Dr. Rebecca Dekker:
Hi everyone, on today’s podcast, we’re going to talk with doula and EBB Instructor Joyce Dykema, along with registered nurse Brianna Fields, about advocating for yourself in birth and positive shifts in birth culture in the state of Nebraska. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.Â
Hi everyone. My name is Rebecca Dekker and I’ll be your host for today’s episode. I have a quick announcement before we get started. This April we are offering a free public webinar all about the evidence on elected induction at 39 weeks of pregnancy. We’re going to dive into the history and criticisms about the famous ARRIVE trial about induction at 39 weeks and talk about the implications of new research that has come out since 2018 on this subject. If you want to attend, you can register for free at ebbirth.com/webinar. If you’re able to register in time, before April 30, you will receive three free video lessons by email, plus an invitation to join me live for a Q+A by Zoom on April 30. So, what do you think? Would you like to join us? Go to ebbirth.com/webinar and register while there’s still a chance to sign-up. And now, let’s turn to today’s episode of the podcast.
Today I have with me two special guests. Joyce Dykema, pronouns she/her, is a birth doula and childbirth educator who lives in Lincoln, Nebraska with her husband and three children. Joyce holds a master’s in biological sciences from the University of Nebraska-Lincoln, is certified as a birth doula with both DONA International® and Hypnobabies®, and she is an Evidence Based Birth® instructor, childbirth educator, community breastfeeding educator, and has been serving birthing families since 2009. Joyce is a partner birth doula and childbirth educator with the Malone Center’s Maternal Wellness Program based in both Lincoln and Omaha, Nebraska, and is on staff at the Malone Maternal Wellness Doula Mentorship Program. Joyce currently serves on the DONA International® Board of Directors as the Director of Communications.Â
We’re also going to have Brianna Fields joining us in a little bit. Brianna is a registered nurse in labor and delivery for the past two years in a Lincoln, Nebraska hospital. She was nominated for a Daisy Award in 2023, and she also won an award through the Nebraska Nursing Association last year. Brianna loves to spend a lot of time with her three cats, and she was one of Joyce’s students in the Evidence Based Birth®, Comfort Measures Workshop for labor and delivery nurses. We’re going to start today first by talking with Joyce about her journey as an Evidence Based Birth® instructor and the challenges and the accomplishments she’s seen in Nebraska birth culture. And then we’re going to invite Brianna to join us to talk alongside Joyce about how nurses are advancing their education on comfort measures and birth and also about advocacy in birth. So Joyce, we are so excited to have you. Welcome to the Evidence Based Birth® Podcast.
Joyce Dykema:
Thanks, Rebecca. I’m excited.
Dr. Rebecca Dekker:
Yeah. So you have been in the EBB Instructor program for a really long time. You know, one of, I would say, our more experienced instructors. Can you tell us, about how you first got into birth work? Because you’ve been doing it for a while. And then what led you to the EBB Instructor program?
Joyce Dykema:
Yeah. So it’s a long story. It starts when I was four years old. When I was four, my parents took me and my younger sister to the birth of our brother. And it was a little bit of just a, well, we kind of have to, we didn’t, you know, they didn’t really have child care options at that time. And I don’t remember a ton. I was four. But what I do remember from my brother being born is that my mom kind of laid in her hospital bed. It was the eighties. She did Lamaze and she, you know, laid in her hospital bed. She closed her eyes. She did her breathing exercises and there was either a window or a light behind her head.Â
And so I remember this light coming like around my mom. So I had just these very angelic images of my mom in labor as some of my very first memories. Then when I was eight, our youngest brother was born and our parents brought us along to that as well. And it was very similar. You know, we didn’t have like the angelic images of a four-year-old’s memory, but she did the same thing. She laid in the hospital bed. She closed her eyes. She did her breathing. She birthed unmedicated again. My dad was supportive. The staff kind of just left her alone. She just did her thing. And then I had another brother.Â
And I didn’t realize how much that impacted me until my husband and I decided to start our family because that was what I wanted for my own birth experience. So before we even got pregnant, I started reading everything about how to have that kind of a birth experience. And everything that I was reading said that I had to get a doula. So I got pregnant. About halfway through my pregnancy, I went to a midwife appointment. And I said, so apparently I need a doula. Do we have those here? And eventually, you know, picked a doula and actually had two doulas because our doula was training another doula.Â
And so we had two doulas for our first baby’s birth, which it was incredibly beneficial. I ended up having a posterior positioned baby and back labor and I needed all the extra support. And I needed my doulas to make sure that my husband was taken care of so that I could have his support for every contraction. And I needed, you know, that reassurance that I was doing well, that my baby was doing well, that everybody around me was kind of taken care of. And I did birth him like I wanted to with no epidural. He never turned. He was born sunny side up. But I knew what was going on. I felt important. I felt respected. I felt cared for. I felt in charge of the decisions. And despite the really physically challenging birth, it was just a beautiful, incredible experience.
Dr. Rebecca Dekker:
And this was in Nebraska?
Joyce Dykema:
That was in Lincoln, Nebraska. Had a hospital birth. And… that really got me thinking, you know, that whole pregnancy experience really got me thinking about how, you know, my undergrad degree is in psychology. I studied animal behavior as my master’s degree. And, you know, just that connection between the psychology and the biology that comes together in birth work was fascinating to me, but I just had this baby, you know, and the plan was that I was gonna be a stay-at-home mom for until our hypothetical youngest child at that time went to kindergarten. So it was kind of just the back of my head. Then I had a friend who had a very opposite birth experience than me. They brought somebody with them for some more additional hands-on support, but that person ended up providing more of an antagonistic kind of presence than a supportive presence.Â
And despite her pretty straightforward labor and birth, she really didn’t know that she could ask questions. She didn’t know that she had a choice with medical procedures. She didn’t know that she should read anything about what to expect for childbirth. And she just really was poorly prepared and poorly supported in the end and ended up, despite a very smooth on paper, smooth birth experience, she had a very traumatic experience. And seeing that difference of how my challenging birth felt so beautiful and so empowering and her physically smooth birth experience was so traumatic. Like I just couldn’t stop thinking about it. The support and the education that I had and that my husband had, was what made a huge difference. Which I knew after my birth, but just seeing how big of a difference it made in the opposite direction. You don’t have the support and you don’t have the education, how much that can turn a birth experience into something that, you know, she didn’t want to have children ever again.
