The DONA Doula Chronicles Gives Thanks

thanks-1060205_640Thanksgiving is right around the corner in the U.S., and so this seems the perfect time to say thank you to all those who have contributed to The DONA Doula Chronicles as writers, editors or idea generators. DONA International’s blog is truly a team effort, and we are thankful for all of the support we’ve received.

Thank you to these birth and postpartum professionals who have contributed content to The DONA Doula Chronicles:

Sujata Gami, ICCE, CD(DONA)
LaQuitha Glass
Melissa Hartley, LCCE, BDT(DONA)
Barbara A. Hotelling, MSN, WHNP, LCCE, CD(DONA), IBCLC
Ana Paula Markel, ICCE, BDT(DONA)
Carrie Murphy, ICCE, CLC, CD(DONA)
Karen Olness, MD
Lysa Parker, CEIM
Wendy Scharp, BDT(DONA)
Selena Shelley, MA, CD, LCCE, CHBE
Susan Troy, CD(DONA)
Barbara Wilson-Clay, IBCLC
Debbie Young, CD(DONA), PCD(DONA)

Thank you to members of the DONA International Board of Directors, Advisory Board and Publications Team who support the blog by sharing and cross posting content, providing feedback, editing and suggesting article ideas:

Sunday Tortelli, Interim Director of Publications, President, DONA International
Melissa Harley, Southeastern US Regional Director, DONA International
Tracy Good, past Director of Publications, DONA International
Susan Troy, editor, International Doula
Leslee Boldman , editor, eDoula
Kyndal May, Director of Education, DONA International
Uta Mattox, Director of Certification, DONA International
Walker Karraa, Ph.D., DONA International Advisory Board
HeatherGail Lovejoy, President-Elect, DONA International

For those celebrating Thanksgiving this week – have a wonderful holiday!
– Adrianne Gordon, CD(DONA), MBA, editor, The DONA Doula Chronicles

Best of International Doula: Trauma to Triumph – Why You Shouldn’t Ask: Tools for Working with Pregnant Childhood Sexual Abuse Survivors

Our feature article in September’s International Doula was about supporting sexual abuse survivors, and we had a lot of great feedback from readers about how this will help them in their doula work. If you don’t know how to approach this topic with your clients or if you currently ask clients about sexual abuse history, reading Selena Shelley’s article will probably change how you handle this with future clients. — Susan Troy, Editor, International Doula

Trauma to Triumph
Why You Shouldn’t Ask: Tools for Working with Pregnant Childhood Sexual Abuse Survivors
By Selena Shelley, MA, CD, LCCE, CHBE

There’s a question often circulating around the doula community that goes something like, “Should I ask my client if she is a childhood sexual abuse survivor?” It is often followed by, “Won’t it help me provide better care if I know?” If you are a doula who has asked yourself these questions, I commend you; it shows that you want to provide thoughtful and excellent care to your clients. I hope this article will help you do exactly that by convincing you NOT to ask your clients about a history of childhood sexual abuse.

Until a couple of years ago, I was convinced the answer to both of those questions was “yes.” I was so convinced that I tried arguing my point with Penny Simkin, PT. Yes, the Penny Simkin, co-author of When Survivors Give Birth and all-around birth guru. Penny Simkin and her When Survivors Give Birth coauthor, Phyllis Klaus, MFT, are two of the most experienced birth counselors and practitioners around. And I, a seasoned doula and psychotherapist of 10 years and one of their From Trauma to Triumph:When Survivors Give Birth certifying trainers, thought I knew better. But once I was able to put my ego aside and listen to what Penny Simkin and Phyllis Klaus have learned over the past four decades, it made a lot of sense to me — doulas just shouldn’t ask.

In general, the potential benefit of confirming that your client is (or is not) a survivor does not outweigh the immense potential risks. There are four main reasons why.

1. She may react poorly to being asked.
Let us first acknowledge that if a woman hasn’t disclosed a history of abuse to you, there is probably a reason why. Maybe it is a conscious reason, such as her partner doesn’t know and she doesn’t want that person to know. Maybe it is an unconscious reason, such as one of her childhood coping mechanisms was to block out what was happening to her, and she doesn’t remember enough to tell you anything. Or maybe she simply hopes that her pregnancy and birth won’t be marred by her history, so she doesn’t want to bring it up. Any of these or a multitude of other reasons are incredibly valid explanations for why a woman might choose not to disclose a history of abuse to you. And if she hasn’t disclosed, putting her on the spot by asking such a personal question could lead her to feel ashamed, defensive, or withdrawn.
• “I didn’t come for counseling about that. She’s not my therapist, she’s my doula.”
• “How can she tell? Is it written all over me?”
• “I don’t want to go there. It’s none of her business.”
• “Why would she ask me a question like that?”

I expect you agree that putting a client in the position where she might respond with any of these thoughts or questions is unhelpful and potentially damaging to your role as her doula. This, therefore, seems like reason enough to refrain from asking about her sexual abuse history. And yet, there’s more.

2. You should instead “hear the music behind the words.”
For anyone who has taken a When Survivors Give Birth training with Penny Simkin and Phyllis Klaus, you know that this is one of Phyllis Klaus’ favorite sayings. Hearing the music behind the words means that we don’t need a disclosure in order to be truly sensitive and helpful. Let’s start with basic probability — as many as one in three women is a childhood sexual abuse survivor (1). Given such a dishearteningly high statistic, you should be prepared for the possibility that your client is a survivor. And then you should use that possibility to provide the best care possible to every one of your clients, regardless of whether she has a confirmed history of abuse.

