Patient Advocates

Over the course of the past few months, I’ve read numerous things from various sources — emails, L&D nurse blogs, links to nurse things — that touch on the topic of “being an advocate for the patient.” One nurse forum had the line, “Be nice to your nurse — we keep your doctor from killing you,” or something similar. Humorous, but probably with a nugget of truth.

One of the links was to a nurse’s forum and a discussion on how much Pitocin the nurse should give the patient — the original question was from a nurse who was given orders by a doctor to give Pitocin in a large dose to start with, and/or increasing it by too large an increment or too close together — whatever it was, it was so egregious that several nurses expressed shock that the doctor would even order it, and strongly recommended that she document everything (to cover her own butt), and other nurses said they would usually say, “Yes, doctor,” and then ignore the order if it was something they were uncomfortable with. (Need I elaborate on how distressed I was to read this thread?)

Some nurses might get a little edgy or “territorial” over things like the woman having a doula, saying things like, “She doesn’t need a doula to advocate for her — that’s part of my job description!” To which I say, that’s pretty good proof, then, that the average woman does need a doula in a hospital. My line of reasoning is this — why do laboring women (and other people in the hospital) need patient advocates in the first place? It’s because sometimes their wishes are not honored or respected, or perhaps the doctor screws up (either due to being only human, or because he’s acting rashly, trying to speed up a birth and not caring if the woman has a C-section or not due to fetal distress from too much Pit), or some other reason. The nurses can be a buffer between the doctor and the patient. So can a doula. While some nurses may be able to fulfill that role, other nurses can’t, won’t, or don’t, and the pregnant woman will have no idea which kind of nurse she will be assigned to prior to going into labor. Having a doula can be a safety net in this area.

If the hospital system were “ideal,” nobody would need anyone else as an advocate, because the doctors would do just what they were supposed to do, and would explain things like they ought, and practice evidence-based medicine, and have a good bed-side manner and all that jazz. But sometimes they don’t; and that’s where a patient advocate comes in. But what if the nurse assigned to the patient isn’t a good advocate either? Where does that leave the patient? The very reason that the nurse needs to advocate for her patient is the very reason why she should have a doula. A doula can’t countermand idiotic medical orders, but she can suggest things that can minimize risk — such as, if the contractions are already in a good pattern, could the pitocin be turned down or off, to see if labor continues? can we try X before we have to do Y? is there any reason why she can’t go to the bathroom herself, rather than get a catheter? — that sort of thing. Being familiar with various medical and labor/birth terms, a doula can also explain things to a laboring woman or her family if the doctor or nurse can’t or won’t.

Patient advocacy is just one aspect of what a doula can do — even if you have a great doctor and/or nurse so don’t need a patient advocate as such, you may still want a doula to help you through labor, because very few medical staff will have the time, desire, or ability to really be with you during labor the way a doula can.


5 Responses

  1. Nurses are so overworked and stressed out that I would always recommend a patient advocate, no matter where you are in the hospital. I would love to be the eyes and ears of a patient, but that is just not realistic. Nurses have more patients and less support in today’s health care environment. One of my biggest regrets with my first birth is not having a doula. I thought “I’m an NICU/OB nurse. I already know it all.” It was the support I was lacking. I would love to know how many nurse out there have used a doula. My guess is, not many.

  2. Oh, I love this post. I’m a doula and this is something I’m quite passionate about. In many ways I think it’s a poverty that my job even exists. What an indication of a system gone wrong that women have to PAY other women to support them through the unknowns of labor and through an intimidating maternity system. Sad that giving birth is so frought with danger in America – but also sad that we aren’t surrounded by mothers and sisters who have done it before and can support us like we need it. So many of our previous generation were afraid of this same system – though for a whole other set of reasons. (and when women bring their mothers into labor with them, I can see the transformation in those older women. Mothers who are terrified of labor and cry at their daughter’s every contraction – they become the best doulas as they see that birth-pain is positive and they can help! What a platform for a new family to grow upon!)

    I know every doula practices differently, but I find that the “advocate” role is my smallest one. I do as much work as I can in the prenatal period to instill a sense of autonomy in my clients. I teach them questions to ask, how to work the system, etc. I teach them that they have EVERY right to say “no”. But when I’m in a birthing room, I do not want the staff having any whiff of an “us vs. them” dynamic. No laboring woman needs that tension in there. I want the staff to be welcoming and glad I’m there to help THEM. But of course, my only goal is my client’s satisfaction and health. This is the hardest part of my job – especially when I drive home, feeling like I partnered in the abuse of a woman. All I can do is show a woman her paths and likely outcomes, warn her as much as is fair in the prenatal period, and support her as she chooses her path. I like to think I’m a no-BS doula, but as long as women are choosing things I know to be less safe or even contrary to my own choices, a little BS will be included. It has to be if my goal really is supporting HER above MYSELF or my dogma.

    And I’ve seen women completely cave in the presence of a white coat and choose interventions she was vehemently against two weeks prior. I’ve also seen a woman fire her doctor when she was 6cm. I’ve seen a woman call a lawyer during her VBAC to ensure that her doctor wouldn’t intimidate her into another Cesarean. I’ve seen women eat food behind their doctor’s backs and a woman lock herself in the bathroom so that pitocin couldn’t be administered. And I’ve seen women who didn’t feel they had a choice cry because their births were being taken from them.

    Women needs advocates, some more than others. But again, I agree with you that it’s a stain on our healthcare system that this is true. And I hate that birth is such a fight for some women.

  3. I think Doula’s should be compensated by medical insurance. I am actually surprised they are not given the push for less intervention with medical insurance companies.

    Any nurse who is not able to say, “No Doctor I cannot administer that dose.” Should not be a nures. Perhaps she could be an ultrasound tech or something of that nature. But anyone who cannot say no to an inaccurate dose should not be a nurse. ANd the Board of Registration of Nursing agrees with me.

  4. Great post!

    I think I would even take it further & say that, even in an *ideal* setting, because doctors are human and laboring moms/families are human, advocacy may sometimes be necessary, just because people may not always communicate well together.

    If it were possible to split up a doula’s various tasks into percentages (like mom-comfort; helping partner help mom; education; advocacy etc), I wonder how variable the advocacy piece would be. In the case of my sister who had a doula but gave birth in a very cookie-cutter, not-respectful hospital setting, my sister felt the doula would somehow protect her from non-evidence-based care & would “stick up for her” so she could have the birth she wanted. She was very disappointed in her doula, for a variety of reasons, but mostly the advocacy piece. There are definitely limits to the advocacy doulas can do, and how skilled they are, as well as how comfortable they are, in that role is certainly variable. I think frank discussions ahead of time to clearly define how the doula sees her role re: advocacy during birth are really important so moms have realistic expectations.

  5. Thanks, Kathy Peterson, for a concise and articulate explanation of one the doula’s many roles — advocacy!

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