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This is an exploration of Emotions, particularly the emotions we know as Love and Fear, and I want to look at them in connection with my experience as a doula and my understanding of the birth process.

A doula is a birth-partner.  The word doula comes from the ancient Greek, meaning female slave, but it is also referred to as “mothering the mother” and was introduced after randomised control trials in Guatemala in which paediatricians studied the effects of partnering the mother in labour and discovered that this resulted in childbirths that were easier and required less intervention.  

A doula is specifically present for the mother, and is not directly concerned with the baby.  Her presence is less about doing and more about being because it is how a doula is present in labour that determines whether or not she is a force for good. In this presentation I will be looking at the doula’s involvement with birthing emotions and why these are important.

I owe much of what I understand about doulaing to my training with the obstetrician and pioneer of water births, Michel Odent.

In thinking about childbirth it isn’t really possible to comprehensively establish what a “normal” or “natural” labour consists in because cultural connotations and conditioning are very strong, and cultural definitions are not universal. Physiology on the other hand, provides a cross-cultural reference point. This, together with maternal intuition and experience, provide a sound basis for exploring the optimal conditions for childbirth.

In spite of the problem of establishing exactly what constitutes “natural” in terms of labour and childbirth, I take a “normal” labour to be one which results in the delivery of a baby without death or injury to either mother or child as a result of the birth, and in which there is no necessity for medical intervention.  It may or may not also be a “natural” birth.  In spite of the increased medicalization of childbirth, many births remain normal in this sense. I am concerned here with the optimisation of a normal birth.

A helpful way to look at birth physiology is from the perspective of the hormones.  Michel Odent describes the labour process as a drama played out between two essential hormones: Oxytocin and Adrenalin.  Now there is more to labour than hormones, and there are more than two hormones involved in labour.  However these hormones are associated with the extreme poles of an emotional continuum within which other hormones also play a part.

Oxytocin, the best known of these hormones, is released in pulses from the hypothalamus.  It is crucial to reproduction and mediates the ejection reflexes that occur during sexual activity, which include birth and placental ejection, and the milk let-down reflex in breastfeeding.  Oxytocin is commonly referred to as the hormone of love because it accompanies every facet of that emotion.  Optimally oxytocin secretions increase during labour and subside only after delivery of the placenta.

While oxytocin, and the emotion of love with which it is associated are my main concern, I want to briefly mention the other main birth hormones.

These include naturally occurring opiates, the beta-endorphins which help transmute pain and are associated with an altered state of consciousness that characterises an undisturbed birth.  Beta-endorphins facilitate the release of prolactin, but they are also stress hormones and in high levels they inhibit oxytocin release.  So while extremely important their role is not straightforward and their production at appropriate levels during labour impacts on other hormonal systems and the progression and experience of labour.

Prolactin, also regarded as the mothering hormone, is necessary for lactation – levels are high during pregnancy, decrease in labour and peak at birth.  It is a hormone of submission, surrender and nurturing and associated with a mother’s fierce protection of her newborn offspring.

Finally, and very importantly adrenaline and noradrenaline – the fight or flight hormones - have a role to play in labour.  These are associated with excitement/fear and vigilance.  They can also disrupt labour if they appear too early.

When fear is present in early labour and these hormones levels rise, they inhibit the production of oxytocin and slow down or stop labour.  For mammals birthing in the wild there is an obvious survival benefit to this, but for humans in a home or hospital environment this has a detrimental effect.

In an undisturbed labour, when birth is imminent, these same hormones, associated with excitement, act in a different way, providing the necessary energy in both mother and child for the stressful event of  birth, and activating the ejection reflex.  After the birth, the mother is very sensitive to temperature, and if she is kept warm, the levels of adrenaline drop quickly, so facilitating oxytocin production, the ejection of the placenta and reducing the likelihood of post-partum haemorrhage.  High adrenaline levels in the baby at birth mean that a baby is wide-eyed and alert and ready to bond with its mother with all the neo-natal developmental processes that that initiates.

These then are the main hormonal players in the drama of childbirth, and oxytocin seems to have the starring role.  But hormones, while to some extent correlating with the emotions we know as Love, Fear, Ecstasy etc, are not identical with these emotions.

