Decision-Making Part 3: Skills for Doulas
Decision-Making in Real Life: Role Plays and Reality
This is the last of a 3-part series on decision-making. In this post, I outline the process I used with my clients when working as a doula.
The Decision-Making Role Play
This process is done in a prenatal visit — a meeting done with clients at the end of their pregnancy — where we talk about their vision, preferences, and concerns for the upcoming birth.
One of the things I want clients to understand is that there may be times during their birth when they might have to make some hard decisions.
They might be tired and in duress, in the throes of labor, and they might be asked to decide about a procedure they weren't planning to have as a part of their birth.
Here’s how the process goes:
Step-by-Step
- Explain there are times when they may need to make a decision.
- Teach them about the BRAIN process.
- Walk through an example scenario to explain the Benefits, Risks, Alternatives, Intuition, and Nothing or Not Now steps of the process.
- Explain that these are questions they would need to ask if a procedure or treatment was recommended.
- Then ask: “Who's going to be asking these questions when you're in labor?"
Making It Real
My pregnant client would often say, “I'll be the asking questions!”
“Ah,” but I’d counter, “you're having contractions every three or four or five minutes. Are you sure you’re going to be able to ask all these questions?”
The lightbulb would go on and they’d look toward their partner.
“Yes," I'd nod, "your partner would need to lead this discussion.”
I’d turn to the partner. “So how do you feel about that? Does this feel like something you're going to be comfortable doing?"
And they would usually say, “Oh, yeah, I've got no problem asking these questions.”
Making it Even More Real
“Great! So now I want you to imagine that you're asking these questions, the care provider is giving you answers, and now your partner is having a contraction. What do you want to do?”
“Well, I’d keep listening and asking the rest of the questions.”
Sounds reasonable. Except, turning to my pregnant client, I’d ask, “Do you think you’d want to hear the questions and answers?”
“Yeah, this has to do with my body.”
“Okay, Partner. Now, what are you going to do?”
“I guess I’d have to tell the doctor to hold on.”
“Okay. You can ask them to wait, but they might be busy, they might have other patients they need to attend to, they may not have time for what’s looking like a lengthy 20-30 minute process. What will you do?”
“I don't know.”
Controlling the Process
“You might need to take control of the process to advocate for yourselves. You may need to tell the care provider ‘Oh, hold on. My partner is having a contraction,’ and then turn your body way from the care provider and toward your partner. Support them through the contraction, and then turn back to the care provider and say, ‘Okay, we can continue now.’”
Now, care providers might not like this. Care providers might be in a hurry. They are used to recommending a treatment and people complying. So this process might not be well-received.
I want my clients to have a good idea that, while this process is not rocket science, it's also not easy to lead and there are things they may have to do to control it.
Because it Could Get Even Harder...
Then I would remind my clients that they might be really tired, stressed, and concerned in this situation. How might that affect their ability or confidence leading this process?
They might have been laboring for 24 hours and have to make these decisions. They might be tempted to just say, “Okay, Doc, you’re recommending this so I guess we’ll do it.”
If my clients were to give consent without going through an informed consent process, I would ask them, “Are there any questions that you have about this procedure?”
That question isn’t so much a literal question as it is a cue.
I taught my clients that if they ever hear me ask, “Are there any questions that you have?” that means they should be asking questions right now.
By this point in our meetings, they had a good idea of what leading the process might be like, and my cue if they needed to be reminded of it.
From Decision to Action
Next, I would ask them questions from the Groopman spectrum, to help them recognize if they're risk-averse or risk-tolerant, if they're a naturalist or a technologist, a minimalist or maximalist, or if they are a doubter or a believer.
(If you missed last week's blog, it explains the BRAIN process and the Groopman Spectrums in detail.).
Once we had gone through the BRAIN process, determined who would lead the process, and assessed their decision-making preferences with the Groopman Spectrums, I would show them how to advocate for themselves after they'd made a decision.
Making a decision is one thing. The next step is communicating it.
Have HEART
The HEART model is an easy way for people to learn self-advocacy skills.
