La palabra doula es en griego una mujer que sirve a otra. La doula hoy se es a una mujer experimentada en el parto y el puerperio, que acompaña a la madre dándole apoyo emocional y físico y ofreciéndole información de forma empática. La doula no tiene responsabilidad en la esfera clínica.
Durante toda la historia del ser humano y en la mayoría de las culturas es habitual que la madre esté acompañada en el parto por otra mujer que, experimentada, le ofrezca sobre todo apoyo emocional y logístico. Esta costumbre desapareció en la cultura occidental industrial al llevar el parto al ámbito hospitalario. A partir de entonces ese apoyo y compañía era brindado de forma esporádica y frecuentemente insatisfactoria por le personal hospitalario. Actualmente ya se permite que el padre esté presente en el parto, pero esta presencia, que es importante, no ofrece siempre la contención y experiencia que algunas mujeres precisan y son pocas las madres que son acompañadas permanentemente por otra mujer.
El papel de la doula en el parto es estar atenta y actuar para que la mujer tenga un buen recuerdo de su parto. Le habla, ofrece sugerencias a la parturienta o a su acompañante, ayuda a interpretar las explicaciones médicas, le puede ayudar a moverse o a tomar otra postura más cómoda. Su función es cuidar el estado emocional de la mujer y velar para que el ambiente de su parto sea íntimo y seguro. La presencia de la doula en el parto domiciliario está bastante extendida- Sin embargo, en el caso de parto hospitalario, es conveniente llegar a un acuerdo previo con el personal médico para que su presencia sea aceptada.
La doula puede dar un masaje, poner aromas o música suave, vigilar que la luz sea adecuada, ralentizar las visitas, pero lo más valorado es el modo en el que acompaña a la madre sin juzgar, con palabras positivas, aceptándola completamente.
Algunos estudios han relacionado la presencia de una doula en el parto (Klaus MH, Kennel JH, Klaus, PH, 2002) con una reducción de la duración del trabajo de parto, de la necesidad de anestesia o analgesia, de la incidencia de cesáreas, de la necesidad de aceleración con oxitocina y una mayor incidencia de partos naturales.
Es España no está generalizado el acudir a ellas, pero cada vez son más y están mejor formadas, ofreciendo a las madres el acompañamiento femenino seguro y sostenedor que habíamos perdido.
Continuous emotional support during labor in a US hospital. A randomized controlled trial
J. Kennell, M. Klaus, S. McGrath, S. Robertson and C. Hinkley
Department of Pediatrics, Case Western Reserve University, Cleveland, OH.
The continuous presence of a supportive companion (doula) during labor and delivery in two studies in Guatemala shortened labor and reduced the need for cesarean section and other interventions. In a US hospital with modern obstetric practices, 412 healthy nulliparous women in labor were randomly assigned to a supported group (n = 212) that received the continuous support of a doula or an observed group (n = 200) that was monitored by an inconspicuous observer. Two hundred four women were assigned to a control group after delivery. Continuous labor support significantly reduced the rate of cesarean section deliveries (supported group, 8%; observed group, 13%; and control group, 18%) and forceps deliveries. Epidural anesthesia for spontaneous vaginal deliveries varied across the three groups (supported group, 7.8%; observed group, 22.6%; and control group, 55.3%). Oxytocin use, duration of labor, prolonged infant hospitalization, and maternal fever followed a similar pattern. The beneficial effects of labor support underscore the need for a review of current obstetric practices.
Br Med J (Clin Res Ed). 1986 September 6; 293(6547): 585–587. PMCID: PMC1341377
Effects of social support during parturition on maternal and infant morbidity.
M H Klaus, J H Kennell, S S Robertson, and R Sosa
AbstractBecause continuous social support during labour is a component of care in many societies but inconsistent in our own, the clinical effect of support during labour on maternal and neonatal morbidity were studied. Social support was provided by female companions. Four hundred and sixty five healthy primigravidous women were enrolled using a randomised design. Compared with 249 women undergoing labour alone 168 women who had supportive female companions throughout labour had significantly fewer perinatal complications (p less than 0.001), including caesarean sections (7% v 17%, p less than 0.01) and oxytocin augmentation (2% v 13%, p less than 0.001), and fewer infants admitted to neonatal intensive care (p less than 0.10). Of the women who had an uncomplicated labour and delivery requiring no interventions, those with a companion had a significantly shorter duration of labour (7.7 hours v 15.5 hours, p less than 0.001). This study suggests that constant human support may be of great benefit to women during labour.
Female relatives or friends trained as labor doulas: outcomes at 6 to 8 weeks
postpartum.Campbell D, Scott KD, Klaus MH, Falk M.