I have referred to undisturbed labour and what may happen optimally.  However, few human births are undisturbed.  Not only are there deeply entrenched and various cultural conditions that interfere with the process, but also the increasing medicalization and industrialisation of childbirth practices in the past 100 years, now make it very hard to establish the optimal conditions for childbirth.

We know from the observation of other mammals and from experience, that oxytocin is a shy hormone.  This means that it is optimally produced when the mother is undisturbed, feels safe and is unobserved.  The very socialised conditions of contemporary childbirth arrangements are far from optimal.  The hospital environment with its constant monitoring and intermittent and intrusive observation are not incidental to the interventions that often occur there – they in large measure create the perceived and sometimes real needs for intervention. No other mammal would voluntarily change its environment during labour except in extremis, but hospital births entail this.  It is not surprising that labour so often slows down or stops as a result of such an unsettling event.

If labour slows down and oxytocin levels are reduced, the hormone is often introduced intravenously to speed things up.  Oxytocin introduced in this way works differently – it does not cross the blood-brain barrier and it does not harmonise with the dynamic rhythms of mother and baby.  Labour ceases to be the co-creative melodious and rhythmic interaction of mother and baby enacting a life process together, and becomes fragmented and incongruent.  The birth may proceed effectively but much of the affect will have been lost – this has huge and ongoing implications for both mother and child in their developing relationships with each other in the lived world.

While childbirth can be seen as a hormonal process, it is more than this.  It is also a life process – in fact it is a pivotal episode of life in process.  Labour and childbirth are important events for both mother and baby, but they are not totally discrete processes entirely separable from the pre-natal and neo-natal developmental periods that they bridge.  Hormonal acitivity neither commences with the onset of labour nor ceases at birth, it merely changes so as to facilitate a particular event at a particular time within the larger process in which both mother and child have been tightly coupled, and initiates the commencement of a new phase within that relationship. I suggest that life in process is intrinsically emotional, sub-personal and transpersonal as well as personal, and using  examples from experience, I’d like to show what the presence of a doula may bring to the process. 

One of the first births I attended, before I had encountered Michel Odent, was for a friend of mine having a first baby at home.  Her husband and I were both with her when the midwife arrived.  The mother wanted reassuring that everything was going ok.  The midwife just said – you’re fine, you’re having a baby, carry on – and she retreated into the kitchen.  She re-appeared occasionally to monitor the baby with an ear trumpet but kept a very low profile.  Later, when the mother was well progressed in her labour she asked if she’d know when to push, the midwife said – you’ll know.  And later, when the baby was born the midwife left the mother, father and baby warmly wrapped up, but on their own, for a considerable time before cutting the cord.  I was surprised at the time that she felt so able to do so little and to remain so unobtusive.  It was a very peaceful birth, and I realise now that the midwife’s skill lay in her ability to observe and to remain vigilant but without intruding and to provide a reassuring but largely passive presence which was beneficial to both mother and baby.

In this next example I was attending a second birth.  The first birth had been at home and resulted in a healthy delivery after a long, but normal labour.   

The mother called me during the night to say she was in labour, and asked me to come over.  When I arrived at her house she was relaxed, she was talking calmly and lucidly, her husband was with her and she said to me “I’m not mooing yet”.  I understood that she was in early labour – still very much in her normal conscious state and able to talk easily – the reference to mooing made sense to me as the possibility of speaking in everyday language once the endorphins and oxytocin levels rise becomes much less possible.

When her husband returned with a drink for me, she suggested that he get some sleep before their toddler woke up.  She and I were left alone.  I didn’t touch her. I didn’t talk to her – but I was present for her. She was just labouring away peacefully, and I sat with her quietly.  It seemed that she settled into her own rhythm pretty immediately, having set up her environment as she had planned and as she wanted.  At this stage I was not required to “do” anything.   Not long after, she stirred, and asked me to call the midwife because she felt a change and was very sure that the baby was coming imminently.  In the event there was no midwife available.  I was obliged to call an ambulance because doulas are not qualified as midwives nor insured to take responsibility for a birth unaided. While on the phone I was taking instructions on how to deliver the baby while leaving the mother to proceed on her own as far as possible since there was no indication that she was distressed.  As a doula I am not medically trained.

