Being on Hyper-alert: the observations of a doula

AIMS Journal, 2023, Vol 35, No 2

By Grace Hall

Last month, I joined a mother for her appointment with a Consultant Midwife to discuss her suitability to have a home birth. The mother, I changed her name to Elise to honour her privacy, a highly accomplished professional, sought my support as a doula because she was concerned about all the aspects of her transition into motherhood, a journey that she and I consider as an important rite of passage.

What made me reflect about Elise is that, when I was listening to her, I could see a mental movie in my mind of all the births I have attended – including the ones of my own children. Watching this ‘movie’ made me wonder, yet again, about how I can facilitate this passage in the most honourable way; a way that will capacitate her to meet the challenges of becoming a mother.

Doulas are not here to solve women’s inner discomforts for them. This could be undermining and may render women less able to recognise, understand and respond to personal triggers, which, in turn, could lead to lost opportunities for personal growth at this time in their lives. As birth workers we are simply meant to hold the physical, emotional and energetical space^[1] for birthing people to go through their rite of passage and to transcend it in a way that will support them with all the challenges parenting brings. However, this is hard for us to do in the hospital setting.

To emerge from the birth experience feeling it has been transcendental^[2] - perhaps feeling stronger, wiser and better-equipped - a positive birthing experience (however challenging) is an important step. To achieve that, the ability to relax or to ‘let go’ to the natural forces at play, is vital.

However, how can the mother let go if she is constantly being prodded and examined by people searching for any and every potential issue? How can she let go if she is constantly being offered old and new solutions that have not even been proven to be effective but are often just based on subjective opinion and policies shaped by the medical mindset?

Family Physician Dr Sarah Buckley and Obstetrician Michel Odent have been campaigning for decades about the importance of guarding the space of a birthing woman, just as it is for any other mammal, as any perceived threat will hinder the process of labour and birth. They explain how an unfamiliar territory and other disturbances during birth puts the mother on hyper-alert and this skews the balance between oxytocin (the hormone that fuels every single uterine movement that will birth the baby) and adrenaline (the hormone that reduces oxygen in the womb by increasing blood flow to our limbs and vital organs for the fight, flight or freeze response). This has the effect of slowing, and at times, stopping labour all together.

So, how can doulas help guard the birth space in a way that enables the mother to let go?? This is a question I asked myself as I saw that very fast mental movie and as I listened to the Consultant Midwife explain to Elise the risks of having a homebirth with low haemoglobin levels. During the explanation very few benefits of giving birth at hospital or at home were given. There was a fixation on the risks.

This is what I see every time; a fixation on the risks. The mother is worried into a state of hyper-alertness but left without clear evidence-based information about the advantages of any proposed action. For example, I heard a homebirth mother being told in the transition stage of labour, when she was almost ready to birth her baby, that her baby had opened his bowels and it was important to transfer to hospital ‘now’. This was despite the mother's and baby’s vital signs showing they were both in great condition. This mother had a major haemorrhage after the birth, very probably because she was in a state of hyper-alertness.^[3]

I see this too often. I witnessed a black mother being told that she should make the 40 minute journey into hospital sooner than she had wished, because her contractions were coming every five minutes and she might not get there on time otherwise. She left the safety and calm of her home only to be told that, according to hospital policy, she was not dilated enough to be admitted. This mother panicked and went into the hyper-alert state birthing her baby not long afterwards, standing up by the door. This led to complications that required her to have major life saving surgery immediately after the birth of her baby.

I feel there is a commonality here whereby many of the procedures and policies that are meant to guard and protect the mother and her baby are actually causing these complications.^[4] The continuous monitoring that puts mothers into the hyper-alert state every time they move and baby’s heart rate is not picked up by CTG machines; the induction for postdates without any other clinical indication but just in case (with about half of these procedures ending up in instrumental birth or caesarean section); the sweeps; the prophylactic antibiotics; and the active management of each and every step of labour; all of these have implications that quite often lead the mother further and further away from the peaceful, calm birth they had imagined.

