Hypnobirthing and doula work in obstetric anaesthesia

Published in the Doula UK magazine in AUTUMN 2017 ISSUE 32

Significance

I NO LONGER WORK AS A DOULA, I CAN ONLY GIVE MY OPINION ABOUT BIRTH

Doula work helped me understand Chinese medical theories.

Traditional Chinese Medicine classifies birth into 4 major DEFICIENCY categories:

Qi birth - characterised by mild mitochondrial dysfunction, muscle weakness, weak immunity and ligamentous laxity

Yang birth -  characterised by severe mitochondrial dysfunction, the above symptoms and digestive dysfunction, adrenal fatigue etc

Yin birth - characterised by elevated levels of chronic inflammation and its associated clinical symptoms during pregnancy such as pregnancy - induced hypertension, preeclampsia, eclampsia, intrauterine growth retardation (small to gestational age), oligohydramnios etc

Blood birth - characterised by similar symptoms like YIn deficiency, more of Estrogen deficiency such as dry skin, brittle nails and hair, anxiety.

These categories have their own management care package which may be used to predict and avoid potential problems during pregnancy and mitigated by simple techniques during birth.

Introduction

Primarily, I am a man, a husband and we were expecting our first baby in December, 2017.

Secondarily, I make a living from medicine: I am a Consultant Anaesthetist, however also studied

doula care and hypnobirthing. There is some medically produced evidence out there to provide a

basis to my work, but my approach is driven by a psycho-medical understanding of how a female

body and mind work together naturally during birth. My aim is to help without overruling,

dominating the woman in labour and support NOT necessarily with an epidural.

My story

My motivation in hypnobirthing and doula work was to avoid the conveyor belt effect in a hospital

environment and reduce interventions. It all started when I was working for a University Hospital

and at 3 am in the morning, I could not do an epidural for a woman in labour. So I had to solve the

situation in a different way: I told the woman that I cannot do her epidural but will not leave her in

pain. I stayed in the birth room, holding the woman's hand, helped comforting her in the bed and

supported her emotionally. It was 3 am, darkness in the room, nobody came around and surprise-

surprise: the woman had a baby! From then on, my life changed completely.

I went to a hypnobirthing course and was taught by a Clinical Psychotherapist then I

attended a doula course as well. In the meantime, I started to read a couple of

books such as Orgasmic Birth and Childbirth without Fear. These authors opened my mind to a

different field and there was no stop from then on.

My practice

I became interested in this field so I simply utilised my medical role for a good reason: to integrate

hypnobirthing and doula care into my work. When I was asked to give an epidural, I walked into the

birth room and used different techniques to avoid medicalisation. These techniques often needed

me to work more or stay longer with the woman for a good reason, but I did not mind. I asked for

the woman's permission and dimmed the light in the room. Then I was waiting for a break between

contractions then I calmed the woman down by synchronising her breathing to help relax her back

in order for me to site the epidural more easily. I asked the woman to sit on the edge of the bed to

utilise gravity while I was slowly - slowly preparing the epidural set. Sometimes the woman gave

birth whilst sitting there and only what she needed was to remain in her birth rhythm, not the

epidural. With prior patient permission, I often slowed down the whole epidural procedure - she

knew that she can have the epidural anytime - and kept connected with her attention to keep well-

synchronised with her birth rhythm. I also helped her to change positions and used a hospital towel

like a rebozo to relax her hip in the hands and knees position. I knew that eventually it is the

woman herself who has to give birth and go through the birth ritual and the epidural is an adjunct

only.

My aim was NOT to withhold a due medical intervention, I just prioritised different techniques with

the patient's permission.When I used an epidural catheter, I built its dose up slowly and gradually to preserve muscle

function in the legs so she could change position in the bed. This way I managed to take the edge

of her discomfort whilst leaving her body to work mostly untouched.

I helped twins to get born: we managed to relax the woman's body between surges, so she could

refresh herself. I asked the husband to take her hands and encourage her. Me and the husband

were standing by her head, the midwife watching from below: working together as a team. Once

the first baby was out, the obstetric registrar wanted to find the heartbeat of the second baby. At

this point, she nearly started to panic which would have been disastrous. I took control and said:

okay, now there is more room in the womb as the first baby is out - relax and find the other baby.

The womb needed some time and stimulation with water on the perineum, and shortly after the

second baby was out.