Dr. Rebecca Dekker:
Wow.
Joyce Dykema:
So that’s what got me into birth work. I did my doula training that next week.
Dr. Rebecca Dekker:
It sounds like you, Joyce. Like, you know, make your decision and go for it.
Joyce Dykema:
Yeah. It does. I know. You know me well enough now that I just jump into things.
Dr. Rebecca Dekker:
So what happened then as you’re practicing as a doula, what drew you to the EBB Instructor program?
Joyce Dykema:
So again, I kind of just jumped, as I do. Coming from an academic background, I was used to having access to just research and having access to research papers. It was fairly common for me to just search something up at the library and find it or find something that got me the information that I needed. And if I couldn’t find it, I had people that I could reach out to. Hey, do you have a copy of this paper from 1963? You know, and when I started as a doula, we didn’t have any of that. It just didn’t exist. Those sorts of resources were behind paywalls. They just weren’t available. And I mean, I think the entire, at least U.S. birth world was just desperate for information so that we could help our families so that families could make informed decisions for themselves. And when Evidence Based Birth® took off, it really took off, as you know. And so, it was just really timely that you started your blog. And, you know, it was just such a necessary change and shift in the birth world. I’m trying to think like how I actually decided I was going to apply to the instructor program. It was something like 11PM. And I was like, I’m just going to apply to this. And so I applied and got in and I didn’t really know what I was getting into. I knew that I was going to get better access to information and to research evidence that was going to help me as a doula and help my families as they were going through pregnancy and childbirth and postpartum. And I just kind of jumped. And I’ve stayed with it ever since.
Dr. Rebecca Dekker:
Yeah, and you got more than you probably bargained for because you got the research. But then one of the things you probably noticed as you went through the training is that we focus a lot on advocacy and making change. So tell us a little bit about what Nebraska birth was like. For those of you who aren’t familiar, you know, the central part of the United States, mostly rural with a couple of smaller cities. And what was going on in birth in hospitals and at home at that time?
Joyce Dykema:
Yeah. So in Nebraska at the time, there was only hospital birth. The only option where you could have a state licensed provider attend your birth. Nebraska, they authorized certified nurse midwives to be maternity care providers in the nineties, I want to say. I don’t remember exact year, but they specifically banned the certified nurse midwife from attending home births at the time. And at the time, the intent was, we’re going to get this on the books so that it passes and we have certified nurse midwives, and then we’ll just remove the home birth restriction next session. And that’s been 30 years, 30 plus years since that was there. And there have been multiple efforts over the years to remove that home birth restriction. And every single one of them has failed for a variety of reasons. So-
Dr. Rebecca Dekker:
Right.
Joyce Dykema:
And at the time there were no birth centers. We have two birth centers that are open. Both of them are owned by hospital systems. One of them is at the hospital. So it’s an alongside unit, but it’s an outpatient portion of the hospital. Functions as a birth center. We had an independent birth center in… I want to say they opened in 2010 or 2011, I had my second or my third baby there. I had my third baby there in 2014. And then they had to close a couple of years later because of some of the other laws about malpractice insurance for midwives compared to physician credential. So it’s been a really interesting experience because home birth is pretty underground. It definitely happens. But I’ve known families to fly a midwife in from overseas to attend their home birth and live with them for a month and then attend their home birth. I’ve known families to contract a midwife to drive over state lines. I’ve known families who’ve left the state to have a home birth or an Airbnb birth. And then there’s a lot of unassisted birth as well. And it’s very interesting.
Dr. Rebecca Dekker:
Yeah, so you basically are living in a state where the legal restrictions are extreme for anything other than hospital birth. What about the hospital systems themselves? When you first started as an EBB Instructor, what were the typical things you would see in a birth or your clients might experience?
Joyce Dykema:
Yeah. So when I had my first baby in 2008, it was a struggle to get delayed cord clamping and skin-to-skin for the golden hour. And because I had a midwife, those things were much more accepted at the hospital because I had a midwife, but I still had to fight for it. And by the time I started as an Evidence Based Birth® instructor, those sorts of fights were becoming a lot less. It was pretty standard for both hospitals. If you had a midwife that you would get delayed cord clamping, you would get your full golden hour. But some of the obstetric providers, they were still doing immediate cord clamping, 30 seconds or less. And the nurses were really pressing to get that weight really quickly. And that has shifted a lot over the last, I’m trying to think, I’ve been an EBB Instructor since I think 2017. So over the last six, seven years, it’s been a good shift. So now delayed cord clamping for at least a minute and the full golden hour, the full one to two hours is standard for everybody, unless there’s a reason why they have to separate a baby from their parents.
Dr. Rebecca Dekker:
That’s been a big shift. What about cervical exams? I specifically remember when you started as an EBB Instructor instructor that your client struggled if they wanted to decline a cervical exam, they were presented as not optional, as required.
Joyce Dykema:
Yeah. One big shift that I’ve seen since starting as an instructor is kind of the level of education among the nursing staff about patient autonomy. That’s been a huge shift in the past seven years. And, because that shift has been largely nurse-led within the hospital systems, it’s gotten a lot better for patients because their nurses are on their side. You know, okay, the patient doesn’t want it, and it’s not strictly medically necessary. So patient said, no, I’m going to chart it. That’s it. So it’s been a good shift.
Dr. Rebecca Dekker:
But it didn’t used to be that way.
Joyce Dykema:
No. No, it didn’t used to be that way. There was a lot of pressure. Like, oh, it’s been this amount of time. We’ve got to.
Dr. Rebecca Dekker:
Yeah, right. Every two to four hour kind of required cervical check.
