UBC Undergraduate Research

Interprofessional doula project Cameron, Tessa; Chung, Mina; Farr, Marcelle; Grebneva, Irina; Grimson, Karly; Lin, Katie 2011

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Interprofessional Doula Project Student Project Members: Tessa Cameron, Mina Chung, Marcelle Farr, Irina Grebneva, Karly Grimson and Katie Lin, University of British Columbia School of Nursing Practice Partners: Dr. Wendy Hall, UBC Academic Faculty; and Lehe Elarar, Registered Midwife at BC Women’s Hospital and Interprofessional Doula Seminar Facilitator Project Context Background Weekly Interprofessional Seminars Doula Support Mini Education Sessions on Fir Square Key Lessons Applications and Next Steps We were fortunate to be part of the Interprofessional Doula Seminar for our synthesis project. The Interprofessional Doula Seminar is an initiative of the Collaboration for Maternal and Newborn Health, an organization of interprofessional maternity care providers whose goal is to increase communication and interdisciplinary practice between all maternity care providers in order to improve health outcomes for expecting mothers and their infants. The doula synthesis project involves participation in weekly seminars, which bring together nursing, midwifery, and medical students to learn doula skills, and to discuss topics relevant to caring for women with addictions. As interprofessional teams, we provide doula support to women who are pregnant and using substances on the Fir Square Unit at B.C. Women's Hospital. The doula project also involves marketing the doula services by creating three brief educational sessions for the women on Fir Square. The objectives of our synthesis project are: 1. To provide labour support 2. To engage in interprofessional education 3. To enhance women's knowledge regarding doula support Student testimonials of the Interprofessional Doula Project: “This comprehensive program gave me a unique opportunity to work with students from other disciplines who shared my passion of maternity care and my concerns about societal inequities in health care delivery.” “I learned so much from the process of working with and learning alongside students from other professional disciplines.” “I learned so much about how my interprofessional colleagues think, gained a clearer perspective on the needs of marginalized mothers, and was honoured to share in the pregnancy and births of the Fir Square clients.” "I am not sure who taught me more - the wonderful presenters, the passionate doulas, or the women we supported. Being part of the doula synthesis project was a fantastic experience!” Fir Square is the first and only unit in Canada, and the second in the world, to care for women dealing with substance use and their newborns in a single unit (PHSA, 2010). Typically infants of substance using mothers are removed from their mothers in anticipation of withdrawal symptoms, and placed in a quiet room with no stimulation (PHSA, 2010). This practice is contrary to the best practice that maternity care centres have followed since the early 1940s of newborns rooming in with their mothers (Temkin, 2002). Fir Square challenges and reorients the standard approach to maternity care for women with addictions and is based upon a harm reduction model of care. Recent research has shown positive outcomes of mother-infant dyads on Fir Square; specifically, the research indicates decreased neonatal intensive care unit admissions and length of stay for term infants, increased likelihood of breastfeeding during the hospital stay, and increased odds of the baby being discharged home with the mother (Abrahams et al., 2010). Technological advances in obstetrics and transition to maternity care in hospital has shifted the birth experience from being a normal, home-based event to an illness-oriented, hospital-based procedure (McCool & Simeone, 2002). In addition to addressing interprofessional education, the doula project also addresses the medicalization of current birthing practices by attending to the emotional and physical needs of labouring women in a holistic approach. Once a week we gathered at Women’s Hospital to discuss client contacts and doula related issues, share birth stories, and hear from presenters on various topics related to maternity care and interprofessional teamwork. Our first four sessions focused on orientation and doula skills education. The following sessions were presented by community activists, care providers, and researchers regarding important issues marginalized women face. Some of the presentations included: Dr. Michael Klein – Attitudes of Maternity Care Practitioners Towards Labour and Birth BCCDC Street Nurses – Drugs, Users, and Outreach Nursing Dr. Wendy Hall – Interprofessional Teamwork Dr. Ron Abrahams – Caring for Women with Substance Use and their Babies Dulce Aparicio Feder, RN – HIV and Pregnancy Through sharing our viewpoints in our weekly seminar discussions, as well as through the process of working with each other in a non- hierarchical team, we gained insight into each other’s professional drivers and constraints, and gained confidence in our ability to communicate and work together. In teams of three or four we provided doula support to women on the Fir Square unit. This included prenatal visits, continuous support through labour and birth, and postpartum care. We have had eight referrals from Fir Square so far, and hope to support more women as the project continues. Each woman we support has unique needs. We have provided information about pregnancy, labour, and birth, given massages and applied cool packs to women in labour, helped control a woman’s own birth environment, and aided with breastfeeding and newborn care. Please ask us to share some of our doula stories! In an effort to promote awareness of the Doula Support Teams, we wanted to create relevant mini education sessions on maternity related topics to present to the women on Fir Square. To meet this goal we created a brief handwritten survey for the Fir Square women to fill out regarding what topics might be most interesting to them. We also created on online survey for the care providers of women on Fir, and invited physicians, midwives, nurses, our practice leaders, and the doulas to respond. We asked the same question as to what topics might be most beneficial for the women on Fir, as well as questions assessing their thoughts on doula care and if it would benefit women. We felt it was important to ask these questions to learn more about the buy-in of our stakeholders. Six women replied, and twelve care providers. Based on their feedback, we selected the top three perinatal topics: discomfort in labour, relaxation in labour, and positioning in labour and birth, to present. All three mini educational sessions were brief and informal. All sessions covered the role of a doula, and the types of support the Doula Teams could provide, in addition to the session’s topic. Women were encouraged to speak to their nurse about a doula referral, or speak to us directly after the presentation. “A doula provides continuous care from the prenatal to the postpartum period. She can provide emotional support, reassurance and physical comfort measures to the labouring woman. She can assist partners or family members to participate in ways that help labouring women. Doulas can also provide information to help decision making” (Doula presenters) Mini Education Sessions on Fir Square 3. January Session - Positioning during Labour and Birth (Mina & Marcelle) Using different positions during labour has a number of benefits.  