The Trend Toward Night Doulas: Exploring the Original Vision of Postpartum Doula Care.

By Vicky York, IBCLC, CPD Web Exclusive Mothering Magazine

There is a growing trend toward hiring a postpartum doula to spend the night with a family after the birth of their newborn. Although it is wise to support a newly delivered mother's need for rest after birth, the financial cost to families for this service is great; therefore other key needs for this time period are being set aside. When a family chooses night help, which usually costs $175-$250 per night, they often feel they can't additionally afford to pay a doula during the day. The family then misses out on guidance with breastfeeding, newborn care dilemmas, and postpartum depression support. Professional, effective help with these concerns by an experienced and knowledgeable doula can often eliminate the need for someone to be hired to just come get up with the baby all night for as many weeks as the money holds out. That set-up is a throwback to the days when parents hired baby nurses who came and lived with the family for 6 weeks, undertaking all the newborn care, then leaving the mother still feeling insecure about how to care for her child herself. Our original goal as postpartum doulas was to enable the mothers to become independent of us, by giving them confidence in their ability to mother their babies. We can teach them to understand and care for their new baby by sharing our wisdom, training, experience and modeling behavior.It has been said, "Give a man a fish and he will eat for a day, teach a man to fish and he will eat for a lifetime." It can be more effective to give mothers education and skilled professional "mother nurture" from trained, certified postpartum doulas during the day. This will boost mom's confidence in her mothering abilities while receiving practical household help during the day and letting her nap, enabling her to endure the night challenges.A new mother needs to be mothered herself, preferably by her family members. In our current societal structure that is very often not possible and these women suffer in isolation. This is a time to learn the art of mothering from other women, a time to be protected, fed, and cared for in special ways by women who know. New mothers need to begin the process of communicating with this child who they will be raising for the next 18 years. Dependence on a night doula does not afford a new mother the intimacy of communication that begins between mother and baby, as they then miss that nighttime connection. The typical service of a night doula consists of getting up when the baby does and bringing the baby to the mom to nurse, then changing the baby, burping him and getting him back to sleep. Once a family has decided to hire a doula to help at night, it is natural to wish to maximize on this support, leading many tired parents to ask the doula to feed the baby a bottle of pumped breast milk and mom then gets up and pumps only when her breasts are so full and painful they awaken her. Breastfeeding is a supply and demand process. When the baby skips a nursing session and gets a bottle and the mom doesn't pump at that time, her breasts get the message that less milk is needed and after a period of engorgement they will lessen their supply. In addition, there is the risk of nipple confusion with the very new baby, as the rubber nipple demands a different sucking technique than the mother's breast. It is a shame for parents to spend so much money on night help that they then can't afford baby carriers, CranioSacral therapy and other bodywork or even a housekeeper. For less than half the price a postpartum doula can come during the day and educate, cook, help the mom through a breastfeeding session while folding the laundry and teach her a swaddling technique that calms the baby. She can demonstrate infant massage and watch the baby while the mom naps or runs an errand. Not to mention the mom's need to talk to someone about her feelings at this time. New mothers can more easily and naturally manage the postpartum time when they are cared for in the ways common to many older cultures around the world gently, thoroughly, and wisely in support of the deeply transforming process of bringing forth a new life. Certified postpartum doulas extend basic postnatal care in the form of household management, baby care, sibling care, lactation support, newborn care tips, and providing resources within the birth community. They charge, on average, $20-$35 per hour across the nation. During the time of childbirth, it's as if a woman's heart is opened up; she is so sensitive to her baby and her surroundings. She would give her life for this new little being and will give infinitely. Her relationship with her husband is being tested and strengthened. Her instincts are finely tuned and she is undergoing the acute phase of lifelong bonding with her infant. This bonding is partially influenced by hormones such as Prolactin. Prolactin levels are associated with the frequency of suckling: the more frequent the feedings, the higher the level of serum Prolactin. (Breastfeeding and Human Lactation by Riordan and Auerbach) There is likely a natural reason why babies awaken and want to nurse frequently at night. Night doula work is one avenue for doulas who want to supplement their income and it can be a lifesaver for the mom who desperately needs the sleep, as during postpartum depression. However, we need to be careful with this service. Postpartum doulas have been through specialized training to support new moms in managing the issues that come up during the months after a woman gives birth, and little of this training is called upon during the course of a typical nights' work, which mostly amounts to babysitting. Mothers often don't realize the extent of a doula's expertise; and they may see her as a housekeeper; and considering night work as an extension of this image. Often a doula who solely does night work doesn't bother to get certified because she doesn't feel there will be a need to utilize the other skills acquired in training. Thus, when she feels pressed to hand out advice and information she may find herself short on accuracy. Someone said that the purpose for pain in labor is to allow a woman to find her unique inner resources for the strength to face other painful experiences in her life and to use this birth power to begin the journey of parenthood. Subsequent challenges she faces after the pain of childbirth are breastfeeding and getting up with her baby in the night. Many women cite a sense of satisfaction and trust in their own "mother nature" after having gotten through this period using their own skills, learning to read their baby's cues, discovering his needs and personality. Perhaps finding that they can rely on their own inner resources is the thing that is so empowering about birth and motherhood. The inter-communication that develops between mother and baby during quiet intuitive times develops precious wisdom and understanding needed for a lifetime. One new mother nursing her baby in her rocking chair in the middle of the night said it gave her a feeling of peace imagining all the other mothers sitting with her in the night nursing their babies. She chose to perceive it as a fraction of her lifetime and although she lost sleep she gained that special bonding that occurs in a dreamy state in the quiet by lamplight, undistracted by the world. As postpartum doulas we can support a mother's sleep by teaching her to nurse in the side-lying position. Through a doulas' caring presence mom learns to understand the joy of knowing she can care for baby entirely herself with her milk, body warmth and protection. Many moms hire a night doula beginning the first night home from the hospital. I will always hold special memories of my first night home with my new son. I wouldn't have wanted someone else to come in and get up with him, however loving, gentle and motherly she may have been. It is surely his own mother whose odor and movements he is wishing to become familiar with. Perhaps a new mom who so quickly gives up this experience is full of fear. Some mothers book night doulas before the babies are even born! They often become dependent on them and keep them for weeks or months. In trying to be helpful to new parents, are we actually supporting them in giving up even before they start? As doulas we can do a lot to instill confidence in these women rather than just show up at bedtime and take over. It is certainly natural to feel fearful as a new mother responding to this important little being, and this is where the support and wisdom of doulas can help to alleviate new parents' anxious concernsThere are times when a night doula can save the day, literally. There are some women who simply can't function at all when they don't get enough sleep. However, a family member or doula during the day can assist far less expensively. We may not understand all that happens within a woman during this time, but we can be sure that she undergoes such a huge change that she needs to be listened to and served in a manner that opens the way for her to have every opportunity to bond profoundly in loving nurturance with her baby while flowing with the changes of her heart and psyche. Doulas better serve new mothers as role models of heart centered mothering, offering support as wise women elders who've been down this path before them. We can remind a woman to be present for this part of her journey. We can hold her hand; be willing to watch her dark side without judgment, while teaching her to surrender to an age-old process as she wrestles with one of the hardest aspects of parenting. Perhaps on some level this prepares us for later adolescent years. It's a difficult initiation and at some points every woman struggles and fights against it, often crying along with her baby. I called my heroine, Jean Liedloff, author of The Continuum Concept, as she is open to consultation calls, to ask her how lack of sleep is handled in indigenous cultures. She said "what lack of sleep? The mothers and babies sleep together. The babies are crying because they want to sleep next to their mothers, not down the hall." She is right; when babies are sleeping with their mothers they can nurse while mother sleeps. She quickly adjusts to the presence of her child next her and soon sleeps right through his little noises and movements and she would awaken if the baby was in distress because her instincts are working while she's asleep. Jean Liedloff says babies must be made to feel worthy and welcome in our beds right from the beginning. She says they will feel safe to leave our beds, at around the age two, when they feel absolutely assured they are welcome to come back. Sharon Wesolowski, an ordained minister who is trained in various modalities of energy work, peacemaking and spiritual transformation is still getting up in the night with her nine-month old. She offers this: "We know that nighttime parenting brings you face-to-face with all the demons within, all the memories of how you were or were not parented, and asks you to push past them to find the heart-centered authentic way to parent from the present, to give to this little babe all that she/he is most needing (and ultimately all that you are most needing). It is very unclear and confusing psychological territory."The newborn night stage can be a confusing time for parents; it often stymies the doula as well, as she wonders how to best model this part of the journey for families. However it is not a time for a mother to be separated from her baby. Being together and reinforcing the mothers' confidence that she is the best person to nurture her child better serves them both.Vicky York, board certified lactation consultant, certified postpartum doula, and author has served nearly 600 families in Oregon since 1992 helping families through the postpartum period and for 15 years before that on a casual basis during her off-duty time as newborn nursery nurse, before she heard of the word doula. Her assistance has included adoption, gay couple support, twins, preemies, and perinatal mood disorders, whether first or eighth babies. Vicky taught the first postpartum doula trainings in Oregon. She can be reached at 503.320.5811

vmyork@peoplepc.com http://mypeoplepc.com/members/vmyork/



THE DOULA COMES TODAY (DONA International)

New babe at my breast, and not sure how...
If only my mother could be with me now.
But a doula comes today.

Why all these hiccups and now he keeps sneezing.
Is he breathing or is he wheezing?
Thank heavens the doula comes today.

I cry as much as my baby does.
Not sure why, just because.
Oh, the doula comes today.

No time to shower, not even eat.
I should fix tea but Im just beat.
But my doula comes today.

At four a.m. we were going full tilt.
I answered my door in a sanitary belt.
When my doula came today.

I should clip his microscopic nails
And bathe him though he wiggles and wails.
Aw heck, the doula comes today.

Its coming together just as she said.
I fed him and burped him and made my bed
Before my doula came today.

With a phone in my ear and my babe at my breast
I was woman and mother, queen of my nest
When my doula left today.


Vicky York, postpartum doula




Perinatal Mood Disorders: Ways Birth Professionals Can Understand and Help Midwifery Today

By Vicky York

In the course of my work as a postpartum doula I never know what the scene will be when I step into the home of a new mother. Thus it was when Liz, tall and dark-haired, opened the door of her home. She smiled apprehensively and thanked me profusely for coming. I followed her to the bedroom to meet her new baby daughter, she apologizing all the way for the mess. But what I saw was a beautiful home on a hill with huge sunny windows revealing a breathtaking view of the city below. Everything was neat as a pin. Too neat for someone who just gave birth. Her husband, Rob, was just finishing up changing the diaper and proudly introduced me to a healthy looking hungry baby girl. He seemed happier than Liz did as she fretted over how the breastfeeding was going, darting around the room and picking things up. I suggested we start with breastfeeding, and after getting mom comfortable and the baby latched we began to talk. Her husband offered her food but she refused, saying she was too tired to eat, not having slept enough. I started getting the feeling of things not being right with Liz, a familiar feeling in the course of my doula work, and asked her how she felt emotionally. The tears began to roll down her cheeks and she confessed that she just felt overwhelmed with all of it, the breastfeeding, the baby crying, worrying that she couldnt take care of herself, let alone her baby, and worst of all feeling guilty for being sad when she had so much to be thankful for. She said she was about ready to give up on the breastfeeding but felt, at the same time, that this was all she had to offer her baby in her state of "inadequacy". Nothing I suggested made her feel adequate or capable. I recognized from experience that she had probably more than one form of perinatal mood disorder. She was too anxious to know when things were ok and too depressed to follow up on any suggestions when they were not and sleep deprivation intensified all of it. She had no appetite and felt guilty for being sad at all. I explained that as a doula I couldnt diagnose but I gave her the name of an excellent counselor who specialized in postpartum recovery. I gave her handouts, some practical tips for calming baby and mother self care, and my own wording of the PSI motto: Youre Not Alone, Youre Not to Blame, You Will Recover.

Twenty percent of all newly delivered mothers will develop postpartum depression and anxiety, but about one third of my postpartum clients have it, because they (or their families) are the ones most likely to reach out for doula help.

Everyone knows these women are out there suffering, and often alone, but few have known how to help until recently as more light is shed on this topic due to celebrities coming forward with their own challenges with PMD and news stories of women with postpartum psychosis. As professionals acquire information it is probably inevitable that there will be some errors in treatment such as over zealous use of drugs without careful evaluation and counseling by specialists, and using drugs too early, when it can be difficult to recognize the difference between PMD and normal baby blues that can last one to three weeks. Evaluation is necessary to make sure she is on the right combination of drugs to treat more than one coinciding illness.
SSRIs have been promoted to treat PMD and have been helpful but they are not without drawbacks, so it is prudent to make sure a mom wouldn't do alright just with a good counselor who specializes in PMD. ACOG published this in a May, 2007 news release: Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed class of antidepressants because they are effective, well tolerated, and have adverse effects that are less severe than those of older antidepressants. However, recent studies have indicated that exposure to SSRIs late in pregnancy has been associated with short-term complications in newborns, including mild respiratory distress, irritability, feeding problems, jitteriness, and seizures. Individuals taking SSRIs may experience other side effects, including nausea, drowsiness or fatigue, decreased sex drive, headaches, weight gain or loss, and agitation..ACOG also advises that paroxetine (Paxil®), a longer-acting SSRI, be avoided when possible by pregnant women or women planning to become pregnant due to the potential risk of fetal heart defects, newborn persistent pulmonary hypertension, and other negative effects.
It is always advisable to first check moms thyroid and physical health status.

Here are some facts to help sort out the confusion.