Joyce Dykema:
Yeah. And now it’s also phrased differently, which is nice. So I had a birth in recent years that the provider wanted very frequent cervical checks. And the nurse presented it as, your doctor would like to have more frequent cervical checks and had a conversation about it. You know, what does the patient want? What does the doctor want? And how do we come to an agreement together? So just the way that it’s phrased is also a huge improvement. Instead of your doctor said this, so that’s what goes. It’s here’s what your doctor said, and I’m going to tell them what you said, and we’re going to figure out a plan together. Much more collaborative.
Dr. Rebecca Dekker:
Talk about the various classes you’ve been able to teach and the impact you’ve seen on your community.
Joyce Dykema:
So I have taught Savvy Birth 101 for parents. I haven’t taught it in several years, actually, because… since you started the Evidence Based Birth® childbirth class, that information is in there, which is fantastic. But that one, it really opened people’s eyes to why they needed to know. You know, kind of their options in childbirth and how to stand up for themselves. And that it’s not about fighting, it’s about having confident conversation skills. And that class really opened people’s eyes to that, which was a really beneficial change. Then I teach the Evidence Based Birth® childbirth class, and that has been just so much fun. It’s been… I started teaching that in 2019 when we first were able to start teaching it and that continued through the pandemic because we moved to all virtual classes. And it’s been a lot of fun because we can do virtual classes. I get to teach families from all across the country. And that’s been really interesting, just seeing the different regional differences and seeing that, you know, birth here isn’t that much different than birth in some other areas of the country. It is different in other areas, but it’s just not the same kind of different. It’s very interesting.
Dr. Rebecca Dekker:
So you’ve been meeting parents from all different areas and finding, you know, the similarities and the differences. How has the class impacted your doula clients who then go to birth in the local hospitals?
Joyce Dykema:
Yeah, it’s been really positive. You know, I’ve had the majority of my clients are seeing a midwife for care, but at this point, it’s only probably a slim majority, maybe 55, 60% of my clients see a midwife for care and the rest are seeing an OB or a family practice who catches babies. And they’re able to have more of these conversations prenatally with their doctors. This is probably similar across the country, but the midwives tend to do a lot more patient education, a lot more conversation with their patients during prenatal visits. And the OBs have much shorter time periods in their appointments. And so there’s just less opportunity for patients to get to know their doctors in prenatal appointments. And so having these conversations as a childbirth class helps them to you know, really figure out what is important to them for their own birth experience and for their baby. And, then they can have that conversation with their providers prenatally. And that’s been very beneficial to all my childbirth class students, as well as my doula clients.
Dr. Rebecca Dekker:
Right. Helping them gain the knowledge and confidence to start talking about issues early rather than waiting to the end of pregnancy or even in labor or just not speaking your mind at all.
Joyce Dykema:
Or being surprised.
Dr. Rebecca Dekker:
Yeah, that’s true because we talk about the different things that, you know, they might practice that you don’t think about exactly.
Joyce Dykema:
Yeah. One of my neighbors called me this past week, actually, she had been with a relative who was giving birth and she was shocked at how little the nurses were in the room. She thought that the nurses would be providing a lot more hands-on supportive care. And she was very shocked. So she called me and said, is this normal? Yep. That’s normal. There’s been research. And that’s normal across the board.
Dr. Rebecca Dekker:
Yeah, yeah, it’s true. We talk about that in the class, the statistics on the amount of time. And we’re going to have Brianna on in a little bit to talk about how nurses can provide support. But as you know, they also have other duties and responsibilities, in the class we talk openly about the limited amount of time you might have with your nurse. So I was thinking, Joyce, one more thing I was wishing you could update us on is, you know, what are some of the legal issues or legislative issues that your birth community is working on right now? I know you mentioned Certified Nurse Midwives (CNM) can still not do home birth. It sounds like CPMs can still not practice legally and there’s no freestanding birth center. So what’s the focus right now?
Joyce Dykema:
There’s a bunch of different groups taking legislative action in Nebraska. There’s some people who are fighting for the certified professional midwife and direct entry midwives to stop being prosecuted by the state of Nebraska for doing what they’re doing. The state does not license the CPM or other midwife credentials, only the certified nurse midwife. And it also does not bar them from practicing in the state. So it’s an a-legal situation. But if, you know, somebody gets caught practicing in a midwifery role, then it’s typically they get arrested and then there’s a lawsuit and things that are just ugly.
Dr. Rebecca Dekker:
Okay, so they are actively arresting and prosecuting midwives.
Joyce Dykema:
They will arrest and prosecute. I believe that all of the recent cases have been dismissed, but it’s still, I mean, it’s an expensive and a very disruptive practice. And so it, there’s a lot of fight to try and it’s very traumatic for everybody. And so there’s a lot of attention to trying to end that practice and get some sort of agreement with the state of Nebraska. There’s also some efforts to get the certified nurse midwife to first, they need to be independent practitioners. Several years ago, I think it was pre-COVID. The state removed the, I don’t know if you know this, this term where the.
Dr. Rebecca Dekker:
The supervision requirement?
Joyce Dykema:
Thank you. Yeah. So several years ago, I think it was pre-COVID. The state removed the supervision requirement for every APRN credential, except for the certified nurse midwife.
Dr. Rebecca Dekker:
Oh my gosh. Of course.
Joyce Dykema:
Specifically removed the CNM before they would move the bill out of committee. And that was passed. And so first we need the CNM to have the supervision requirement removed so that they can be independent practitioners, as they are trained to be. Then we can get certified nurse midwives to it’s a felony at this moment, if a certified nurse midwife attends a home birth. And so then we have to remove that. And then, you know, there’s so many different efforts. You know, there’s some efforts over the past several years to get Medicaid to cover for doula services. There’s a lot of, you know, push for more birth centers, more independent birth centers. There’s a push for that insurance cap to be a lot lower for the certified nurse midwife so that a nurse midwife can open their own birth center and practice independently, you know. So there’s just a lot of changes that need to be made to make birth better in Nebraska.