It can: •    Aid in the progression of labour by increasing the efficacy of contractions (upright and lateral positions) (Roberts,1984, as cited in Lawrence, Lewis, Hofmeyf, Dowswell and Styles, 2009) •    Increase a woman’s sense of control during labour (Albers, 1997, as cited in Lawrence et al., 2009) •    Increase the level of comfort experienced by the laboring women •    Provide a source of distraction for the laboring woman •    Decrease women’s need for pharmacologic analgesia during labour (Simkin & O’Hara, 2002) We prepared a presentation on positions that were helpful to use in various stages of labour (see pictures below). • Can ease pain of contractions • Help to speed your labour • Gravity helps the baby to move down into the pelvis • Upright position, allows gravity to assist • Promotes relaxation, allows you to rest • Source of support and stability • Takes pressure off your back • Increases diameter of pelvic outlet • Encourage descent of baby into pelvis • Protects the perineum • Gravity neutral • A break from intensity of contractions • Turning a posterior baby • Good position for counterpressure Through the mini-education sessions on Fir we were able to market our doula services, as well as gain insight into the lives of the women on Fir. Many of the seminars progressed into a general discussion about doulas, pregnancy, labour and birth with the women present. Being present on the unit and open to conversation with the women was very successful in soliciting new referrals, and building relationships with both the clients of Fir Square, as well as the staff. Focus on building relationships on Fir Square Plan regular drop-in sessions with the women on the unit Fewer “appointments” and more “availability” Plan around the needs of both the staff team and the clients on Fir Square Find meaningful ways to provide doula care for clients during antenatal and postpartum periods Increase visibility of doulas on Fir Square Plan regular drop-in sessions to establish a “doula presence” on Fir Square Post a current photo of the interprofessional doula team on the unit Continue educational sessions to foster connections Continue offering informal, mini-educational sessions as a flexible component of the doula drop-in sessions Consider developing several plans for the mini-educational sessions to available for incoming interprofessional doula teams (topics could include: pain management during labour, labouring positions, infant feeding, comfort measures for labour, community resources) Ensure language of mini-educational sessions is appropriate and accessible Continue to offer the women living on Fir Square opportunities to voice their topic preferences for the mini-educational sessions Be flexible! Plan to extend Interprofessional Doula Group work with women who are involved with Sheway Speak up for the role of the nursing profession in interprofessional maternity care! Overview and Outcomes of the Project 1. November Session - Coping with Discomfort  (Karly & Katie) Some of the non-pharmalogical methods that we discussed for coping with the discomfort in labour included: •    Immersion in water-the natural healing properties of water, may acclerate labour, increase the mothers control over the environment and result in less perineal trauma and interventions (Enkin, 2000) •    Transcutaneous electrical nerve stimulation (TENS)-a low voltage electric current that transmits to the skin, resulting in a tingling sensation. The labouring woman is in control of the intensity of the sensation (Enkin, 2000) •    Counter Pressure: using a steady strong force of pressure applied to the lower back during a contraction, or using both hands applying pressure of each side of the hips (double hip squeeze) (Simkin, 2002). 2. December Session - Relaxation during Labour (Tessa & Irina) The discomfort of labour can be intense, with anxiety and fear making it worse. Relaxation is fundamental to a comfortable birth experience, as it calms the mother, softens her muscles, and allows for an easier descent of the baby (Gaskin, 2003). Research has shown that relaxation techniques may decrease pain and help create a positive birth experience for the mother (Tournaire & Theau-Yonneau, 2007). We discussed many possible ways to relax in labour, and provided some demonstrations of the following: •    Aromatherapy                                   •    Hydrotherapy •    Music •    Heat or cool packs •    Lighting                                             •    Massage • Interprofessional collaboration is essential to high quality maternity care and the interprofessional education programs should become part of clinical and academic learning • Doulas are essential part of maternity care teams! • Critical reflection on our own beliefs and values around addiction and pregnancy is crucial • Don’t allow our expectations and assumptions about the care pregnant women with substance abuse should have to muffle their voices: listen without judgment, build up their trust, be protective of their space • Use evidence based research results to dispel stigma around pregnancy and substance abuse to promote social justice • See the women as capable and whole, as the equal partners in their care, not as the ones that are needed to be “saved” or “rescued” • Small acts such as wiping a woman’s face with a cool wash cloth and touching her hand can become powerful and real vehicles by which we, as doulas, can convey that we see her not as a tainted or discounted person but as a whole person deserving excellent maternity care 6 1 3 5 3


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