Christina and Brian met their sweet baby girl, Gianna May (Gia) on May 6, 2021. It was a love-filled labor and birth and I wasn’t surprised in the least. The first time I met them over a virtual interview, I could feel their love. This was a baby wanted and desired for a long time and through the gift of IVF they were finally expecting. We were excited for the day they would welcome their baby for it would be the closing of a chapter and the first page of an incredibly different one.

Christina reached out at 8:00 am on May 5 to tell me about the contractions that had been keeping her up since 4:00 am. They were surprisingly painful which threw her off since things had only just begun. She had a hard time keeping anything down, even water, so after several hours she called the midwife to see about going in to get fluids.

She was dilated 5-6 cm upon arrival which was quite remarkable, but she was also dehydrated. The fluid would help her uterus and hopefully give her a little boost as well. She was shown to her room after admission and once she got through the initial questions and procedures, she decided on an epidural and that along with some Zofran helped with her comfort and rest immensely. She was well on her way to rest around 5:00 that evening. And she was dilated 6 ½ cm and 100% effaced too.

We rotated Christina into a variety of positions. There was a pesky window of pain that was managed with position changes and the PCA button. But the only true relief would be delivery. Christina was grateful for the relief the epidural provided, even if it wasn’t 100%. The midwife came in around 7:00 pm and confirmed on exam that Christina was dilated to 9 ½ cm! It wouldn’t be long, or so we thought. She tried to rest but it was hard to sleep when you are excited to meet your baby!

The position changes continued and we all waited for Christina to feel the landmark “pressure in her bottom” that would signal full dilation and descent and a reasonable time to start pushing. She developed some signs of transition that were actually a low grade fever. But that lip of cervix while reducible, persisted. Her doctor preferred not to mess with it and rather let nature run its course. So Christina continued to rest and we continued to rotate her into various side-lying positions using a peanut ball and stirrups, and the runners position. At 11:30 pm the lip was still there and since it had been several hours at that point, the doctor recommended a little bit of pitocin in the hopes the contractions would move baby’s head against the cervix and melt it away.

Her baby’s heart rate dipped, but it was always manageable and partially due to the head compression that signaled it would soon be time to push. And just prior to 2:00 am, Christina’s cervix was fully dilated. Pushing began around 2:15 am and because her baby was already so low (she had been at +2 station for hours), we saw hair almost immediately! The doctor joined us thirty minutes later and Christina even reached down and felt her baby’s head herself at 2:52 am. And that touch inspired some great pushes because the nursery staff was called in for delivery with the next push!

Christina managed to allow her baby’s head to crown gradually in spite of the epidural, and her patient doctor applied oil and counter pressure to encourage everything to stretch. And the diligence and patience paid off because Gia was born at 3:13 am! Christina and Brian cried at the sight of their daughter and she was gripping her daddy’s finger within minutes. Although I think Brian was the one wrapped around her finger in that moment!

Christina and Brian immediately searched for family resemblances in their daughter’s features and fell in love with every bit of her. Christina propped her baby girl on her legs and marveled at her, really taking her in. Daddy got some skin-to-skin time too and eventually the official stats were recorded: 7 lb. 7.8 oz. and 20 in. long. Yes, Gia was perfect.

This birth was encircled in such love. The way Christina and Brian care for each other is evident, and labor was such a beautiful picture of that. And their love for Gia is inspiring and I couldn’t help but be touched by their gratefulness of finally holding their baby in their arms. Their birth and their path to become pregnant, was an example of patience, something that is a good reminder for those of us working in birth. I’m so glad their providers were patient as well.

In an effort to facilitate contacting hospital administrators to return doulas to the birth space, I have written a blanket letter for the intention of distributing as you see fit. Please copy and paste it and mail or email to those in leadership at the facility in which you have chosen to give birth. Feel free to make any changes you see fit. DONA International has also drafted a letter than can be forwarded on concurrently or separately. Whether you use my letter, DONA’s, or your own doesn’t matter. The more letters the better! Just reach out.  If you are looking for more evidence, visit my previous blog post for links.