Dr. Rebecca Dekker:
Yeah. Wow. Joyce, I’m just, I’m sure some of our listeners are like, what a felony for attending a home birth, you know, as a certified nurse midwife. And, and I love that, you know, you just matter of factly share, like, here’s where we were, here’s where we are, here’s where we still need to go. And, you know, for you, this is what you’ve been dealing with for, you know, more than a decade. And for other people, it, you know, it’s just, it just, to me, it’s really, yeah. It’s a challenge and shocking and horrifying, all the things. But I love how you can help share the perspective that, change is happening. I think some of the legislation changes are the hardest because then you really come up against the people with power and money. But I wish that there was a way that they could realize what they’re doing to families and nurses and midwives. It’s horrifying. At the same time, there are people working to change this. So can you share where people can go if they want to get involved?
Joyce Dykema:
Yeah, there’s several different organizations. Probably the most visible is Nebraska Friends of Midwives.
Dr. Rebecca Dekker:
Awesome. And anything else you want to share before we bring Brianna on to talk about? The labor and delivery nurses and how they’ve been getting educated and educating themselves.
Joyce Dykema:
So one thing that I’ve been very aware of. For my own practice and for… newer doulas for, you know, other families is that I’ve worked in this system for 14 years plus. And just because I don’t see the negative things happening doesn’t mean that it isn’t happening here. And I know that because I’ve also talked with families who’ve experienced coercion, families who’ve experienced just really poor care. I’ve talked with other doulas who witnessed these negative things happening. But… I think that my reputation precedes me and there’s benefits to that because then my clients benefit, but there’s also downsides because I’m not seeing the negative as much as I used to be and as much as other families and other doulas are. And that is another challenge. You know, it’s just a different side of it. So I know that these things are happening, that these negatives are occurring in Nebraska birth. And I just don’t see it.
Dr. Rebecca Dekker:
And not everyone can have a Joyce Dykema with them at the birth. You know, like you have a limited, limited time and you’re right. It’s one thing to say, you know my clients get better treatment, you know, because they know who I am and that I’m in the room watching and that I have, you know, reputation, like you said. But everybody should be getting that kind of care.
Joyce Dykema:
And I have relationships with a lot of the nurses and I have relationships with a lot of the providers. But that’s not fair. We should be providing this level of care to everybody.
Dr. Rebecca Dekker:
Yeah. I think it also reminds me of research we’ve been looking at for that Signature Article update on the Evidence on Doulas and how the importance of labor companionship, having a companion there alone, whether they’re an experienced doula or not, should increase the chances that you’ll be treated respectfully because there is somebody witnessing. Now, it doesn’t work all the time, like you said, but it does have some protective effect. And I think everybody should be treating their patient like their own family member. But unfortunately, that doesn’t always happen as we know. And we talk about the evidence on anti-racism and other things like that. So Joyce, thank you so much for bringing your perspective and for the work you’ve been doing in Nebraska since 2009. And we’re really lucky to have you in the EBB Instructor program. So let’s bring on Brianna and welcome her to talk with us about how she was impacted by Joyce’s class on comfort measures for labor and delivery nurses. Joyce and Brianna, welcome to the Evidence Based Birth® Podcast.
Joyce Dykema:
Thank you, Rebecca. I’m excited to be here.
Brianna Fields:
Thank you. So excited to be here.
Dr. Rebecca Dekker:
So let’s start with Joyce. So Joyce, you know, you’ve been an EBB Instructor instructor for a long time, and we’re going to talk about that in another podcast episode. But today I was wondering if you could talk about, you know, why you wanted to start teaching the comfort measures workshop and like, what are some of the challenges in your community that inspired you to start offering this workshop as an EBB Instructor?
Joyce Dykema:
Yeah. So when I first started as an EBB Instructor, the only professional workshop that we had to offer was the Savvy Birth Pro. And then we had the seminars, which for some reason, it just never really took off in my community, which is, it is what it is. And when you created the comfort measures workshop, I think all of us instructors were so thrilled. You know, comfort measures is something just so practical for doulas, for nurses, for childbirth educators, for midwives to always continue learning more about. And when, especially when you combine, you know, the practical, here’s how you do the comfort measures with the research about why they’re effective and why they’re helpful for comfort and for promoting the labor process. It was just a no brainer. I had to start teaching it.
Dr. Rebecca Dekker:
Yeah. And so for, you know, most of our listeners here have probably not attended one of these workshops. They’re typically attended by birth pros that can be attended in person or online. Can you talk a little bit about, you know, the practicalities, like what the workshop is like? So the people kind of have an overview of what you cover and you mentioned evidence. So if you could talk a little bit about how evidence is woven throughout. So kind of just walk us through what the typical workshop looks like.
Joyce Dykema:
Yeah. So we start off with discussion. You know, what’s the importance of using comfort measures? Why do we need comfort measures and why do we need to learn more about comfort measures? And that’s from obviously the professional standpoint and why it’s important for us as birth pros to stay up to speed on the comfort measures that are available and why we use them. So we start out with discussion in the workshop, and then we move into different stations. So we rotate the whole class through different stations and try out the different comfort measures. We also discuss each comfort measure and talk about, you know, what this is good for, the research behind it, the research comparing this comfort measure to other alternatives. And it’s always such a fun time. I mean, there was so much laughter during our workshop.
Dr. Rebecca Dekker:
What are some of the stations people rotate through then?
Joyce Dykema:
So we rotate through two sets of different stations. Some of the favorites are the water birth station or hydrotherapy station where, you know, the instructor brings in a tub or uses a tub if the facility has one available. And, you know, in my class, I tell the people like, okay, get into the tub and, you know, try it out and try different positions in there. And then they talk about the research and how to do it safely from a nursing or other birth professional standpoint. Another favorite is always protecting the perineum because, a lot of people have a mindset of like, there’s not really much you can do about protecting the perineum during the pushing.
Dr. Rebecca Dekker:
Like you’re either going to tear or you’re not.
Joyce Dykema:
Right. And there’s some element of that that you just can’t control. But there’s also some elements that you can control. And we talk about those things in the workshop as well. The pushing positions is always a favorite. The peanut balls is a good one. So yeah, we talk about a lot of things. We also talk about the evidence behind eating and drinking during childbirth. And that one recently has been a really huge one, a really great conversation starter in my workshops as well.