The paramedics are geared up for emergencies rather than a straightforward home-birth, so when they arrived my job was to try to limit any unneccessary intrusion into a peaceful environment and a birth that was climaxing very easily without intervention, for example they came in talking loudly to the mother and turning the lights on full.  In the event this didn’t matter much as the baby was already emerging.   When the baby was born the paramedics were very quick to set about cutting the cord – something they are used to doing but which does not have to be done immediately – indeed there are good reasons for waiting until the cord has stopped pulsating -  and which delays what is optimally the first and undisturbed perinatal contact of a baby with its mother.  My client suddenly became fiercely protective and vocal, insisting that she be given her baby – this is entirely consistent with the behaviour of someone with high levels of prolactin, which is as they should be immediately after giving birth.  The baby was born within an hour of my arrival at the house.

Now, a single birth proves absolutely nothing, I realise that.  But it made me think.  The labour speeded up the instant her husband went to bed.  The birthing room was quiet, felt safe – there was an unintrusive other present, and until the last moments the mother was uninterrupted.  The mother was not examined – a factor that Odent considers will always inhibit the birth-ejection reflex and so make the final stage of labour more difficult.  When I later asked the mother why she had sent her husband away, she said that she found his concern and attentiveness distracting – she was aware of his anxiety for her, and how it induced fear/anxiety in her also – he was not obviously nervous but she was sensitive to him.

If we allow that the birthing environment has some impact on the progress of a labour then there are questions that arise.  My active role as doula was minimal – I made the phonecalls to midwife and emergency services and mediated between those I was speaking to and the mother so that she was as little disturbed as possible.  I felt that my role was to hold the environment for the mother – to amplify an aura of calm containment and support. But what does this mean?  Either I had no functional purpose, or there was something in my way of being present that was facilitating of a process that was not dictated by the conscious intention or attention of the mother. 

Births progress well or badly but wishing alone does not make them happen.  The description of oxytocin and adrenalin as personas in a play is a metaphor of course, but it has the advantage of suggesting that there is something purposive that guides their presence and their optimal and timely performance.  And this purpose can be facilitated or thwarted by environmental factors.  The immediate environment of the hormones is the mother and her child, but this in turn is co-influenced by the mother’s external environment.  

The third example I want to cite is one where the mother’s conscious attitude was the single biggest impeding factor in her labour. While many of the impediments to an optimal birth arise from intrusive environmental factors – situational and procedural – in this last case, these were the things I did feel I was able to mediate and help with, but they weren’t enough.

I was attending a young mother in difficult circumstances for whom a home birth would have been inappropriate for social rather than medical reasons.  The mother was feisty and tough, and had developed a resilient facade to the vicissitudes of life.  Her approach to childbirth was supremely confident.  She was sure she would cope well, that she had a high pain threshold, boundless energy and that it would be easy.  Even though we had met and talked about the birth, she was both warm and profoundly unreceptive and remained entirely unaware that she was about to experience something completely unknown, very powerful and demanding.  Something that would not be under her conscious control and which she could only co-operate with, or not.  

A mother’s expectations and fears will make a difference to her labour.  Information, care and support may all help mitigate the detrimental effects that undue fear engenders, but only to the extent that the mother is available and wants to be guided, and so listens.

In the event her labour was long and increasingly medicalised for reasons that might have been avoided if she had entered into it with a more open and responsive attitude – and I don’t think this was possible for her at the time.

The mother was not willing to surrender her will to the dynamics of the labour as it unfolded.  For example she insisted on going shopping in early labour, talking endlessly, rushing around, posting on facebook – none of these being appropriate for the production of oxytocin, for the altered state of consciousness that signals the productions of beta-endorphins, or for the conservation of energy that sleepiness facilitates and which is helpful for what is after all a very demanding physical process.

Whenever she started to drift away into an altered, more suitable, state of consciousness she hauled herself out of it though an act of will – the loss of high cortical stimulation seemed to represent a threat to her but only because she had decided that she could control her labour – to make it happen the way she had planned.  She failed to do so, became exhausted and defeated and ended up with a forceps delivery but not for medically imperative reasons.