To Whom it May Concern:

First and foremost, I want to express my appreciation for your diligence in keeping your staff and patients safe during the COVID-19 pandemic. It is no small task, and as with any unprecedented outbreak, evidence and information is constantly being weighed to assess potential risks to your staff and patient population. However, my request to you addresses the safety of your patients and has evidence to back up the benefits to their experience in your facility. I am writing this letter to ask you to please reintegrate doulas into the birth space by acknowledging them as a member of the labor and birth team, not as a visitor subject to the hospital restrictions. At the time of this writing, several Hampton Roads hospitals permit doulas to be physically present in the labor and delivery room. Sentara Leigh and Riverside Regional have opened back up to doulas and Sentara Williamsburg never restricted them. Please consider following their lead to insure your patients receive the support they expect.

The Centers for Disease Control and Prevention’s guidelines on caring for a mother with COVID-19 recommend healthcare facilities follow, “infection control guidance on managing visitor access, including essential support persons for women in labor” (Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings, February 2020). They go on to state, “If restriction of all visitors is implemented, facilities can consider exceptions based on end-of- life situations or when a visitor is essential for the patient’s emotional well-being and care.” Surely, labor and birth should be considered an experience in which a doula’s presence is essential for the patient’s emotional well-being.

The evidence is overwhelmingly in favor of the presence of a doula during birth, showing a significant improvement in birth outcomes for both mom and baby. A 2017 Cochrane review of 26 trials of continuous labor support and doula care involving over 15,000 women in 17 different countries in high and middle-income settings found many improved incomes for women and infants including: “increased spontaneous vaginal birth, shorter duration of labor, and decreased cesarean birth and instrumental vaginal birth, as well as a lower incidence of the use of any analgesia or regional analgesia, less likelihood of a low five-minute Apgar score and fewer negative feelings about childbirth experiences. We found no evidence of harms of continuous labour support.”(Continuous Support for Women in Childbirth, Cochrane Database Syst. Rev, July 6, 2020).

 In an effort to improve outcomes and lower the rate of the primary cesarean, both ACOG and SMFM came together with a list of guidelines to that end. Using the evidence collected by the Cochrane review quoted above, they encourage the continuous presence of support personnel, such as a doula, due to evidence showing improved outcomes, including a lower rate for cesarean delivery. (Safe Prevention of the Primary Cesarean Delivery, American Journey of Obstetrics and Gynecology, March 2014).

And in a timely response to the Coronavirus, both DONA International and AWHONN made public statements in March 2020 about the vital role of the doula and how the doula should not be a visitor relegated to hospital restrictions, but rather considered an essential member of the birth team. (AWHONN Position Statement: Continuous Labor Support for Every Woman, Journal of Obstetric Gynecological and Neonatal Nursing, 47, 73-74; 2018). Nurses are not able to spend as much time with their patients as the doula can. And it is specifically that constant one-on-one presence that provides the benefits demonstrated by the numerous studies. In fact, with heightened vigilance and increased task load in response to COVID-19, nurses are busier than ever. Laboring women are also dealing with heightened fears and concerns giving birth in the pandemic. Their need for emotional support and attention is greater than average. Clearly the doula is more beneficial than ever, and more essential for every member of the birth team. The evidence in favor of a doula’s presence cannot be ignored. 

It also bears mentioning that I have hired my doula to be present with me during my birth. She is contractually secured as part of my birth team. She is certified and has a skill set that she brings to the birth space, skills different and separate from those of the nurse, and skills that cannot be expressed the same virtually. The benefits conveyed by her steady one-on-one presence may be compromised in the virtual setting. 

For all of these reasons, I respectfully urge you to reconsider integrating doulas into the birth space. With the benefits clearly stated in evidence and the strong desire by your patients for doula support, with adherence to personal responsibility and safety through PPE, frequent and thorough hand washing and sanitizing, I am confident you can see to it that doulas return to the labor and delivery room. 