Dr. Rebecca Dekker:
Yeah. And it seems like from the pictures you’ve been posting on social media and the videos, like you’ve been getting a really welcoming response. Can you talk a little bit about, you know, where you’ve been offering the workshops? Were you invited or did you reach out? Like, how has this been going with the local hospitals?
Joyce Dykema:
Yeah. So with all three of my workshops in 2023, I was invited, which was such a delight. We’ve got two hospitals in Lincoln that offer childbirth services, and both of them had workshops last year. And I’m in conversations with them to do more for this coming year and hopefully beyond as well. It was really a partnership between the Malone Center that I also work through and the hospitals. With the Malone Center, we provide birth doula services to primarily Black families as well as other families of color. And it just came about in all the conversations that my director has been having the last several years that we really wanted some opportunities for the nurses and the staff at the two hospitals in Lincoln to do some collaboration with the Malone doulas. And this was a perfect opportunity. And it’s really my director who kind of got the ball rolling on that. So it was great.
Dr. Rebecca Dekker:
It sounds like, you know, for an EBB Instructor, for me as the founder of EBB it’s kind of a dream come true to have doulas and nurses collaborating together in this kind of educational environment that you’ve created. And I love that they invited you and that they were wanting a doula to educate their nurses. So you’re saying there were both birth workers, doulas and nurses. Any other professionals in the workshops?
Joyce Dykema:
For some of my volunteers, because with the comfort measures workshop, we also have volunteers who help the instructors with the different stations, with answering questions, reading the quizzes that we have for people at every station. And we had some of our staff members from the Malone Center volunteering at several of these. I think all three of the workshops, actually.
Dr. Rebecca Dekker:
Okay. That’s awesome. And are these new nurses or experienced nurses who tended to be at the workshops?
Joyce Dykema:
So it was… across the board. We had in the workshop that Brianna took, we had a nurse who had literally started the week before, as well as nurses who’d been on the floor for 30 years and everything in between. And that was pretty common for all three of the workshops that I taught last year.
Dr. Rebecca Dekker:
Awesome. Okay. So Brianna, that leads me to you, you know, what drew you to attend the workshop? Was it like something offered to you or is it a requirement? Like how did you end up in Joyce’s class?
Brianna Fields:
So personally, I’ve worked with Joyce a few times, like with patients I’ve had. So I’ve always really loved her and what she did. I think that advocating for patients has always been really important to me. So when I saw, you know, we’re offering a class, it’s going to be Evidence Based it’s comfort measures. The hospital can only teach us so much about how to like labor a patient. It’s more clinical, obviously, at the hospital. And so, to have a class, that would help with the things that I thought would be really impactful in the way that I can take care of my patients. And I think that that was true, personally.
Dr. Rebecca Dekker:
Mm-hmm. Yeah. So thinking back to nursing school, because you’ve been a practicing registered nurse for two years, so school wasn’t that long ago. Did you feel like you adequately learned comfort measures for labor and delivery or was your nursing school labor and delivery rotation more focused on like the medical clinical tasks?
Brianna Fields:
Absolutely, like medical clinical tasks. I feel like the culture on our unit is very, like with our nurse educator, is very centered around trying to be less medical all the time. Least invasive interventions. We try to be very welcoming to like other birth workers and doulas. But as far as school, I think it was just very clinical.
Dr. Rebecca Dekker:
Okay. And then is this kind of your first formal learning opportunity then where in a classroom setting you were focused on these hands-on comfort measures or was that included as part of your orientation two years ago?
Brianna Fields:
I think it wasn’t included in the orientation we had two years ago. We do like continuing education on our unit. And then during our meetings, we try to incorporate a little bit of comfort measures, but this was the first time we’ve all… like sat down and had like stations and it was really just completely focused on comfort measures.
Dr. Rebecca Dekker:
Okay, cool. So can you share with me then like a memorable moment or skill from the workshop with Joyce that you found particularly valuable?
Brianna Fields:
Yeah. Oh my goodness. There was a station we were talking about.
Dr. Rebecca Dekker:
And you can share more than one.
Brianna Fields:
Yeah, absolutely. There’s a station about positions. And all I remember was there was like a yoga ball and it was, it was really lighthearted and fun. But I think it was impactful, because it changed the way that I thought about positions for my patients. I don’t know if that made sense.
Dr. Rebecca Dekker:
How so?
Brianna Fields:
I think it gave me more ideas than just we can stand at the bedside. We can use a peanut ball in the bed. I think there’s a lot more options for positioning patients for them to be more mobile during the labor process, then like I realized there was.
Dr. Rebecca Dekker:
Okay. So previously you’d kind of thought of like, we can do standing, you can sit on the birth ball, you can put a peanut ball between someone’s legs, but what were some of the, like the other positions that you can help people be more mobile with?
Brianna Fields:
Yeah, we can do more hip rocking. When we’re on the yoga ball, we can have the support person like massage the hips or the back. We can lean more into the bed. You can have the support person stand behind them and kind of support them up a little bit. I think those are more things that I would incorporate into taking care of my patients now.
Dr. Rebecca Dekker:
Mm-hmm. What other moments or skills stuck out at you in the stations?
Brianna Fields:
We did the acupressure and learning about like the different pressure points I thought was really interesting. Personally, I have never used it yet. But I do encourage support persons if the patient is really okay with that, to be very hands-on in the labor process. You know, massage the back. If they want their feet massaged, do that. So I thought like acupressure point was really fascinating. I hadn’t heard of that before. Yeah.
Dr. Rebecca Dekker:
Okay. And I would love to hear about like some of the discussions you all had. So maybe you both can talk about this together, but what are some discussions that came up? You know, we start with discussion and then we’re in small groups moving through the stations, talking about each one. And at the end, you know, we kind of wrap up talking about challenges and implementing these comfort measures, but what were some of the discussions that stuck out to both of you?
Brianna Fields:
We talked a lot about the fear pain cycle. And we had a big discussion where we wrote on the whiteboard, like, reasons, like helping your patient cope through labor and reasons you might like recommend they get an epidural. I thought that was really impactful, personally. Where the big discussion was like, how are we helping the patient emotionally cope through what they’re going through and what kind of things we can say to help them get to the goal that they want to have?
