How Do I Advocate for Clients in a Birth Room?

Some doula trainings will teach you that you should never speak to a doctor, like you are unworthy or not educated enough to interact with an expert medical provider. Other trainings are fire and brimstone - BURN DOWN THAT FUCKING BROKEN SYSTEM!!!!! While I do in fact believe that the system needs a fucking overhaul, your birth is not my protest. In other words, I love nuance, so I'm neither of those two extremes. I think I use just about every single medical advocacy strategy known, but I use each one judiciously.

Fun fact: I once got to attend a birth with a client's sibling who IS a medical advocate. We swapped tips and tricks in the down moments of their sib's labor.

I have a toolkit of strategies that I use, but I will mention just a few here. I adapt based on who is in the room, what matches my client preferences, and what the situation calls for. I've had people come to me worried that they shouldn't have had a cesarean or an induction or some other intervention - and it is because they did not get truly informed consent in the moment. In situations like that, I view my role as helping someone understand what was happening and how to ask follow up questions to their provider in order to get a debrief from both me and also their medical team. I do not employ any of these strategies as a rule. Not every labor calls for the same thing.

Silly Goose

When used thoughtfully, humor really can be medicine. At one client's birth, their baby came out needing additional help. The NICU team does what they do best and intervened medically, but quickly decided that the baby needed some more help in the actual NICU. They were going to whisk the baby away without the birthing parent ever having a chance to see or touch their child. I made a snap decision - to be silly. I piped up, "Just one smooch?" Everyone in the room stopped and stared at me, which is really saying something during an urgent medical situation. "Do we have time for just one smooch before you go?" I think because I looked like an idiot, and I was reminding everyone of our humanity, no one wanted to argue with me. How can you say no to something so small as a smooch? They brought baby over and I felt the energy change as the baby and birthing parent connected - and then baby let out their first cry!

I think my client tells this story better themself and you can read it here.

Doula Math

Like non-gendered Girl Math but birthy. I am sometimes sitting quietly in the corner but I do not do anything at a birth that isn't deeply intentional.

• I'm staring into space? That is me trying to construct a 3D model of your pelvis and your baby in my mind so that I can figure out what positions we should try next.

• I'm reading a book? It is because you are supposed to be taking an epidural nap and I want to signal that all is well and you don't have to worry about me or anything else (I believe the OG midwife version of this was sewing; forgive me for not bring my holey socks to your birth).

• I am watching you intensely? I'm not a freak, I promise. I am watching for signs of progress. Looking for signals that maybe it is time to leave for your birth location or that you may enter transition soon. Sometimes I am just trying to figure out how to make you 1% more comfortable. Experts call this attunement. I call it Doula Math.

I actually learned that I do this from a client who observed me at her sister's birth before hiring me. She said that she could tell that my wheels were constantly spinning as I brainstormed what we needed to do - without anyone really knowing that is what I was up to.

Nick Miller Scrappy Fix

I had an experience with the kind of older white male OB that makes me feel like all white male OBs should have to take some sort of competency test every 2 years to be allowed to practice, like a driving test for the aging. He was dismissive and not evidence-based. As soon as my client started pushing, he put her in stirrups which made it impossible for her to change positions. He also actively discouraged her pushing efforts and was openly impatient, even though pushing for a couple of hours with an epidural is completely normal. First, I watched. He wasn't going to let me fancy fix the situation (i.e. help her roll onto hands and knees). Then, I made my voice louder than his - but only when my client was actually pushing in the right spot, which gave her a real feedback loop. He didn't like that so much and left the room. I used the alone time to reassure my client and brainstorm how to help her change position. No fancy fix, so I went full Nick Miller: I rolled a towel up and stuck it under one of her butt cheeks. After 3 pushes, I pulled it out and stuck it under her other butt cheek. Between the accurate feedback loop and the position change, baby came under her pubic bone and we were calling the OB back to catch the baby within 30 minutes.

Dumb Doula

I talk about this one in my podcast Birth Gossip with midwife Carly Ann. The Dumb Doula act is a tried and true strategy when you are with providers who don't trust you or know you well. If I show up confident and informed, they get nervous that I will overstep. So instead, I ask questions that I already know the answer to. I'm not being malicious. Sometimes my clients really benefit from hearing the answer, and always it signals that I am open to hearing the provider's perspective. Which I genuinely am! I lead with curiosity in all parts of my life and sometimes this strategy results in me learning something new. For example, I was working with a new nurse who was really nervous about position changes during an epidural. I asked a simple, "What position do you think would work best to help the baby navigate the midpelvis?" She suggested a position that I agreed with and we did it together as a team. After that, she was more comfortable with and even curious about my suggestions.

Broken Record

A quick and easy one that anyone can do anywhere and anytime. Repeat what the person in the vulnerable position is saying, literally to amplify their voice.

• "Owwww this really hurts!" ➡ "She said that really hurts! She seems to be in a LOT of pain. What can we do?"

• [about a client that uses they/them pronouns] "She is due for another blood pressure." ➡ "Thank you so much for looking out! They are just using the bathroom. As soon as they are out, I can call you so that you can take their blood pressure."

  • Note that I will get more or less direct about pronouns depending on what a family has requested.

• "Is everything ok?" ➡ "I'm not sure. Is everything ok with the baby?"

Anchoring the Ship

Sometimes, I know something is coming - or probably coming - before my clients do. I can then give them a heads up or what is sometimes called anticipatory guidance. For example, sometimes a baby's heart rate dips in labor. There are normal "Labor is stressful!" dips that help babies get ready to be born, and then there are bigger "Something is not right! Help!" dips that sometimes result in emergency interventions. Recently, I was at a birth where a baby had a big dip, clearly asking for help. The nurse hit The Clown Car Button: the alarm that asks a whole bunch of extra hands to come into the room and assist. It usually feels like a clown car is unloading at your birth room door as people pile into your room. As the nurse hit that button, I leaned calmly toward my client and said, "A whole lot of people are about to come into this room to help." I stayed visibly close and calm as the chaos unfolded, like an anchor.

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When I get this stuff right, I can feel it in my bones. I know that clients are getting better care and more informed consent because I am in the room with them. Scenarios when I have used humor or invented something new on the fly in order to help a client are my proudest moments in birth work. I am never so cocky as to think that I can control a labor or birth outcome, but I do feel that I can influence someone's experience. Moving that experience needle further toward positive and empowered is what I live for, and why I love my job.

Sometimes I help by doula-ing your pup