Beyond that, you need to educate yourself about the possible signs or triggers that might indicate a woman has a history of childhood sexual abuse. This will allow you to hear the music behind the words and improve your care of every client, without putting the onus on her to confirm or deny your suspicions. To learn more about common signs and resultant maternity triggers for a trauma survivor, read When Survivors Give Birth, by Penny Simkin and Phyllis Klaus and/ or attend a training session on working with childhood sexual abuse survivors. For a current list of trainings, go to

3. What if she says no?
You can imagine how this scenario might go. You strongly suspect your client has a history of childhood sexual abuse based on what you learned to look for in your reading and training. You let your ego get in the way and ask her if she is a survivor, and she denies it. You have now not only risked her reacting poorly about being asked, as mentioned above, but also potentially caused discord in your doula client relationship.

You might start to question your own skills and judgment (i.e., “How could I have gotten this wrong?”) or begin to second-guess whether she is being honest with you. The minute we start questioning a client’s decision to disclose or not, we shatter a part of our relationship. It is her right to keep that information private, if she chooses.

In addition, some survivor clients do not consciously choose to keep anything
from us. As a way to keep their world a little safer, some children who are being abused have an amazing ability to repress memories of the experience. And sometimes those memories get buried so deep that a woman may not actually remember that she was abused, or may not remember some of the details. In this case, when your client says “no,” she is being as honest as she can.

In either case — whether she knows she’s a survivor and chooses not to disclose, or she is a survivor but doesn’t consciously remember the abuse — you haven’t gained any value from asking.

Rather than put her on the spot, ask yourself the classic question that Penny Simkin and Phyllis Klaus train professionals to ask: “Would everything that I see, hear and feel with this client seem more natural or understandable and make more sense if she were, in fact, a childhood sexual abuse survivor?” And then, if your answer is yes, you simply get to hold additional space for her experience and for any triggers that may arise before, during or after her birth.

Hopefully, if you’ve taken a training on working with survivors, or at least read When Survivors Give Birth, you’ll have good tools for how to serve her more effectively and compassionately, under the premise that all women deserve better care, especially if they have a trauma history.

4. Trust issues
The final reason not to ask a client about a history of childhood sexual abuse is an amalgamation of all the other reasons: You risk breaking trust. Many childhood sexual abuse survivors have difficulty establishing trusting relationships, especially if their perpetrator was someone they or their family trusted. This is more common than you might think. According to the U.S. Department of Justice (2):
• 93% of juvenile sexual assault victims know their attacker.
• 34% of attackers were family members.

If we reluctantly accept that more than one-third of sexually abused children are abused by a family member, sometimes a family member they are being raised by and are dependent on for their basic needs, we can certainly understand why that child (and eventually that adolescent or adult) would have difficulty trusting people who are supposed to be trustworthy. And yes, that includes their doula.

Trust yourself. Trust your client. If and when she is comfortable and ready, and if and when it feels necessary and helpful, she will disclose her history to you. At that point, the disclosure actually has the ability to build trust, rather than strip it away. I should add that including the question on an intake form may prevent the client from feeling singled out, and may or may not improve the odds that you won’t second-guess yourself, but it is still not extremely helpful; at the time she is filling out intake paperwork, your client probably does not yet trust you. She probably hired you because she felt a connection with you at your interview, but it takes time to build trust, and that is often more true for a survivor. So, if you ask an incredibly personal question on an intake form, such as, “Do you have a history of abuse/trauma that you would like to discuss before your birth?” the chances are high she will answer no because she does not yet trust you enough to disclose that information.

In this article, I will not delve into what to do if you do include that question on your intake form and your client answers yes. But the general rule is you must follow up on such a brave and honest response. Do not allow your own discomfort, lack of time, or anything else keep you from reaching out to your client. Not addressing a trauma disclosure could potentially rewound your client and is, frankly, quite unprofessional.

Rather than including the question on your intake form, wait until you have a stronger, more trusting relationship with your client and then open the door for a disclosure of anything, ranging from her fear of pooping in labor to a history of childhood sexual abuse, by asking something like, “As we approach your birth, is there anything else that would be helpful for me to know about you, your history, your wishes or your fears so that I can be more supportive and helpful to you?” (For postpartum doulas this might sound like, “Now that we’ve been working together for a few weeks, is there any information or feedback that would help me better serve you and your family?”) I can almost guarantee that waiting for trust to organically grow in your doula-client relationship will not only increase the overall trust but make your job so much easier and more enjoyable.

My hope is that this information and reasoning resonated with you, and that you will now (re)consider whether to ask your clients if they have a history of childhood sexual abuse. As you continue to build a relationship with your client, allow the trust to build, as well. If she is a survivor, allow her to be the one in control, allow her to find her voice if and when it feels right, and ultimately allow her to have a repatterning experience that begins with you.

About the Author: Selena Shelley has more than 15 years of experience as a social worker, psychotherapist, birth doula and trauma consultant working with pregnant childhood sexual abuse survivors. As a certified From Trauma to Triumph trainer, she helps professionals learn how to work more easily and effectively with survivors during this transformative time in their lives. She loves serving clients and training other professionals, and also strives to find her own work/ life balance as a wife and mother to two beautiful children. You can learn more about Selena at her website

References :
1. Briere, J., Eliot, D.M. Prevalence and Psychological Sequence of Self-Reported Childhood Physical and Sexual Abuse in General Population: Child Abuse and Neglect, 2003, 27 10.

2. Bureau of Justice Statistics, Sexual Assault of Young Children as Reported to Law Enforcement: Victim, Incident, and Offender Characteristics, (January 2015)

A New Policy Statement on the APGAR Score from ACOG and AAP

newborn-863923_640The American Academy of Pediatrics Committee on Fetus and Newborn and the American College of Obstetricians and Gynecologists Committee on Obstetric Practice published jointly a policy statement on the use of Apgar scores recently in the journal Pediatrics. The policy revises the 2006 statement by AAP and addresses the inappropriate use of Apgar scores to predict health outcomes in individual infants.