These procedures, these modern but often unproven ‘rites of protection’, can indeed save lives when there is time to know the pregnant person and understand their health and emotional particularities in advance. I have seen appropriate medical support working so well. Mothers birthing in hospital, birthing centres and at home, being listened to and heard. Birthing practitioners collaborating with birthing people to provide tailored solutions for health issues that could impact labour, birth or the health of mothers and babies. But medical procedures applied routinely by people the mother is meeting for the first time, especially when fear is used to gain compliance, take her out of her calm birthing zone and even further down the medical route.

By contrast, I remember a homebirth mother whose placenta was not born until three hours after the birth of the baby. The midwives called the hospital and then explained to the mother that their shift had just finished and that they could not continue to support her at home. They said that she would need to be transferred to hospital for the birth of the placenta. Instead, the mother and I went into the bathroom and closed the door. Unwatched and private, able to relax and let go in her bathroom with the familiar aromas, warmth, silence and physical contact with her baby and partner, the placenta came away immediately.

I wish you could hear about the home birth mother I supported recently. She was so deeply into her zone that there was not even enough time to call me. I have seen a few of these now. Women who simply trust the natural rhythms of their body; the natural rhythms of labour. Without any conscious thought, they allow their instinctive movements to make extra room for the babies as they travel from the womb out into the world. They talk to their babies and I imagine the babies listening to their mother’s voices humming through the uterine waves. When the mother’s birth space is adequately protected, mothers simply get on with it. They wait, they walk, they cry and laugh, they lose hope and they find their second wind. Then they give birth to their babies and feel elated. Birth is beautiful when women feel completely supported and are able to make space for themselves and their babies.

Working with many women over the last few years, I have also had to face my own challenges. Challenges of the romanticisation of motherhood and of taking total responsibility for looking after myself before seeking external answers. I had to come to understand that a medical practitioner’s uniform does not automatically equal compassion, common sense, competence or integrative knowledge. Medical practitioners may know about medicine, but labour and birth goes beyond that – it digs into the depths of the mother in places she never imagined. Undisturbed birth is truly magnificent to see.

I also see, and I feel on my skin, both sides of the perception of medical practitioners and of the families that I supported.

Many midwives and doctors welcome the presence of a doula as an advocate, space holder and pregnant person’s support. They cheer us, and appear to sometimes even wish that they could share our role and our experience - that they could share in using the encouraging words that we say, the dim lights, projectors, smells and visual prompts that change the environment to a safe haven - that they had time to offer massage and drinks and to never ever move away from the birthing person’s side.

Conversely, there are other midwives and doctors who feel undermined even before we doulas open our mouths. Now they feel that there are keen eyes looking at what they are doing, and at how or if consent is being gained. When questions to the midwife or doctor are not answered clearly or objectively, parents seek contact with our eyes to understand what they are being told. We are their continuity of carer; they turn to us. Sometimes parents tell me after the birth that they felt too scared to even put their questions to the midwife or doctor, and then ashamed that they did not. This atmosphere of mutual unease and distrust leaves the mother in that state of hyper-alertness that is so bad for her.

I feel that supporting other mothers like me is my life-mission, but when they start their labour from this place of hyper-alertness, things often end in a way they would have hoped to avoid. For me as the doula, I am bound to the parent’s journey – always respecting their will and bringing calm to the environment. But in the medical birth setting this is increasingly hard to do. Nevertheless, my role is to support the birthing person’s autonomy as they go through their rite of passage solving their internal dilemmas independently, never alone, but with sovereignty so they can continue to do the same as parents.

Author Bio: Grace Hall is a mother, Hypnobirthing educator, holistic doula, complementary therapist and ceremonialist, supporting women to reclaim their autonomy as they enter motherhood. Grace believes that she has inherited her deep calling to this work from her paternal grandmother and great grandmother, both of whom were traditional midwives in Brazil.