Thank you for your time and attention to this matter,

(Your name)

Our community was thrown off kilter mid-March with the official arrival and acknowledgement of COVID-19 as a global threat in the United States. It was upon us and as with any stressful event, many birthworkers, myself included, walked through the stages of grief in regards to the pandemic. First there was denial. Surely this wasn’t really a thing, was it? Then anger. I felt this acutely as a doula. The restrictions on birth support hit me in the gut and I’m not ashamed to admit that initially I took it as a personal attack on doulas. Of course, I have since come to my senses and understand that at the heart of the decision by hospital administration was to keep everyone safe, including doulas, which brings me to the third stage, bargaining. Birthworkers explored how to continue to offer birth support, even if virtual, and they pivoted to accommodate the needs of their clients through FaceTime, Zoom, text, and phone. Depression, stage four, was in there too, and lingers today for many of us. As doulas, we yearn to be with our clients, sharing their birth space and offering physical support in their presence. It pains many of us when we are separated from our clients during birth. It’s truly a struggle that hits a doula right in the heart. And finally, we encountered acceptance. COVID-19 would remain in our midst for awhile and would have far-reaching implications on how births would look for the foreseeable future. It was our new, indefinite normal, restrictions, masks, hand sanitizer, and all.

Now it’s time to act. We’ve had our six months of processing, doulas and birthing families alike. But the last stage of acceptance is unacceptable, especially when it comes to restricting doulas from physically attending births in the hospital setting. It’s time to push more aggressively to reintegrate doulas in-person at birth. If you are a birthing parent, I implore you to advocate for your doula, and for all doulas, to return to the hospital. Doulas should be permitted to attend in person because it is the right of every laboring woman to have support, but also because the research is extensive proving that the continuous labor support doulas provide improves birth outcomes. Doulas help everyone, including the staff and care providers! In fact, reputable birthing organizations made statements early on defending doulas as essential members of the birth team, and encouraging them to be permitted to continue to serve in person DURING the pandemic. On March 12, 2020, DONA’s statement for including doulas as an essential member of the support team was compelling, as was AWHONN’s pro-doula statement from March 11, 2020.

So what are we to do to affect change in hospital policies? There needs to be a push from the patients to hospital leadership. Contact the manager of the labor and delivery unit, and the administrator of the hospital. Make a phone call. It’s harder to ignore a voice on the line. Follow up your phone call with an email and a letter. Paper trails are also hard to dismiss. DONA has made this easier by drafting a letter to hospital administrators. They have already done the work for you. You can find that letter here. Simply print it and send it along. Furthermore, if there are other hospitals who have allowed doulas to return, be sure to mention them as well. In Hampton Roads at the time of this writing the only hospitals permitting doulas to attend births alongside the primary birth partner are: Sentara Leigh, Sentara Obici, and Sentara Williamsburg. And don’t forget to express your wishes with your provider. Not just one, but to each doctor and/or midwife at every single appointment. 

This push needs to come from the birthing families, not the doulas. The amount of research in favor of the presence of a doula is dizzying. And the number of statements by various obstetric, nursing, and birth organizations is compelling. The evidence is there and the need for one-on-one labor support is higher than ever. What’s lacking is the advocacy for the presence of doulas during the pandemic. I have compiled some links in an effort to cut down on your need to research data. You will find them at the end of this post. Feel free to use any or all that you see fit. And write those letters, send those emails, and make those phone calls. The change must begin with the birthing women. Not the doulas. We believe in you and we support you. You can do this! (Sound familiar?) Thank you so much for trusting us to serve you and for fighting for that right…for all of us.

Below are some links to incorporate into your letters/emails/calls campaigning for the reintegration of doulas to attend births in-person. Please don’t forget the links embedded a couple of paragraphs above to statements by both DONA International and AWHONN for having doulas attend births in-person DURING the pandemic. They are particularly timely and relevant since the statements were made in March 2020, right as the pandemic was taking hold in the US.

Cochrane Database Evidence that continuous labor support may improve outcomes for mom and baby

 AWHONN Position Statement for Continuous Labor Support for Every Woman

 ACOG (American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine’s joint document on the Safe Prevention of the Primary Cesarean Delivery

 ACOG Approaches to Limit Intervention During Labor and Birth

 March of Dimes Position Statement on Doulas and Birth Outcomes, January 30, 2019

 Evidence Based Birth: The Evidence on Doulas, Updated May 4, 2019