Apgar Overiew

The Apgar scoring system was created by Dr. Virginia Apgar in 1952 as a standardized method to quickly assess newborn infants. The 10 point score has 5 elements: color, heart rate, reflexes, muscle tone and respiration with each element receiving a score of 0 – 2. Newborns are assessed at 1 and 5 minutes after birth with infants receiving a score lower than 7 being reassessed at 5 minute intervals until 20 minutes of age. Apgar scores at 5 minutes between 7 and 10 points is considered “reassuring”, between 4 and 6 “moderately abnormal” and lower scores “low” according to ACOG and AAP.

Apgar scores are described in the new policy statement as “an accepted and convenient method for reporting the status of the newborn infant immediately after birth and the response to resuscitation if it is needed.” Apgar scores are also used as important data in research to evaluate how newborns are impacted by a variety of prenatal and birth factors including the mother’s health, prenatal care, birth interventions, birth location (i.e. hospital, home, water) and type of care provider.

AAP/ACOG Policy Statement on The Apgar Score – Summary

The 2015 policy statement replaces the 2006 joint statement from ACOG and AAP and provides 4 recommendations:

1. The Apgar score should not be used to predict outcomes for individual infants.

2. The Apgar score alone is not an appropriate method to diagnose asphyxia or deprivation of oxygen. The policy statement notes that additional information is necessary for this diagnosis.

3. Blood gas samples from the umbilical cord should be obtained when an infant has an Apgar score of 5 or less at 5 minutes of age.

4. To support consistent assignment of Apgar scores during resuscitation efforts, an expanded Apgar score reporting form is encouraged. This form is provided in the policy statement.

Why should doulas know about this new policy statement

While doulas do not assess newborns, of course, staying up-to-date on how tools like the Apgar assessment are to be used and what the scores mean (and don’t mean) is important information to share with clients.

While the Apgar score is considered a standard method of assessment, the score is determined by care provider observations and so is open to interpretation. Conversations among care providers just after a birth can sometimes be heard as they share among themselves their observations if there is a difference in opinion on what the Apgar score should be. It can be helpful for families to know that this is not cause for concern.

Apgar scores can also be a useful way for families to obtain information about the health of their baby and why certain care is administered to their baby.Doulas can help facilitate this education process by asking families if they remember what makes up the Apgar score and encouraging them to inquire with care providers about the individual rating components of their baby’s score. Apgar scores are also helpful for care providers to let parents how their baby is responding to interventions in a quick and easy to understand way. Hearing that a score has changed from 4 to 6 is a clear sign of improvement yet conveys that additional medical support may be needed, for example.

It’s important, also, that doulas know and remind their clients that Apgar scores are not a predictor of a baby’s long term health, as this new policy statement points out. While there are some correlations between Apgar scores and outcomes in large population studies, a low or reassuring Apgar score alone does not indicate what an individual baby’s future health will be.

Resources for More Information

Policy Statement on The Apgar Score from AAP and ACOG (free to access and share)

New articles on the policy statement:

Nurses and Doulas Playing Nice For Optimal Birth

By Barbara A. Hotelling, MSN, WHNP, LCCE, CD(DONA), IBCLC

I was recently speaking with a fellow doula about her experience with nurses at births, and she shared this with me:

“My general experience with nurses varies widely. Sometimes I am greeted right off the bat with warmth and welcome, sometimes with curiosity and a bit of awkwardness and at other times with open disdain and coldness. At a recent birth, the nurse came up and hugged me with great enthusiasm before she even greeted her patient ‐‐ much appreciated by the doula but maybe a little over the top.”

This doula’s experiences mirror those of many birth doulas, including mine. I’m always a little nervous going to a birth because I’m not sure how I will be received by the nursing staff. I would have heard from the mother if her provider was supportive of doulas and I’ve usually met the mother and her support people, but the nurse is an unknown team member. I’m ecstatic to work as a member of the mother’s team with collegial nurses and saddened for the extra stress when we don’t focus our energies on the mother.

From my own experience as a birth doula for 30 years and my experience as a nurse for even longer, I’ve wondered why the two don’t always complement each other. We are there for the same purpose of welcoming a new life into this world safely and with joy. To be honest, not all doulas or nurses feel this way. Some nurses and doulas have underlying agendas of protecting women from potential negative experiences. Some of those involve negative birth outcomes and some of those involve past history with nurses and doulas.

Complementary skills and goals
Our skills used to support this magical event are different. Doulas are not trained in the medical skills the mother may need. In fact, if we do perform vaginal exams, monitor vital signs or electronic fetal monitors, or even taking the monitors off for a trip to the bathroom, we are not functioning within the scope of practice we agreed to with DONA International certification. Nurses provide these skills and they can also support mothers with information, advocacy and intermittent emotional and physical support.

Doulas are the continuous presence that the nurse cannot provide no matter how much she or he wants. Without clinical responsibilities or decisions to make, the doula is free to be present in each moment with the mother. With doulas, mothers have continuous emotional support, information about choices, the ability to change her birth plan and the physical support to ease the passage of her infant.

The goals of nurses and doulas differ as well. The goal of the nurse is to ensure a safe outcome for both mother and infant. The nurse’s skills of assessment, treatment, and communication with the provider take time. Rarely is the laboring and birthing mother the nurse’s only patient. The goal of the doula is to ensure that the woman feels safe and confident. (Ballen & Fulcher, 2006)

Global View
Throughout the world we see teams of complementary caregivers working to meet women’s needs. In the Netherlands, nearly half of Dutch women have midwife-assisted births, attended by familiar caregivers. Family and friends provide continuous labor support.