I think I met lovely, cooperative and open-minded midwifes: some asked me to describe what I am

doing to the obstetric registrar colleague, others encouraged me to do it in other cases as well. I

always do these things on the safe side: normal CTG and / or the mother is having regular,

effective contractions. Once, I helped a woman to give birth to a 4.3 kg boy and I am sure in that

case the epidural could have done more harm than good as the mother was progressing well and

all what she needed was changing positions (hands and knees), rebozo relaxation of the hip and

breathing techniques. If I had given the epidural, it might have stopped the regular contractions and

we end up in theatre. My colleagues were slightly concerned about the big baby: what she needed

was full relaxation of the soft tissues of the perineum. The baby came out quickly and healthy,

without any tear.

Once I was called for a stillbirth. In this case the baby's body was as large as a living one so she

needed the same technique to give birth as a normal one.

My conclusions

Better recognition of doulas in the birth room would be important. Regional doula representatives

and hospital leaders could possibly negotiate to find common grounds to work for the client. There

is a possibility for the hospital to save money by better optimising workload on hospital staff by

integrating doulas into their care. There is a study in progress in Oxford investigating these

questions. I am also emphasising that it is most likely the woman herself who can initiate this

process of integration by asking for her doula to be present.

We healthcare professionals cannot pretend any more that doulas are not out there by simply

ignoring your existence. Instead, we hospital staff could possibly team up with you by finding

common ground, clarify each other's goals and the possible benefits we can achieve together.

A psycho-medical approach is key to the normal birth process, which can be delivered through a

team effort of midwifes, obstetricians, anaesthetists and doulas. The higher the pregnancy risk, the

more normalisation we need.

Women come to the hospital for a good birth, not for an epidural. The priority is to optimise our

anaesthetic activities to facilitate female bodily mechanisms first before supportive anaesthetic

interventions.

Darkness, privacy, minimal communication, changing positions, water pool, positive affirmations,

giving more time with up-to-date obstetric definitions, doula approach, emotional support and

breathing techniques take priority to enhance female bodily mechanisms and anaesthetic

interventions should only support them.To facilitate minimal communication, information about an epidural could be given well before birth.

It could be declared in the birth plan that the mother is aware of the possible complications of an

epidural. Doulas could facilitate this, hence the anaesthetist would not need to tell them to the

mother. I doubt the effectiveness of this anaesthetic communication at 3 am in the morning with an

exhausting, disorganised mother who is crying for pain relief.

As a doula, I kept contact with the mother while the midwife was busy with documentation etc.

I mostly worked with women who had not attended a hypnobirthing course previously, so it would

be much easier to work with ones trained previously in these techniques.

To cope with the intensity of labour:

I think often saying "please use gas and air" or "I am asking for an epidural" is probably not

enough.

• Following patient consent, I was massaging the patient's back, the father could help with this -

retrospectively some midwifes commented "inappropriately touching" the patient - ironically, the

patient was very happy with that.

• I also used a simple hospital towel like a rebozo to rock the patient's hip for relaxation.

• I helped changing positions

• I offered emotional support over the tipping points, and communicated with the midwife about

how I can help to achieve her goals as well as keeping the birth as normal as possible

• I kept the woman synchronised with her breathing

• some doulas could perhaps use acupressure

• kick-starting the labour with natural techniques or an oxytocin infusion and once there are regular

contractions present, leaving it on the same dose to avoid excessive pain

Once I have seen a midwife tweaking up the oxytocin infusion because the number of contractions

stated in the hospital protocol was not achieved yet - despite the mother having regular, effective

contractions. This caused excessive pain.

As a doula, I motivated the father as well by asking him to hold the mother's hand, help us

changing positions, massage the back etc. Whenever I really needed to use the epidural, I often

inserted it in the darkness with a spotlight on, letting the father observe my activity. I think the

father can help the woman to come over each mental tipping point - when she feels "I cannot do

any more". In this topic, education is important: Mark Harris book Men Love Birth may be helpful.

I cannot comment on midwifery education but as medical people we are not trained to keep the

birth process normal. On the other hand, a standardised doula training, perhaps based on a

nursing or midwifery qualification with due recognition from the Nursing and Midwifery Council

could help raising respect of the profession among other health care staff. Once we start realising

that doulas could be a useful member of the team and "a good extra pair of hands" when needed,

hospital staff could perhaps change their mind.

Finally: doula profession is a new and promising trend in the contemporary birth care, which could

be successfully integrated into hospital care, both private and public. More awareness and impact

studies are needed for healthcare professionals to give credit to this old but newly discovered

approach.