Dr. Rebecca Dekker:
Okay, so Brianna, I think you’re talking about the station where we talk about… like, language. So there’s a station that one of the comfort measures is not like a physical tool, but we talk about our words and how the words you use as a nurse have an impact on someone’s comfort level. Joyce, can you add a little bit more to that?
Joyce Dykema:
Yeah. So that’s actually the same moment that I had in mind to discuss for this question. You know, we talk about like the importance of using comfort measures, the reasons why somebody might choose an unmedicated birth to avoid an epidural or other pain medications, and how the staff can support that and the doulas can support that as well. And, you know, we talked a lot about. You know, the words that we use, you know, they have an impact on people and the way that we frame things, the way that we frame experiences, the way that we frame sensations, it can really impact somebody’s one memories of the experience and how they are currently framing the physical sensations themselves. And, you know, we have to be there and we have to help them through what they’re experiencing physically, emotionally, but it’s also not our births. And so we have to be careful and mindful of, you know, what does this person, this laboring person wanting for their experience and how can we support them? And then when necessary, how do we help them incorporate changes and plan when they are necessary? Or when they’re, you know, when the patient or the client is changing their mind about what they previously wanted. How do we frame that? We talked a lot about, you know, just being supportive.
Dr. Rebecca Dekker:
And yeah, there’s this and there’s a list of affirmations that nurses can use. And it made me think, Brianna, when you brought that up about an episode 299, I talk with a family and they’re sharing their birth story. And she keeps recalling these words her OB said to her when she was 20 weeks pregnant or 25 weeks pregnant. Well, you’re too small probably anyways to give birth vaginally. And how even though she switched providers and gave birth in a completely different hospital, when she was pushing those words flashed back into her head and would not leave. And it really impacted her mentally and emotionally. Brianna, were there any… any sayings or words you’ve heard nurses use in the past that the workshop made you think differently about?
Brianna Fields:
That’s a really, really good question. Honestly, I don’t think there’s like a specific word. But… changing my mindset on how to… be honest with my patient that this is going to be painful. But you can do this if you don’t want to have a medicated birth. You can do this. And your body’s made for this. And that. You know, it’s going to be uncomfortable and you’re going to be uncomfortable until you, you know, have your baby, but you can do this because your body is made for that. If that makes sense.
Dr. Rebecca Dekker:
Yeah. So kind of reframing it from, oh, you can’t do this. You might as well not try to, like affirming people’s ability to, to do what they want to do. Yeah, instead of kind of like… like cutting their confidence subconsciously by, by implying that they can’t do it and that they shouldn’t do it. Joyce, any other words? You know, I know you have a long practice as a doula. You’re one of our most experienced EBB Instructors. What are some examples of things people, you’ve seen providers or nurses say during labor that maybe they meant to be helpful and they didn’t realize how disruptive it was?
Joyce Dykema:
Yeah, I can do one that I did.
Dr. Rebecca Dekker:
Okay.
Joyce Dykema:
In my defense, I was very, very, very, very tired. I had a client where I was suggesting position changes and things and you know, for a lot of really valid reasons, you know, they just weren’t possible for this client. And I said, very offhand like well if we won’t do these things then and like, as soon as the words left my mouth, I was like, oh, that’s not what I meant. That’s not what I meant. You know, it’s not your fault that you can’t do positions or different comfort measures. It’s not your fault that you, you know, you can’t handle…whatever it is, it’s not your fault that, you know, this is hard for whatever reason. And so that was one that I did myself.
Dr. Rebecca Dekker:
Like you were about to tell someone if you can’t do this, then like.
Joyce Dykema:
Then consequences, whatever.
Dr. Rebecca Dekker:
Yeah. Almost like a threat.
Joyce Dykema:
Yeah. And I was like, oh, no, that’s not what I meant. Oh, you know.
Dr. Rebecca Dekker:
I shouldn’t have said that.
Joyce Dykema:
I should not have said that. And I said, you know, I apologized immediately. But I was like, that is not what I meant. So.
Dr. Rebecca Dekker:
Yeah.
Joyce Dykema:
That I’ve done myself.
Dr. Rebecca Dekker:
Well, we all have negative thoughts. You know, I think it’s one of those things that comes with maturity. And like you said, your energy and we talk in the EBB Instructor training about the iceberg beneath our words, how there’s a lot going underneath surface with a doula or a nurse or a midwife or an OB, you could be tired. You could not have slept last night. You might have personal things you’re worrying about that make you not 100% on top of your game. And then we all have negative thoughts. Like even as my kids have been growing up, sometimes I’m like, where did you get that negative thought from? Because I’ve certainly never said that to you, but they pop into our heads. And sometimes as birth workers and nurses, we have to be really careful about which words we choose to use. Not that we’re necessarily censoring ourselves, but we don’t want to burden someone else with our own negative thinking.
Joyce Dykema:
Yes.
Dr. Rebecca Dekker:
Yeah. Brianna, what are some other, you know, we’ve talked about the language and positions and acupressure. Joyce mentioned you all had interesting discussions about eating and drinking. So what have been the policies on eating during labor? In general in Lincoln, Nebraska, and how did that impact your discussions?
Brianna Fields:
That’s a really good question. During my nurse residency, my group, we actually did eating and labor, and we got the policy change that if patients are low risk, we can typically let them eat up until if they get an epidural, they can eat until then. But if not, then they can eat the entire time during labor and we don’t have to get like a separate order for that. I’ve seen a huge movement towards we do really want patients to eat during labor. And… a lot of us are feeling very passionate about that. The uterus is a muscle, and we feel very strongly on people being able to eat, not just Jell-O, and applesauce and juice. I’m very glad to see that. It’s the focus is shifting towards eating and labor is good.
Dr. Rebecca Dekker:
Eating solid food is okay too. It doesn’t just have to be liquids. And you mentioned the epidural issue. And we talk about that in our podcast on epidurals and our handout, how evidence does not support withholding food during an epidural. So currently is the policy at your hospital, then no eating if you have an epidural?
Brianna Fields:
Unfortunately, the pushback is that it has to be a unanimous decision from the anesthesia group. And we haven’t been able to reach that yet. So I think we’re still actively working towards it. It would be wonderful if we could get the policy changed completely. But I’m glad to see at least a little bit of a shift.
Dr. Rebecca Dekker:
Yeah. I think, you know, sometimes the changes don’t happen all at once like we want. Like they happen in stages. And we talk about that on our podcast on eating during labor, how often it is. One or two anesthesiologists that are the hold up for that. Joyce, what other conversations came up when you were kind of leading that discussion about eating and drinking during labor?
Joyce Dykema:
I mean, that’s kind of the bulk of the conversation that we had in the workshops that, you know, oh, the evidence is really in favor of being able to eat solid foods during labor. And then epidural is kind of the last holdoff for a lot of a lot of facilities. One really good change that I’ve seen personally over the last several years is that, you know, now patients with an epidural are at least allowed like a clear diet. Whereas when I first started for many people, it was ice chips.
Dr. Rebecca Dekker:
Hmm. Yeah.
Joyce Dykema:
Maybe, maybe you could drink water. So that’s been, that’s been a positive change.
Dr. Rebecca Dekker:
So did you talk at all about kind of the human right to eat and of how a patient doesn’t want to follow the policy that they’re not legally required to? Did you, did that come up?
Joyce Dykema:
Yeah.
Brianna Fields:
Yes.
Joyce Dykema:
Absolutely. And that’s another, another great conversation that I’ve seen. You know, just in my practice as a doula and that we did talk about in the workshops that, you know, your patients aren’t beholden to hospital policy. It’s not their policy, so.
Dr. Rebecca Dekker:
Yeah.
Joyce Dykema:
You can’t really control what people do behind closed doors.
Dr. Rebecca Dekker:
Right, exactly. Just like you can’t control if they need to use the bathroom. It’s a bodily function that you can’t take away from them. You can try to, but… technically you can’t. Any other specific examples? Brianna, I was thinking of hydrotherapy and the use of water during labor. What are the options at your hospital right now for that?
Brianna Fields:
Yeah, really good question. So at my facility, we have no providers that would attend a water birth or have any policies built around being able to allow a water birth. We have two tub rooms. The really hard part is… is that if you’re on an induction medication or if you’re like a high risk induction, we really don’t technically allowed the patients to use them, if we can’t safely monitor baby, of course. I’ve seen very positive things from hydrotherapy. For patients that are able to use it and really benefit from. Using the tubs. We have like a Bluetooth monitor sometimes we can use. If that works. Technology. Or if we can do like intermittent auscultation, we’ll do that while the patient’s in the tub. We also offer like a shower. Sometimes we’ll just unplug people for 20 minutes from the monitor and say, you know, maybe a hot shower would be really nice for you. Maybe that would feel relaxing. So I’ve seen really good benefits from both of those. I think it would be very… awesome for our patients if we could do water births or more hydrotherapy. But unfortunately, in my facility, we’re just not there yet.
Dr. Rebecca Dekker:
Joyce, did you feel that after the water labor discussion? In the stations where you’re talking about the evidence on water labor and water birth and the benefits, but also the challenges. Do you feel like nurses leave that discussion with more of a hope and wish that someday their facilities will offer water birth?
Joyce Dykema:
Yeah, definitely. Once people learn about the potential benefits of water labor and water birth, people are like, oh, of course we need to offer this. And that gets us into the barriers discussion from the workshops, which tends to be the OB providers and then the anesthesia providers and things like that. Yeah. That’s kind of the holdup.
Dr. Rebecca Dekker:
Yeah. But one of the things I love about it is that I feel like nurses have more power in numbers, in greater numbers. And so one of the benefits of the workshop is when you get all these nurses in the same room at the same time, focused on this, they’re not distracted by patient assignments or their upcoming shift. And they’re really focusing on this and building like rapport with each other and realizing, hey, we’re all on board with this. I feel it makes it much more likely that five years in the future, your hospital will have more options because the nurses are sold. And when many of them are like, yes, we’re on board, it can make a difference.
Joyce Dykema:
Yeah, definitely. Yeah.
Dr. Rebecca Dekker:
One other really important station in the workshop is upright birthing positions. So Brianna, can you describe what that station was like? What picture comes up in your mind when you’re remembering that station?
Brianna Fields:
We do kind of like hands and knees or tabletop, but the head of the bed is raised. So the person giving birth can kind of hook their arms, up above the head of the bed? To kind of help gravity aid giving birth.
Dr. Rebecca Dekker:
Yeah. So you practice that together?
Brianna Fields:
Yes. Yeah.
Dr. Rebecca Dekker:
Okay. And how often do you see upright births, you know, in the last two years where somebody’s not on their back? But they’re squatting, standing, or hands and knees or one of something similar to that.
Brianna Fields:
Ooh, that’s a really good question. It really depends on patient mobility. If a patient has non-medicated birth, we typically let them deliver in the bed. Usually that is seen as the safest in my facility. We typically let them deliver in any position that’s comfortable for them. They feel like hands and knees or squatting in the bed or like I’ve seen a lot of on their side with the leg up a little bit more to be very beneficial for them. With an epidural, we like to do like a lot of different position changes. During the pushing process. So I didn’t say the squat bar, the birthing stool. For non-medicated, but we do use that for non-medicated and epidural patients. Do hands and knees. Or tabletop with patients with an epidural. So I actually see it quite often. That we’re able to deliver and labor and push in a variety of positions.
Dr. Rebecca Dekker:
That’s really interesting because, you know, it’s so interesting, Joyce, you’ve probably seen this as a doula going from. Hospital to hospital, the policies, the practices are different. So it sounds like where Brianna is, upright birth is supported more than other places.
Joyce Dykema:
No, now it is. It’s changed. Yeah. It has changed at the facility that Brianna was at probably in the last three, four years.
Dr. Rebecca Dekker:
It didn’t used to be that way?
Joyce Dykema:
It did not used to be that way. And again, that’s really just, you know, the providers that have privileges there have sort of shifted their mindsets as well as, you know, there’ve been new providers who’ve come. So it’s been a really positive change.
Dr. Rebecca Dekker:
That’s wonderful to hear. And I think this brings me towards the conclusion of the workshop. You know, basically you all sit in a circle and talk about barriers and the main barriers tend to be similar from workshop to workshop, but can I guess the main one was provider pushback? Is that one of the main barriers? Correct me if I’m wrong.
Joyce Dykema:
That’s one of the main ones.
Dr. Rebecca Dekker:
Okay. What were the other ones?
Joyce Dykema:
What do you remember Brianna?
Brianna Fields:
I feel like maybe… Lack of staff. Like, knowledge or tools. Available for the staff to help a birthing person. Is also A barrier, yeah. Lack of staff knowledge or tools. Could be a barrier. During the labor process.
Joyce Dykema:
Yeah, so lack of knowledge.
Brianna Fields:
Yeah.
Joyce Dykema:
And then… With that, if you haven’t seen… An upright pushing stage before you don’t know that it’s a possibility or know that it could be potentially beneficial. So it’s just you don’t know what you don’t know.
Dr. Rebecca Dekker:
Okay. Kind of goes back to the lack of knowledge. So the workshop ends with newer addition that I added to it is I realized that although a lot of the information is empowering, it’s also can be discouraging to be like, I want to do this, but my manager won’t support me or the providers won’t allow it. And one of the things we do at the end is try to help people do a comfort measures exercise for the nurses and the attendees. Joyce, can you describe what that looks like?
Joyce Dykema:
Yeah. So at the very end of the workshop, everybody gets into a comfortable position and that might be sitting with their head down on the desk. It might be laying on the yoga mats. It might be getting into that birth tub and laying down, sitting on the floor, wherever you’re comfortable using the birth stool. And then we play a recording that Rebecca did of a relaxation track and 10 minutes long.
Dr. Rebecca Dekker:
Yeah. Maybe seven to 10 minutes long. Yeah.
Joyce Dykema:
And it’s one of the favorite things about the workshop. From all the attendees. It’s one of their favorites.
Dr. Rebecca Dekker:
Brianna, how did you feel after the relaxation exercise?
Brianna Fields:
Wonderful and relaxed. I thought it was really interesting and cool to experience. I have three cats I’ve never given birth. The only things I know about birth are the things that I’ve seen at work. So, even seeing like a snippet of what I could see being like. Something you could play during labor, I thought that was really cool.
Dr. Rebecca Dekker:
And the thing about that exercise is it’s not just, you know, relaxing, which that’s a hard word to ask someone to do during labor. But it’s it’s guided kind of a meditation with deep abdominal focused breathing and positive thoughts. And kind of letting go of tension and stress. And it kind of takes you back full circle to what we talked about at the beginning about the fear, tension, pain cycle and how anxiety and stress can make people more uncomfortable during labor. And it also helps remind us that. Even as nurses and birth workers, we also need to take care of ourselves. And it’s just really cool to see everybody’s energy when they kind of slowly rise up off the ground. And they feel calmer and more centered. And you realize, wow, this can really work. Like words are powerful. And some of these comfort measures are really. They’re simple and they don’t cost anything. All right, so Joyce, what are the next steps for your workshop attendees after they leave a comfort measures workshop?
Joyce Dykema:
Yeah, that’s a great question. So for the nurses that take a comfort measures workshop, one of the ticket options is to be a super user that’s aimed at the nurse educators, and they can take, you know, lesson plans to their units and teach more of the comfort measures to the rest of the staff. You know, not everybody on staff can usually take a workshop. Somebody’s got to be there on the floor. And so then, you know, you get more continuing education that is aimed at a staff meeting time period.
Dr. Rebecca Dekker:
Okay. Awesome. Yeah. So thank you, Joy, so much for sharing about how you taught the workshop and Brianna, how you experienced it. Brianna, do you have any, you know, final thoughts about how educating yourself on comfort measures will impact your practice as a nurse going forward?
Brianna Fields:
Yeah, absolutely. I feel like it makes me a more rounded nurse to be able to care for my patients. I think that birth is very emotional as well as physical. And caring for the whole person is very important. And some people come in, they don’t have a support person. They don’t have anybody else to be there with, and it’s hard because I think having a doula is such a great tool, but it’s also a privilege as well. And not everybody has that privilege. So it’s nice to know that. I can at least try to be more… Caring holistically of the patient. And I’m really glad that I got to experience. Even a snippet of what doulas do. I think. You know, it’s amazing to be able to work beside everybody. Just thank you for everything you guys do.
Dr. Rebecca Dekker:
Awesome. Thank you, Brianna. And thank you, Joyce. And I just want to remind our listeners, if you want to see if there is a comfort measures workshop for birth pros and labor and delivery nurses coming up near you, just go to ebbirth.com/events and click on I’m a birth pro and you can see the future scheduled workshops. You can also reach out to an EBB Instructor in your area. You can find one at directory.evidencebasedbirth.com and you can find the closest instructors to you, instructors can also teach this workshop online. So we have an in-person version and a totally online version. And also Evidence Based Birth® has published a lot of research on the different comfort measures. We have podcasts on protecting the perineum. We have Signature Articles on birthing positions, water birth, eating during labor, fetal monitoring, and more. So I’ll make sure to link to some of those in the show notes. So if you want to learn more on your own, you can get started that way. Thanks everyone for listening and I’ll see you next week. Bye. Today’s podcast episode was brought to you by the online workshops for birth professionals taught by Evidence Based Birth® Instructors. We have an amazing group of EBB Instructors from around the world who can provide you with live, interactive, continuing education workshops that are fully online. We designed Savvy Birth Pro workshops to help birth professionals who are feeling stressed by the limitations of the healthcare system. Our instructors also teach the popular Comfort Measures for Birth Professionals and Labor and Delivery Nurses workshop. If you are a nurse or birth professional who wants instruction in massage, upright birthing positions, acupressure for pain relief, and more, you will love the Comfort Measures workshop. Visit ebbirth.com/events to find a list of upcoming online workshops.