We also see places where collaborative care could provide safer and more satisfying birth. In a section of Liberia, rural women who need life-saving care resist going to the hospital because they feel they are not treated well by the medical staff. They prefer to continue their care with the familiar midwives who unsuccessfully urge them to seek more intensive medical care. Lives are unnecessarily lost because of women’s refusal to go to the hospital. Doulas or attendance in the hospital by midwives would make the transition easier and more acceptable.

In Reykjavic, Iceland, mothers get prenatal care from midwives and then go to the NEST to give birth. The NEST is a birth center on the first floor of the hospital. If medicalization beyond the midwife’s skill is necessary, Icelandic women are transferred to the obstetric unit on the third floor. The mothers are then cared for by unfamiliar nurses and physicians. Doulas are available and for women with doulas, the transition is not nearly so traumatic.
Parents’ Expectations and Realities of Nursing Support

In a 2001 study by Tumblin and Simkin, 57 first time mothers in their second Lamaze class completed surveys of their expectations of nursing support in hospital births. The authors matched the mothers’ answers with dimensions of labor support including physical comfort and emotional support, and information and advocacy.
Women in Tumblin’s class reported that they expected 53% of nursing tasks would be providing direct supportive care in which 29% of their tasks would be to provide physical comfort and emotional support and 24% of their time would be spent in informational support and advocacy. The remaining 47% of responses pertained to direct and indirect clinical care activities, of which one-half were related to monitoring the mother, baby, or labor progress (Tumblin & Simkin, 2001, p. 54).

pie_chartMcNiven, Hodnett, and O’Brien-Pallas conducted a work sampling of the activities of labor and delivery nurses in 1992. They observed the activities of 18 nurses in 616 randomly scheduled 15 minute blocks over four daytime shifts. Activities were divided into two major categories: supportive care and other. There were subcategories under each of the major categories below:

Supportive Care

  • Physical comfort: cool cloths, warm compresses, bathing, assist w/shower, linen changes, ice chips/fluid, position for patient comfort, massage back/other body parts, reassuring touch
  • Emotional Support: reassurance, encouragement, praise, keeping patient company, laughter, joking, social chitchat
  • Instruction/Information: instruct or coach (breathing/relaxation/pushing), give advice (suggest techniques to promote relaxation, comfort, improve physical condition), explain/provide information about progress, fetal well-being
  • Advocacy: Support patient’s decisions, negotiate patient’s wishes with other team members


  • Other Direct Care: all other activities in the presence of the patient, such as all physical assessment, performing or assisting with procedures
  • Indirect Care: teaching other than with patients, documenting care (not in patient’s presence), notification of physicians, attendance at meetings, all other activities not involving direct patient care (McNiven, Hodnett, & O’Brien-Pallas, 1992).

We see from the graph below that the expectations of nursing care by pregnant women in 2001 were not aligned with the realities of McNiven and Hodnett’s work sampling in 1992. Nurses were not able to spend more time supporting each mother due to heavy demands of communication and documentation. I expect nurses’ care in 1992 did not change much almost a decade later when Ann Tumblin surveyed her class parents. Documentation has increasingly become more difficult and nurses now work 12 hour shifts, leaving them tired and strained. The team approach of nurses and doulas working together would meet mothers’ expectations of more supportive care.

bar_graphHodnett, Lowe, Hannah, et al, studied the capacity of nurses to achieve similar decreases in cesarean rates when trained by a professional doula and given one-on-one care with laboring and birthing women. 6,915 women participated in a randomized controlled trial during a two-year period from 1999 to 2001. Women were randomly assigned to receive usual care or continuous labor support by a specially trained nurse. The primary outcome measured was cesarean birth rate. Other outcomes included intrapartum events and maternal/neonatal morbidity both immediately postpartum and in the first six to eight postpartum weeks. There were no significant differences between the two groups in the measured outcomes including cesarean birth rate. The mothers with continuous labor support did state a preference for that care in the future. These researchers concluded that in hospitals characterized by high rates of routine interventions, continuous labor support by nurses did not achieve the same outcomes as seen in research of continuous labor support by doulas.

For optimal birth outcomes, nurses and doulas need to respect each other’s talents and gifts and center their focus on the woman giving birth. The doula I quoted earlier, related her positive experiences with nurses:

“There is one hospital that is known to be very doula friendly and we work so well together there! Everyone understands each others’ roles and assumes good intentions. The women benefit so much!

I love these experiences! Everyone is successfully serving in their role. The nurse is able to get what she needs (heart tones, questions answered, vitals taken, connection with her patient), and the doula is able to fully support the woman (comfort measures, helpful suggestions, encouragement, advocacy). The nurse and the doula see one another as important parts of the team. We can ask questions and learn from one another.”

About the Author
Barbara_IMG_8785Barbara Hotelling has been a Lamaze educator and trainer, DONA birth doula and trainer for the past several decades.  She is passionate about the way humans enter this world and about their families.  She has become a IBCLC, Hug Your Baby teacher and trainer, and has studied infant massage to further her knowledge.  Presently she is a clinical nurse educator at Duke University School of Nursing where she trains Dukelas every semester – nursing students who are also passionate about caring for pregnant, birthing, and postpartum women and their families.  Nana has 5 children and 7 grandchildren ranging from 12 to 1 week.

Ballen, L.E., and Fulcher, A.J. (2006). Nurses and Doulas: Complementary Roles to Provide Optimal Maternity Care. JOGNN, 35, 304-311.
Gagnon AJ & Waghorn K. Supportive care by maternity nurses: A work sampling study in an intrapartum unit. Birth 1996;23:1–6.
Hodnett ED. Nursing support of the laboring woman. J Obstet Gynecol Neonatal Nurs 1996; 25:257–264.
Hodnett ED. Caregiver support for women during childbirth. The Cochrane Library.Issue 1.Oxford:Update Software,2000.
Hodnett ED, Lowe NK, Hannah ME, et al. Effectiveness of Nurses as Providers of Birth Labor Support in North American Hospitals: A Randomized Controlled Trial. JAMA.2002;288(11):1373-1381. doi:10.1001/jama.288.11.1373.
Klaus MH & Kennell JH. The doula: An essential ingredient of childbirth rediscovered. Acta Paediatr 1997;86:1034–1036.
McNiven, P., Hodnett, E., & O’Brien-Pallas, L.L. (1992). Supporting women in labor: A work sampling of the activities of labor and delivery nurses. BIRTH, 19:1, 3-8.
Tumblin, A. & Simkin, P. (2001) Pregnant Women’s Perceptions of Their Nurse’s Role During Labor and Delivery. Birth, 28:1, 52-56.
DOI: 10.1046/j.1523-536x.2001.00052.x

Certification Requirements for Birth Doulas Revised

Last week, DONA International announced revised requirements and documentation for birth doula certification.

“As we see changes in the maternity care environment and hear from our members on what they need to succeed as professional birth support providers, it is important that we make adjustments to our criteria and processes to ensure that doulas receive the necessary training and experience to be an effective doula while continuing to uphold the high standards for the profession that the CD(DONA) designation provides.” — Sunday Tortelli, President, DONA International Board of Directors

Birth doula certification by DONA International still involves hands-on and individual study including a workshop, childbirth education, breastfeeding education, and readings. Additional options have been added to several requirements to assist doulas in obtaining the education DONA International feels is necessary for professional labor support while offering greater flexibility to members. Newly added is the requirement to view a DONA approved business themed webinar so that certifying doulas also receive important training on managing their doula practice. Committing to DONA International’s Code of Ethics and Standards of Practice remains as does birth support experience. Certifying doulas must still submit evaluations for three births. Under the new requirements, only two evaluations per birth are required – one from the birthing person and one from an attending healthcare provider (doctor, midwife or nurse).

The new birth doula certification requirements for DONA International are outlined here (hat tip to Melissa Harley, Southeastern US Regional Director, DONA International, for the infographic):

DONA Birth Certification (1)View a larger version of this infographic here.

An overview of the new birth doula certification requirements can be found on the DONA International website with additional links to the reading list, etc. An updated suggested timeline and associated costs for birth doula certification is available as well.

For those already pursuing birth doula certification who have a DONA International birth doula certification packet purchased before October 21, 2015, no changes are necessary. However, doulas may choose to certify using the new options for the childbirth education requirement (using the new forms) and evaluations for births attended after 10/21/15 (also using the new instructions and forms).

A comparison of the previous and new requirements (again hat tip to Melissa Harley for the infographic):

Certification Changes Comparison (1)View a larger version of this infographic here.

Refer to your certification packet or contact with questions about birth doula certification with DONA International.


ACOG to OBs: Consider Operative Vaginal Delivery to Reduce Cesareans

The American Congress of Obstetrics and Gynecology (ACOG) issued an updated practice bulletin to their members supporting the use of operative vaginal delivery, which is birth using forceps or vacuum extraction, to reduce cesareans and improve outcomes.

The full practice bulletin was published in the November issue of the journal, Obstetrics and Gynecology, and is available to ACOG members and the media via their website.

Reducing the cesarean rate appears to be a major driver of this updated bulletin. In encouraging physicians to consider the use of forceps or vacuum extraction over a cesarean, the bulletin notes that operative vaginal delivery can often be accomplished faster than a cesarean and avoids the short and long term risks associated with surgical birth including hemorrhage, infection, prolonged healing time and increased costs. (1)

In the last 30 years, the rates of operative vaginal delivery have declined while cesarean rates have increased. Just 3.3% of all US births were operative vaginal deliveries in 2013, declining from 9.01% in 1992 “accounting for part of the increase in cesarean birth rates in the United States” according to the bulletin.

This updated practice bulletin states that only experienced care providers should utilize forceps and vacuum extraction and those care providers should have the ability to perform a cesarean should the operative vaginal delivery be unsuccessful.

ACOG has outlined the following prerequisites for operative vaginal delivery including:
• Cervix is fully dilated and retracted
• Membranes ruptured
• Head is engaged
• Head position has been determined
• Baby’s weight has been estimated
• The mother’s pelvis is considered adequate
• Adequate anesthesia has been provided
• The mother’s bladder has been emptied
• The mother has agreed to the procedure after being informed of the risks and benefits
• The doctor is willing to perform a trial of operative delivery, abandon the trial if unsuccessful and has a back-up plan in place

The bulletin provides additional recommendations related to operative vaginal delivery including:

• Routine episiotomy is NOT recommended with operative vaginal delivery. The document states, “There are no data to support the use of routine episiotomy with operative vaginal delivery.” The bulletin also cites poor healing, prolonged discomfort and risks of anal sphincter injury as reasons that routine episiotomy not be performed with the use of forceps or vacuum extraction.
• Use of forceps is more successful than use of vacuum extraction, but there is an increased risk of third- and fourth-degree perineal tears with the use of forceps.
• Specific situations are outlined in which each method of operative delivery may be more useful (forceps to rotate baby from occiput anterior to occiput posterior position).

ACOG notes that the outcomes of operative vaginal birth for both mother and child should be compared to cesarean birth since that is the clinical alternative.