H Hear “I hear your recommendation, care provider,...”
E Empathize “and I appreciate your care and concern for me and my baby.”
A Assert “I have chosen to do XYZ for now...”
R Reassure “but I will let you know if I change my mind.”
T Thanks “Thank you for your support.”
The HEART model gives people an opportunity to articulate the process and their plans clearly.
***
So how did going through this process with clients play out?
As you’ll see, there are some additional tricky things that can come into play...
Harassment
Client A was pregnant with twins. In many parts of the country, a twin pregnancy meant an automatic cesarean birth. But where my client was giving birth, that wasn't the case. Her first baby — the one closest to the cervix — was head down, but her second baby was breech. In most parts of the country, a breech baby meant an automatic cesarean as well. But since her first baby was head down, and her second baby was smaller than the first baby, her doctor said her first baby would probably 'pave the way,' so she was a candidate for a vaginal birth.
But when she got to the hospital, her doctor wasn't on call. The doctor who was attending said, “Oh no, we need to do a cesarean. You've got twins. One of them is breech. A cesarean is absolutely the safest way to birth.”
Now this client kicked into gear. She said, “I know the statistics. I've talked about this with my physician. I know there's a possibility that I could give birth vaginally to the first baby and the second baby would need to be born by cesarean. But that is a chance that I'm willing to take.”
She was very well-informed, and articulated what she knew and what level of risk she was comfortable with.
Within the next hour, seven different physicians came in to tell her about the risks of having a vaginal birth. Seven. This is not an exaggeration. (Okay, some of them did come into pairs, so it wasn’t seven separate visits — it was 4 — but still...within one hour, seven different physicians came in to tell her how she was endangering her babies.)
Later that day, she had a vaginal birth of both her babies.
Isolation & Coersion
Client B was planning to have her baby at the hospital, even though she came from a family of home birth advocates, because that's the place she was most comfortable. She was a physician herself and she spent most of her adult life in hospitals. Her family thought she was crazy to have her baby in the hospital.
My client’s obstetrician knew that her family was pro-homebirth and I guess the doctor assumed that I was a home birth advocate, too (a common misconception of doulas). But I'm actually an advocate for people having their baby where they want and how they want. That's what I'm there to support.
But this doctor didn't trust me. And when my client’s birth wasn't going well and her doctor started to bring up the idea of having a cesarean, there was a point where the doctor said, “Okay, everybody out. I need to talk to my patient about her options and I need all of you to leave the room.”
I don't argue with medical staff unless my client asks otherwise. I asked if she was okay with that, and she said, “Yes” so I left.
Normally, a conversation like that would take 10-15 minutes. Thirty minutes later, we were still standing in the hallway wondering what was going on inside. What is the doctor saying? What are my clients needing? They're still having contractions. Are they getting the support they need? It’s an awful feeling to be banished from providing the support you were hired to give.
And to make it worse, I was really hungry but my purse was inside the room.
So I knocked on the door and stuck my head inside. The doctor said, “We don't want you in here. We don't need you..” and I interrupted, saying, “I'm just coming in to get my purse so I can get some food.”
As I passed my clients, I asked them, “Are you guys doing okay? Do you need anything?”
“Yeah,” they replied weakly. They didn't look super happy, and their faces showed the stress they were under. But they dind't ask me to join the conversation. So I left again, and waited outside in the hall eating my package of crackers.
Another 15 minutes later, the doctor opened the door and said we could come back in. “We're getting ready for a cesarean.”
My worst fear is that clients go into the O.R. without being prepared. There are many ways I can help them get ready so they have the best cesarean possible. I did what I could with what little time I had.
My clients had a cesarean and technically it went fine, but they did not have positive memories of that experience.
Disrespect
Client C was having a great birth; everything was going the way she wanted it to. She was having an unmedicated birth. It was going quite fast, a little too fast because when it came time to push, she was overwhelmed. She couldn't quite get into her groove, and there was a lot of hustle and bustle in the room to get ready for the birth that was happening faster than anyone expected.