Depression and Anxiety During Pregnancy 10% of all women Depressed and anxious
Baby Blues first three weeks 80% of all women sleep deprived, hormonal, crying over everything. , Overwhelmed, but can sleep given chance.
Postpartum Depression and Anxiety 20% of all women Sad, guilty, cant sleep, too much worrying. Chronic
if untreated.
Obsessive/Compulsive Disorder 5% of all women Repetitive intrusive thoughts, abhorrent to the woman re: h hurting the baby, feeling guilty
Irrational behavior (hiding knives)
Postpartum Panic Disorder 10% of all women Extreme anxiety and worry. Physical sensations, dizzy,
palpitations, cant breathe, cant sleep.
Postpartum Post Traumatic Stress Disorder 10% of all women Triggered by traumatic event. Flashbacks, intrusive m images
of event, hyper vigilant, jumpy, depression and anxiety
can concur. Traumatic birth, rape.
Postpartum Psychosis 2 in 1000 women Need hospitalization, early onset, three days to three
months hallucinations, mood instability, suspicious, may be in denial of the birth.

Regarding postpartum psychosis, there have been newspaper stories about women who did horrific things while in a state of psychosis, leading women to believe they could do such things themselves. It needs to be noted that psychosis is a different illness than depression and depression does not turn into psychosis. The first symptoms of psychosis typically begin in the first two weeks, and involve delusional beliefs; there would be no doubt in the familys mind that she needs to go to the hospital right away. It will be a good thing when journalists themselves learn to differentiate between the two before frightening so many pregnant women with their stories.

There are many hypotheses regarding the cause of PMD but few real facts. Fluctuations in hormones and brain chemical imbalances play a part in ways not yet understood. We do know there are risk factors and prevention techniques that can help. There is strong evidence that birthing at a hospital increases the risk of PMD because the liability based thinking there leads to many harsh interventions from the beginning of labor that affect the mothers moods and feelings of control and capability. Unnecessary C-section is the worst but only one of many harsh forms of treatment to both mom and baby. Often the conflicting advice regarding breastfeeding of two to three shifts of nurses is enough in itself to have the mother crying at home at our first postpartum doula visit. Over testing and monitoring often leads to comments from staff to indicate that baby might have this problem or that. Sometimes one test that shows an abnormal reading is enough to cause mom to feel her baby might not be ok even if another test shows her baby to be normal, thus affecting her willingness to bond for some time (with a baby that might not make it in her subconscious). There is some evidence that Omega-3s can prevent depression and fatigue. Women also need good health care, resources when she is beginning to stress, preparation for parenthood, a social network rather than isolation, a good support system at home, arrangements for some way to get necessary sleep and be aware of past history predisposing her to PMD.

Most of us arent trained professionals, yet there is much we can do. We can validate our sisters suffering rather than tell her to pick herself by her bootstraps. We can reassure her that we will be there to help when she needs us, and we can carry the hope that shell recover. She has so little hope while in the crisis state; it is the biggest thing you can provide. Tell her she is not alone, not to blame and she will recover. Find handouts for her, prepare good food for her and do whatever it takes to enable her to get some sleep. Then most importantly of all, follow up with a plan.

If you are a birth professional you can listen without judgment and dont diagnose. Be with the mom; educate yourself and be comfortable with mental illness, rather than be fearful yourself. Support her family; they are frightened and confused as well. Refer her to help that may take one or more of three forms. There are medications that can be prescribed by her OB, GP, nurse practitioner, and psychiatrist. Most of them can be taken while breastfeeding but check with Thomas Hales Medications and Mothers Milk. She needs good counseling that can come from social workers, psychologists, or family counselors. She will always need social support (not advice) from peer support groups, church, phone support, family and friends, and doulas. Doulas generally are educated and informed about PMD and one of the best sources of woman to woman support. The birth professionals role is to give mom a plan and follow up with it at least through phone calls.

Postpartum Support International is an international organization that has been helping women for years to find information and resources. http://www.postpartum.net/. 1.800.944.4PPD.

There are many good books now that can shed a little light on this often-dark disease. The Baby Blues Connection web site has an excellent page containing most of the best reading material for these families and much other helpful information, founded by Wendy Davis, Ph.D. an Oregon PMD expert.
http://www.babybluesconnection.org/resources/reading_list.htm.ThiI: Postpartum Support International


Vicky York, board certified lactation consultant and certified postpartum doula, has served nearly 600 families in Oregon since 1992 helping families through the postpartum period. Her assistance has included adoption, gay couple support, twins, preemies, and perinatal mood disorders.

Vicky York, IBCLC, CPD
Portland, OR
vmyork@peoplepc.com
http://mypeoplepc.com/members/vmyork/

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