Like many aspects of birth, the use of forceps or vacuum extraction cannot be planned for in advance. As we doulas support families during or after a birth where these interventions took place, it is important to keep in mind ACOG’s comparison to a cesarean in terms of recovery. While our client will have had a vaginal birth, her experience and physical and emotional healing are likely to be more similar to those who have birthed via a cesarean than a low intervention vaginal birth.


1. Operative vaginal delivery. Practice Bulletin No. 154. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;126:e56–65.



Updated Standards of Practice from DONA International

At their August meeting, the Board of Directors for DONA International approved revisions to the Standards of Practice for both birth and postpartum doulas. These documents, which all DONA International certified and member doulas agree to abide by, include the important definitions of our scope of practice. The primary changes to the Standards of Practice were made to section I.B. Limits to Practice.

Board of Directors President Sunday Tortelli, explains:

“The Standards of Practice were updated to clarify the scope of practice for doulas who are also trained in other modalities, such as lactation or aromatherapy. Many doulas are expanding their skills and offerings by receiving training and certification in complementary services. While this is wonderful in terms of the additional options available to families and the expansion of one’s services, it can create confusion on what is within the scope of practice for a doula. Our hope is that the revised documents help provide clarity for doulas, our clients and the community as a whole.” — Sunday Tortelli, President, Board of Directors, DONA International

The new Limits to Practice section of the Standards of Practice are as follows:

Birth Doulas

Limits to Practice.  DONA International Standards and Certification apply to emotional, physical and informational support only. The DONA certified or member doula does not perform clinical or medical tasks, such as taking blood pressure or temperature, fetal heart tone checks, vaginal examinations or postpartum clinical care. The DONA certified or member doula will not diagnose or treat in any modality.

  1. If the doula has qualifications in alternative or complementary modalities (such as an aromatherapist, childbirth educator, massage therapist, placenta encapsulator, etc.), s/he must make it very clear to her/his clients and others that those modalities are an additional service, outside of the doula’s scope of practice.
  2. A healthcare provider (such as a nurse, midwife, chiropractor, etc.) may not refer to her/himself as a doula while providing services outside of a doula’s scope of practice.
  3. On the other hand, if a health care, alternative care or complementary care professional chooses to limit her/his services to those provided by doulas, it is acceptable according to DONA International’s Standards of Practice for her/him to describe her/himself as a doula.

Postpartum Doulas

Limits to Practice. DONA International Standards and Certification apply to emotional, physical and educational support only. The DONA certified doula does not perform clinical or medical tasks, such as examining the mother or baby, or taking temperatures, blood pressure checks or any other type of postpartum clinical care. The DONA certified or member doula will not diagnose or treat in any modality.

  1. If the doula has qualifications in alternative or complementary modalities (such as aromatherapy, lactation, infant sleep, child development, etc.), s/he must make it very clear to her/his clients and others that those modalities are an additional service, outside of the doula’s scope of practice.
  2. A healthcare provider (such as a nurse, mental health professional, pediatric provider, etc.) may not refer to her/himself as a doula while providing services outside of a doula’s scope of practice.
  3. On the other hand, if a health care, alternative care or complementary care professional chooses to limit her/his services to those provided by doulas, it is acceptable according to DONA International’s Standards of Practice for her/him to describe her/himself as a doula.

Other changes were made to the documents as well to refer to requirements for certification rather than state them explicitly. This will help the Standards of Practice remain current should any requirements change.

The Standards of Practice documents are available on the DONA International website:

Birth doulas:

Postpartum doulas:

All DONA International member and certified doulas are also bound by our Code of Ethics, which was last updated in March 2015:

Code of Ethics for birth doulas:

Code of Ethics for postpartum doulas:

— Adrianne Gordon, CD(DONA), MBA

Celebrating Attachment Parenting Month: Parental Presence: Birthing Families, Strengthening Society

By Lysa Parker, CEIM

How Doulas Can Support Parental Presence

When I think about my own birth experiences over 30 years ago, I had no clue as to what a doula was or how important a doula could be in the trajectory of a family until I began reading the work of Marshall Klaus and John Kennell. I don’t think I was very “present” at my first birth because I was too busy fending off what I considered unnecessary childbirth interventions and advice. Everything I learned from that point on was through trial and error, doing my own research and finding my own tribe of like-minded mothers.

Fortunately, my son and daughter-in-law were able to hire a doula for the birth of my granddaughter two years ago, and we all felt it was an incredible experience.  What a difference doulas make in the lives of families! Doulas help take away the fear of the unknown and empower mothers and fathers in making informed decisions. When parents feel they have a trusted and knowledgeable advocate at their birth, it allows them to be present and focused on each other and the birth process that benefits the bonding process.

Parental presence is the theme of Attachment Parenting Month, sponsored by Attachment Parenting International, a nonprofit organization I cofounded with Barbara Nicholson, over 20 years ago. Being “present” can mean a lot of different things to a lot of different people, but in our world of pregnancy, childbirth and parenting (and grandparenting) we see it as a continuum, a life practice and our life’s journey.

How can you as a doula help parents become more conscious and present in their children’s lives? The way we see it, doulas are pivotal in this role because they have established a relationship of trust with the parents. You are their “sherpas” or guides for the magnificent parenting expedition they are embarking on, where they can discover more about themselves than they ever thought possible.

Your role doesn’t necessarily end with the birth of the child. You can help prepare and guide parents to seek out trusted resources to help them nurture their parent-child relationships; strong loving, connected relationships that will truly make a difference not only in their families but in society as a whole. We at API believe that attachment parenting is a natural progression for the parents you serve, and we want to work with you as a trusted resource that cares about families and nurturing children for a more compassionate world.