A new doctor she hadn't met came in to be the one to catch her baby. The nurse was trying to get the equipment tray set up while coaching her on pushing. Then another nurse came into the room to talk to the doctor about another patient.
There was a lot of talking going on so my client turned to me “There's too many voices!I don’t know who to listen to. Can you please tell them to be quiet?”
I turned to the room and said, “Shhh! My client is trying to focus.”
Everyone stopped talking, and then her nurse resumed telling her what to do and my client was still very disorganized. I tried to help her focus and find her groove and within 10 minutes her baby was born.
My client was thrilled that everything went well as far as she was concerned. But a little bit later, the second nurse that had come in to talk to the doctor entered, pointed to me, and said, “Come with me.”
That nurse took me out in the hall and berated me, literally wagging her finger in my face: “You do not shush me”
“I’m sorry,” I replied, “my client was having a really hard time, there were a lot of voices, and she asked everyone to be quiet. I just simply did what my client asked for.”
The nurse wasn’t having it. “Well, we had a medical event going on and you can't shush the medical staff.”
And I had to accept that the medical staff just didn't respect my client. They came into her birth space. She asked for something specific, easy to do, and was ignored.
So even people who know how to ask for what they want may not get their needs met.
But When It Works...
The final story I want to share with you is about Client D, who was prepared for decision-making, so when a medical situation came up in her labor, she asked the BRAIN questions. She got all the information she needed and opted for the ‘N’ part of the model.
“I'd like to wait an hour. I'm going to try walking, and then we'll reassess.”
She walked the halls for an hour, had her cervix re-examined, and when she found out it hadn’t changed at all, she said “Okay, now I'm ready to do that intervention you suggested.”
Her ability to choose an alternative, control the timeframe, and revisit the recommendation was very empowering to her.
The Take-Aways
What’s important about each of these stories is that how people are treated during labor has a big impact on how they experience their birth.
They will remember their care and it will impact how they think about themselves. Empowered and respected, or isolated and ignored?
When people aren't able to integrate a negative experience, they will find different coping strategies such as blaming.
They might blame a doctor, saying, “Why was that doctor so lenient? They should have intervened sooner,” or “Why was that midwife so conservative? They should have let me do XY and Z!”
They might blame their childbirth educator, “Why didn't they teach me about cesareans so I would have been prepared?” or their doula, “You didn't come when I called and therefore XYZ happened.”
And often, they blame themselves: “I should have known better. I should have known these things. I should have made a different choice.”
The thing is, when people are blaming, they’re looking for something to pin the responsibility on because it was taken from them and they can’t quite accept that yet. Blame may find new targets and morph over time until they are able to integrate their experience, understand the meaning it made for them, and learn the lesson of the heroic journey that comes out of challenging experiences.
If somebody is blaming others, it's usually a sign that they need help integrating their experience.
If you're frustrated with the decisions that others make, remember the things that I've talked about in this 3-part series on decision making. Decision making is not clear and scientific. It’s messy. It's complex. It's very human. Please have compassion.
People do the best that they can in the moment, but they might need help cleaning up afterwards.
If you or someone you know is struggling with birth trauma, a story that doesn't make sense, or a negative experience, I encourage you to look at some resources I have.
Find somebody who does birth story listening. It's a really beautiful process that helps people make sense of their birth story and develop new meanings, so that what was a challenging experience can become a heroic journey.
And if you or somebody you know struggles with memories from traumatic situations, you might find a therapist who specializes in Memory Reconsolidation. This is a technique that takes old memories from traumatic experiences that are still driving aspects of your life and overlays them with other things that you know to be as true or more true, so you can have more freedom to respond to things that are happening in the here and now and not be controlled by past traumas.
I'm all for people having powerful experiences, having agency and autonomy in their lives, and developing good coping skills and resilience so that they can make the most out of this crazy challenging life we have. Thanks for reading!
Birth Story Listening:
https://thresholds.info/birth-story-healing/
https://diveintobirth.com/birth-story-listening/
https://birthstorymedicine.com/
https://www.jamiemossay.com/birth-story-healing
Memory Reconsolidation:
