotomy.’” The doctor began addressing the doula regarding the ‘need’ for the episiotomy, and the interaction eventually devolved into an argument between the doula and the doctor! The mom eventually gave in and just yelled, “Alright fine, just give it to me!” and that was how it ended.

While I feel so deeply for this doula in having to deal with this situation, I feel strongly that this is the exact type of situation in which a doula is most effective, and most necessary. I feel very strongly that a doula is most effective at her job when she can facilitate communication between the client and their doctor, and that she can actually hinder the experience by causing unnecessary tension and argument in labor like in this situation.

Witnessing a person violating another person’s body is horrific, and there is no place for it in the birthing room, or anywhere else. But while I can’t imagine a doula wrestling a doctor to the ground for performing a procedure without consent,

There is a more effective and appropriate tool we have to initiate and protect consent. OUR WORDS.

Those are the very tools that we get our certifications for. That is the exact thing that helps a woman’s birth go more smoothly than it would without.

I see this story as sort of a good step in the right direction, but not enough. Yes, the doula helped to prevent an unconsented medical procedure, and consent is tantamount to preventing birth trauma, and malpractice suits. But, I believe that in order for women to actually feel GOOD about their birth experiences, they need to feel not only that they gave consent to the events that transpired, but that they were involved in the process of decision-making that led to those events - That they feel in control of their birth*, to a reasonable extent. That their voices were heard and reflected and reasoned with and obeyed.

Doulas can give women some of that power back. Here is how I imagine a more idealized version of the scenario from the story:

Woman: pushing

Doctor: begins to sterilize a scalpel and a lidocaine shot

Doula: “Client, I see the doctor beginning to prepare some lidocaine. Do you want to express to your doctor how you feel about an episiotomy?”

Client: “I don’t want one unless it’s necessary!”

Doctor: “Well, it’s necessary.”

Doula: “Client, would you like to ask any more questions about that?”

Client: “Why is it necessary? Is something wrong?”

Doctor: “Well no…” or “well yes, the baby has shoulder dystocia and I need room to reach in and move his shoulders.”

Client (or doula): “Is there something else we can try first? I heard moving positions can help the situation…”

And so on, etc.

In this scenario, the doula never really has to speak directly to the doctor, the mother still has minimal talking to do, and the topics needed to be covered for informed consent can be taken. Granted, things may not always go this way in the event of a true emergency, but reminding both the doctor and the client to USE THEIR WORDS, even in the midst of an emergency, is extremely helpful to the doctor in documenting informed consent, and empowering for the mother in helping her feel more in control of her environment and getting her voice heard.

I’ve heard a few people say that their doula just gets so in sync with their client beforehand, that they let them talk in their place so that they don’t have to. But there are so many challenges that make that arrangement not ideal in a real birth scenario. It’s impossible for a doula to know everything that happens in the mother’s mind - it is her birth, not the doula’s. And the mother can always reserve the right to change her mind! A client’s feelings on a particular intervention beforehand are only one of the many factors to consider when making a medical decision in the moment, and while birth plans are excellent tools for documentation and education, they are not equivalent to informed consent. To me, being an advocate for my clients means using my words as my most effective tool for ensuring informed consent, and maximizing birth satisfaction and pleasure.

 

*References:

Perineal massage in pregnancy:

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005123.pub3/full?highlightAbstract=withdrawn%7Cperineal%7Cperin%7Cmassage%7Cmassag

Perineal massage during pushing:

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006672.pub3/full?highlightAbstract=perineal%7Cin%7Cmassag%7Cwithdrawn%7Cperin%7Cmassage%7Clabor%7Clabour

Control is relevant to birth satisfaction:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2910238/pdf/nihms-211609.pdf

Further Reading:

https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Ethics/Informed-Consent?IsMobileSet=false

https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Ethics/Refusal-of-Medically-Recommended-Treatment-During-Pregnancy?IsMobileSet=false

https://improvingbirth.org/resources/