About Attachment Parenting

All the discussion and controversies that have surrounded attachment parenting (AP) through the years are many; what it is and what it isn’t seems to overlook what underlies the reasons why parents are attracted to or choose to practice AP. At the heart of practicing AP is the process of learning to become attuned to our children and to one another, to listen with our whole hearts, to be more respectful and empathic, to communicate in a more loving way. We are asking parents to be emotionally present in their children’s lives. Sounds easy until we realize how difficult it can be when we often can’t even be present to our own emotions and needs in this chaotic, disconnected world we live in.  Dr. Gabor Maté once said, “We can only be as attuned to our children as we are to ourselves.” When we talk about being “present” with our children, our spouse, or others, it most definitely becomes an inside job.

One of the key points we discuss in our book, Attached at the Heart, has to do with reflecting on our own childhood experiences before or during pregnancy. We tend to parent our children the way we were raised, and that often involves overreacting, yelling and spanking because we don’t understand child development, which colors our perceptions and expectations of children. To learn to be present with our children requires new tools and new understandings to help us be more conscious and calmer in our interactions. Our book goes into depth on the comprehensive new science that supports API’s Eight Guiding Principles of Parenting, such as “prepare for pregnancy, birth and parenting” and “responded with sensitivity” (Check out all of API’s Eight Guiding Principles of Parenting!) that we believe strengthens the attachment relationship and supports the optimal emotional development of children.

We invite you to learn more about AP and about API at

Lysa ParkerLysa Parker is the cofounder of Attachment Parenting International. She received both her bachelor’s in education and her master’s degree in Human Environmental Sciences specializing in human development and family studies. She earned her designation of Certified Family Life Educator (CFLE) from the National Council on Family Relations in 2004 and was the 2014 president for the Southeast Council on Family Relations. Lysa is also a Certified Educator of Infant Massage (CEIM).

She is the coauthor of Attached at the Heart: Eight Proven Parenting Principles for Raising Connected and Compassionate Children (HCI, 2013) and the co-developer of a new curriculum based on her book. The first edition of Attached at the Heart won the 2009 Book of the Year Gold Award from Foreword Magazine. She is a frequent guest on national, international, and local radio and TV programs. Currently Lysa is a writer, speaker and parenting consultant in private practice at  She is the mother of two grown sons and a stepdaughter and is the grandmother of three grandchildren. She lives with her husband in the Huntsville, Alabama area.

Breastsleeping – New word, Old concept

Changing the Conversation On Infant Sleep to Keep Babies Safe

For many in the birth community, the name James J. McKenna is well recognized. An anthropologist, Dr. McKenna has served as the Director of the Notre Dame Mother-Baby Behavioral Sleep Laboratory since 1994. He is a world renowned expert on infant sleep and the protective role breastfeeding plays in sleep safety. McKenna has long been an advocate of co-sleeping or bedsharing, where mothers and infants sleep together. He has contributed to much of what we know about the nocturnal behaviors and physiology of mother-baby dyads. Dr. McKenna has recently published a commentary along with Notre Dame colleague Dr. Lee Gettler in the peer-reviewed European journal Acta Paediatrica. In it, they propose a new term for co-sleeping nursing families — breastsleeping. As he explains in the commentary:

“There is no such thing as infant sleep, there is no such thing as breastfeeding, there is only breastsleeping.”


For mothers who have had babies who spent most of the night at the breast – nursing, sleeping then nursing again without seeming to fully wake – the term is likely to elicit a wry smile (myself included!). McKenna and Lee are quite serious, though, and the point is well taken. We cannot talk about sleep without talking about breastfeeding and we cannot talk about breastfeeding without talking about sleep. To separate the two topics would be to ignore half the conversation. Babies need to be nursed both day and night. Mothers and babies need sleep. Ergo, breastsleeping.

Research, including studies led by McKenna at the Mother-Baby Behavioral Sleep Laboratory, demonstrates that the sleep patterns of breastsleeping mother-baby pairs are unique and appear to be protective of Sudden Infant Death Syndrome (SIDS). Breastleeping babies show lighter sleep, arouse more often and nurse more than those who sleep alone. Breastfeeding alone is also protective of SIDS and McKenna states that the more a baby is nursed, the higher the protective factor. Mothers who breastsleep “exhibit impressive behavioral sensitivities to their infants’ presence and behavior even while in deeper stages of sleep.” (Source:

Expanding the Conversation on Co-Sleeping, SIDS & Breastfeeding

Yet, families are discouraged from co-sleeping with their infants. As recently as July 2014, the American Academy of Pediatrics issued a statement entitled, Bed Sharing Remains Greatest Risk Factor for Sleep Related Infant Deaths. So-called “Safe to Sleep” public health education campaigns worldwide also recommend against all forms of bedsharing regardless of feeding method. McKenna and Gettler suggest the concept and terminology of breastsleeping as a response to such positions and campaigns saying they can lead to mothers sleeping with their babies on sofas or in recliners, which is more dangerous than bedsharing. The researchers also note that separate sleeping arrangements can undermine breastfeeding and reduce its protective factor against SIDS.

McKenna and Gettler have been working to change the conversation about co-sleeping for some time. In 2010, the anthropologists authored a paper entitled, “Never Sleep with Baby? Or Keep Me Close But Keep Me Safe: Eliminating Inappropriate ‘Safe Infant Sleep’ Rhetoric in the United States” available here. In it, they note that while few mothers intend to bedshare (15% in one study and 16% in another), most end up doing so after baby arrives (65% and 84%). It would appear then, that information on how to breastsleep safely rather than telling parents to never sleep with their baby would help keep babies safer, McKenna and Gettler point out.