When I left the hospital after 24 hours I wept with exhaustion and felt utterly useless.  Yes, I had been slave to the mother – perhaps a bit too literally dancing in attendance on her every demand.  But this birth felt like a battle rather than a complex and dynamic but harmonious process, and in spite of the healthy baby at the end of it I felt we had all been unnecessarily battered.

The co-influence of organism and environment raises questions about the nature of the affective sphere of influence beyond and between individuals, and the means by which organisms and their environments are co-influential and co-creative at different levels of awareness.

If a doula is slave to the mother, the mother, it seems to me, is slave to a psychophysical process that is purposive, creative and largely unconscious.  What or where are we to find the master, the ground, from which these processes have their source?

The etymology of the word Emotion gives us a literal meaning of “outward movement”.  Emotion is the welling up of an impulse that tends towards outward expression and activity.  Lived movement is a result of perceptual changes and the dynamic constant of attraction or repulsion.  Emotion is directed towards some future state that is being determined by an organism in conjunction with its perceptions of its existing and evolving conditions, and its past experience.

Childbirth, as part of life in process, is accompanied by many conscious feelings and emotions on the part of mother and child.  The process is a dynamic one, continually informed and transformed by the enkinaesthetic entanglement of both mother and child with each other and the environment beyond this dyad.  

So, for example the mother’s expectations and fears will make a difference to her labour.  Information, care and support may all help mitigate the detrimental effects that undue fear engenders.   A doula may contribute to this by mediating medical intervention.  The birth hormones need quiet and calm, they do not respond well to high cortical activity in the mother who needs to be in altered state of consciousness in which talking has very little place.  The intrusion of questions requiring thoughtful responses is unhelpful to the mother, and in this way a doula who is sensitive to the mother can minimise the intrusion and any environmental disturbance of the mother.  These are a few of the more active contributions that a doula may make as birth partner.

It is in this sense that I think that a doula is a slave to the mother, but my understanding of the role of the doula goes beyond this, and beyond this sort of interaction.  Simply put I consider that a doula’s job is to prevent or diminish fear.  We have seen that childbirth is a life process that takes place normally only when it engenders the hormones that we associate with Love.  I think of childbirth as an emotional process, which is optimally expressed when informed by love.  Mother, child and world all participate in that process – it is not so much that the mother actively chooses labour, rather that labour is an instance of life enacting itself and the mother has a part – the major part – in that process.

The hormones that are seen to enact labour are an instance of emotion, or life in process.  Emotion seems to me to be more than a conscious feeling, perhaps more than a personal unconscious impulse towards movement, and certainly more than the hormonal secretions with which it is correlated.  It seems to be more like an intrinsic life tendency; a universal habit.  

I find Rupert Sheldrake’s concept of morphic fields and morphic resonance helpful.  He suggests that rather than talk of instincts or universal physical laws, it may be more appropriate to think of the universe as habitual in nature.  Habits are both conservative and endlessly being created anew.  Some, like the birth process in mammals are well-established, and in giving birth an organism is attracted to, resonates with, and dynamically contributes to the existence of a morphic field.  Morphic fields, through resonance, invite outward movement – emotion.  Birth may perhaps be regarded as an emotional process because the cosmos is intrinsically emotional.

Considering the role of a doula with this in mind, it appears to me that the work of a doula is not primarily about doing, rather it is essentially about being.  It is about being present to the emotional dynamic of life and its tendancy to express itself in habitual and resonant ways.  

Assuming that an optimal birth is one in which the hormones work in concert with one another harmoniously and efficiently, are produced spontaneously in the mother and result in the normal delivery of a healthy child ready to continue its ongoing ex-utero development, then I think that a doula has a very particular role.  

She is a slave to the process, she needs to be sensitive to the mother, her needs, hopes and fears, and she needs to know how to help prevent anything that will inhibit the process as it unfolds thus allowing the labour to enact itself unimpeded.  She will be sensitive to changing conditions, so she will re-assure the mother if she seems to be alarmed – but she will only talk if the mother is already alert or showing signs of anxiety.  In a medical emergency she will still have a role to play in minimizing the negative adrenaline-inducing affects of fear.

Together mother, baby and doula are slaves to an emotional and creative process in its enactment, and so go with life as it expresses itself forth into new being.