One of the most meaningful ways that I can show respect to my clients and ensure that I maintain a reputation of professionalism and safety is to adhere to a very clear SCOPE OF PRACTICE. I love this work! I am so excited to further my training as a midwife and continue caring for birthing people! As a doula and future midwife, I find that it is important for me to be very clear about how I function differently in these two roles.
In preparation to write this blog post, I have realized that I find myself in very few conversations about scope of practice. We talk about the things we DO as doulas during our interviews. Surprisingly few people ever ask about what we DON’T DO! It seldom comes up in discussions with other doulas. I assume that this is because there really isn’t much to talk about. From my perspective, the boundaries are so very clear there is not a whole lot left to explore amongst the Bright Birthing team or in professional gatherings with other doulas.
I LOVE the Evidence Based Birth article about the evidence on doulas. I share the article with all potential clients to provide research to back up what we already know: having a doula can make for a better birth experience! This blog post, however, is focused on what doulas don’t do. Knowing our limits is just as important as knowing how to use comfort measures and positioning, create a calm environment, and provide emotional support. Perhaps we will elaborate on what doulas DO do in a future blog post?! Because what doulas DO and DON’T DO is so clear in the Evidence Based Birth article, I’m gonna use their words instead of my own to clarify the boundaries of our work -- efficiency for the win!
Here’s an excerpt from the article Evidence on: Doulas, taken from https://evidencebasedbirth.com/the-evidence-for-doulas/
What is NOT included in doula support? Doulas are not medical professionals, and the following tasks are not performed by doulas:
They do not perform clinical tasks such as vaginal exams or fetal heart monitoring
They do not give medical advice or diagnose conditions
They do not make decisions for the client (medical or otherwise)
They do not pressure the birthing person into certain choices just because that’s what they prefer
They do not take over the role of the partner
They do not catch the baby
*They do not change shifts (although some doulas may call in their back-up after 12-24 hours)
*YOUR TEAM DOULAS DO CHANGE SHIFT, but you don’t get a stranger, you get your caring, compassionate, skillful OTHER doula. YAY!
Seems pretty simple and straightforward, right?! NO cervical checks, NO monitoring heart tones, NO medical advice. Of particular importance to me is that I do not see my role as BEING the voice of my client. I believe it is my role to AMPLIFY the voice of my client. I am very clear within myself, with the Bright Birthing team, and with potential clients that I am not in this work to project my own ideals about birth onto anyone else’s experience. My job is to educate and empower. My job is NOT to make decisions for birthing people.
Now, I think there’s a lot to be desired in modern maternity care. So, for the record, choosing to support my clients, empower them to make decisions, encourage them to be educated consumers, and walk with them through the maze of machines and medications in no way means I’m giving a high-five to the madness of hyper-medicalized birth and our country’s very not evidence-based approach to all things labor, birth, and child care. But I REALLY, REALLY so very strongly believe that healthcare consumers will be the drivers of change. And I REALLY, REALLY so very strongly believe that birthing people will drive change when they are informed, educated, empowered and having their own experiences that make it so very clear that the system IS NOT SERVING THEM.
Ok, so why am I on about this? Well, it occurs to me how VERY important it is that birthing people understand that a doula who might be offering services such as cervical checks and fetal heart tone monitoring has stepped outside of the boundaries of doula work. If you’re interviewing a doula who offers those services, it would be important to ask what other qualifications and experience allow the doula to perform those tasks safely. Then, it would be necessary to clarify that those still ARE NOT things that doulas DO, so it would be important to hash out exactly in which capacity that provider intends to serve you. See where I’m going here? INFORMED CONSUMER-VILLE! When birthing people, doctors, midwives, doulas, and whoever else is involved as a pregnancy support team are all on the same page about who does what, the whole system works better! AND clients are safer!
A couple of years ago, I learned that an organization based in Richmond, ToLabor, was including vaginal exams and fetal heart tone monitoring in their doula training. I was shocked! Alarmed! Concerned! How could they?! Then, I read their website FAQs (http://www.tolabor.com/about-tolabor/faqs/) about the training and it made so much sense! On the surface, this was so contrary to everything I understood about the doula role. But ToLabor wasn’t teaching doulas to perform vaginal exams so they could send them out into the world of doula work to harm clients and put themselves at risk for some serious loss of credibility within their communities. ToLabor offers student-doulas the VOLUNTARY opportunity to perform vaginal exams and listen to fetal heart tones so that they can become more comfortable with touch, better understand pelvic anatomy, and get a real sense of their clients’ vulnerability. I actually kinda think it’s brilliant. They also have anyone who comes through their workshops sign a scope of practice agreement and make it completely clear on their website that performing vaginal exams and checking fetal heart tones is NOT part of a doula’s work.
I never attended a doula training workshop. When I became pregnant with my first babe, I turned into a bit of a self-study maniac on all-things pregnancy, labor, birth, and parenting. I read so much. I was never without a book on one of those topics, well into my son’s first year. Then I started midwifery school and began the process of becoming a Certified Professional Midwife. So, I learned to be a doula by learning to be a midwife and through my own yearnings to learn about pregnancy, birth, and child care. I’ve participated in voluntary vaginal exams. I’ve measured fundal height. I’ve checked fetal heart tones. I’ve assisted with something like 75 prenatal appointments, during which I checked urine screens, checked the pregnant person’s vitals, and palpated pregnant bellies. But learning to do these things as a midwife, did NOT ever give me the impression that they were part of my work as a doula.
As a result of participating in voluntary vaginal exams, I understand the importance of talking to pregnant people about what is happening during pelvic exams and why the information gained might be helpful. I understand pelvic anatomy because I have felt the ischial spines, and the ovaries, and the pubic arch with my very own short little fingers. I’m more comfortable with touch because I’ve measured, palpated, and assessed. Really, it is hard for me to imagine my doula practice without the deeper understandings I gained from being a midwifery student. So, I can appreciate ToLabor’s approach. I see the value in learning about things that are OUTSIDE of the scope, to better inform the work that is done WITHIN the scope. And I trust the people doing the work to know the boundaries.
If you ever have questions about the limits of the doula’s role, feel free to give us a shout! You might also check out the DONA (very credible doula organization) statement on the doula scope of practice, which can be found at https://www.dona.org/wp-content/uploads/2017/08/COESOP-2017-FINAL-Birth.pdf.
We’re also happy to answer questions about our training and experience any time-via email, fb messenger, or at our regular gatherings!