However, the “babies should sleep alone” message is so pervasive, they say, that families are not receiving critical information on how to co-sleep safely (i.e. in a bed without other children, a heavy duvet or gaps between the mattress and headboard) and the risk factors that make co-sleeping unsafe ,such as smoking during pregnancy. The study released by the American Academy of Pediatrics referenced in their statement defined bedsharing as sleeping on the same surface with a person or animal. Feeding method was not considered. McKenna believes that both feeding method and the specific location the adult-infant pair are sleeping (i.e. a bed versus a recliner) are key distinctions that should be made when educating parents on safe sleep. In addition, the AAP study noted that for older infants, lying prone and having objects nearby such as stuffed animals or blankets, were the greatest risk factors for SIDS and not bedsharing. This indicates that additional education on hazards, such as pillows, blankets and stuffed animals is needed regardless of where babies sleep.

In this video, McKenna explains why co-sleeping, when done safely, protects babies from SIDS and the information parents should have, but are not receiving, about safe co-sleeping. While released prior to the establishment of the term breastsleeping, it’s still a valuable resource for doulas and the families we serve about safe sleep:

Source Links:

10 Ways Doulas Support Baby Safety

characters-696951_1280September is Baby Safety Month, an opportunity to raise awareness and resources for safety of newborns and infants. What role do doulas play in baby safety? We are support professionals, of course, and not medical or emotional health professionals, safety inspectors or social workers. Doulas have an important role in providing evidence based information to families and as a source of referrals when needed for a variety of areas including those related to infant safety. Here are some areas where doulas support the safety of babies in the course of our relationship with clients:

Before Birth

In the course of prenatal visits with client families, birth doulas may touch on a number of topics related to baby safety without even realizing it:

  • Car seats: Many doulas provide families with resources to ensure their car seats are properly installed or comply with expiration date rules. In some cases doulas connect a family with area services to obtain a car seat, a major contribution to baby safety!
  • Home preparation: While doulas are not home safety experts, we do sometimes find ourselves helping families think through how they will keep their newborn safe around family pets, family members who smoke, woodstoves or fireplaces and the like. Often simply asking questions prompts families to address these safety concerns on their own.
  • Postpartum support planning: Assisting clients in creating a plan for postpartum support for emotional needs, meals, and child care is a common aspect of doula services. We know support is crucial for the overall wellbeing of new mothers and given their role as caretakers of babies, a healthy and supported mom goes a long way to support the safety of a baby.
  • Perinatal Mood and Anxiety Disorders: Opening a dialogue with parents about what is normal to feel and see in one another after a new baby versus what is not can help with early detection of postpartum mood and anxiety disorders. Encouraging families to have a plan of action – how they will address concerns around mood or anxiety and who they will contact for support or intervention is also appropriate for doulas. Resources such as support groups, information on signs and symptoms from reputable sources and therapists can be provided as well to ensure families have the tools they need to address postpartum mood disorders should they arise.

After Birth

Postpartum doulas have a significant opportunity to impact infant safety in the course of supporting new families. Being in the home with the family provides important insight into how the family is coping and where additional support is needed. Postpartum doulas use education, demonstration, active listening, observation and referrals to support baby safety while supporting client families. Birth doulas may also address these topics in postpartum visits.

Family Adjustment & Parenting
A new baby is a big adjustment for a family! Postpartum doulas plan an important role in observing how the family is coping and providing appropriate education or referrals on:

  • Soothing techniques and normal newborn behavior: Helping parents expand their techniques and resources for soothing their baby often begins by increasing their understanding of newborn behavior needs and communication. In addition to improving bonding between parents and their baby, increased knowledge of newborn sleeping and feeding cycles as well as ways to soothe baby can go a long way to reduce the chances of Shaken Baby Syndrome. Support in this area can include recommending area support groups, books, articles or videos as well as demonstrating swaddling or other techniques.
  • Perinatal Mood and Anxiety Disorders: Postpartum doulas use their training, observations and referral network to help connect families to professional mental health services when needed. Education on normal thoughts, moods and emotions in response to physical and hormonal changes while sleep deprived and caring for a new baby can go far to help families know when to seek additional support even after postpartum doula support ends. Introduction to support groups and evidence based information are also key methods of support.

Using evidence based practices for safe sleep reduces the incidence of Sudden Infant Death Syndrome and Sudden Unexplained Infant Death.

  • Sleep safety: Doulas often share information about baby positioning and hazards, such as loose bedding, from evidence based sources. Families may have had one plan for where baby would sleep, but in adjusting to their new addition may be practicing something entirely different. Postpartum doulas can play a valuable role in helping parents adjust their sleep plan safely.
  • Breastsleeping: For families that are nursing, it’s impossible to talk about sleep and not discuss breastfeeding. Dr. James McKenna, Director of the Notre Dame’s Mother-Baby Behavioral Sleep Laboratory, recently published a commentary proclaiming, “There is no such thing as infant sleep, there is no such thing as breastfeeding, there is only breastsleeping.” Not only is bedsharing while breastfeeding convenient for both mother and baby, it increases the frequency of feedings and has been shown to increase sleep safety. There are, of course, important safety considerations for breastsleeping families to know and postpartum doulas can and do share evidence based information with clients.

Baby Gear

  • Recalls and expirations: Families planning to use a crib handed-down from a family member may not be aware of newer regulations on slat spacing or that the car seat passed on to them may have expired. While our role as doulas is not to police such things, sharing websites and articles on evaluating the safety of baby gear is very much in line with providing informational support.
  • Babywearing: Whether it’s helping new parents figure out their wrap or sharing articles on wearing newborns to ensure adequate neck support, doulas are often asked to contribute to safe babywearing through assistance and demonstration.

What other topics related to baby safety do you find yourself contributing to while supporting families as a doula? Share in the comments or in The DONA International Facebook group.

— Adrianne Gordon, MBA, CD(DONA)