Graduate Division, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.
BACKGROUND: Data collected on more than 12,000 women in 15 randomized controlled trials provide robust evidence of the beneficial effects of doula support on medical outcomes to childbirth. The objective of this paper was to examine the association between doula support and maternal perceptions of the infant, self, and support from others at 6 to 8 weeks postpartum. The doula was a minimally trained close female relative or friend. METHODS: Six hundred low-risk, nulliparous women were enrolled in the original clinical trial and randomized to doula support (n = 300) or standard care (n = 300). The mother-to-be and her doula attended two 2-hour classes about providing nonmedical, continuous support to laboring women. For the secondary study, presented here, research participants (N = 494) were interviewed by telephone using a 42-item questionnaire. RESULTS: Overall, when doula-supported mothers (n = 229) were compared with mothers who received standard care (n = 265), they were more likely to report positive prenatal expectations about childbirth and positive perceptions of their infants, support from others, and self-worth. Doula-supported mothers were also most likely to have breastfed and to have been very satisfied with the care they received at the hospital. CONCLUSIONS: Labor support by a minimally trained female friend or relative, selected by the mother-to-be, enhances the postpartum well-being of nulliparous mothers and their infants, and is a low-cost alternative to professional doulas.
PMID: 17718872 [PubMed- indexed for MEDLINE]
1: J Obstet Gynecol Neonatal Nurs. 2006 Jul-Aug;35(4):456-64
A randomized control trial of continuous support in labor by a lay doula.Campbell DA, Lake MF, Falk M, Backstrand JR.
Study on Sleep & Functional Performance in Heart Failure at the University of Medicine and Dentistry of New Jersey, School of Nursing, Newark 07101-1709, and Division of Maternal Fetal Medicine, Saint Peter's University Hospital, New Brunswick, NJ, USA.
OBJECTIVE: To compare labor outcomes in women accompanied by an additional support person (doula group) with outcomes in women who did not have this additional support person (control group). DESIGN: Randomized controlled trial. SETTING: A women's ambulatory care center at a tertiary perinatal care hospital in New Jersey. PATIENTS/PARTICIPANTS: Six hundred nulliparous women carrying a singleton pregnancy who had a low-risk pregnancy at the time of enrollment and were able to identify a female friend or family member willing to act as their lay doula. INTERVENTIONS: The doula group was taught traditional doula supportive techniques in two 2-hour sessions. MAIN OUTCOME MEASURES: Length of labor, type of delivery, type and timing of analgesia/anesthesia, and Apgar scores. RESULTS: Significantly shorter length of labor in the doula group, greater cervical dilation at the time of epidural anesthesia, and higher Apgar scores at both 1 and 5 minutes. Differences did not reach statistical significance in type of analgesia/anesthesia or cesarean delivery despite a trend toward lower cesarean delivery rates in the doula group. CONCLUSION: Providing low-income pregnant women with the option to choose a female friend who has received lay doula training and will act as doula during labor, along with other family members, shortens the labor process.
PMID: 16881989 [PubMed - indexed for MEDLINE]
1: Matern Child Health J. 2008 May;12(3):372-7. Epub 2007 Jul 3
A hospital-based doula program and childbirth outcomes in an urban, multicultural setting.
Mottl-Santiago J, Walker C, Ewan J, Vragovic O, Winder S, Stubblefield P.
Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, 91 East Concord Street, Rm 4113, Boston, MA 02118, USA. Julie.MottlSantiago@bmc.org
OBJECTIVES: The objective of this study is to determine whether there are differences in birth and breastfeeding outcomes for women who received labor support through a hospital-based doula program, compared with those who did not receive doula support in labor. METHODS: We conducted a retrospective program evaluation to compare differences in birth outcomes between births at 37 weeks or greater with doula support and births at 37 weeks or greater without doula support through the first seven years of a hospital-based doula support program. Log-binomial regression models were used to compare differences in cesarean delivery rates, epidural use, operative vaginal delivery, Apgar scores, breastfeeding intent and early breastfeeding initiation after controlling for demographic and medical risk factors. The propensity score was included as an additional covariate in our regression model to minimize issues of selection bias. Analyses were conducted for the whole cohort of 11,471 women and by parity and provider service in subgroup analyses. Cochran-Mantel-Haenszel test was performed to detect differences in effects over time. RESULTS: For the whole cohort, women with doula support had significantly higher rates of breastfeeding intent and early initiation. Subgroup analysis showed that having doula support was significantly related to: (a) higher rates of breastfeeding intent and early initiation rates for all women regardless of parity or provider with the exception of multiparous women with physician providers; (b) lower rates of cesarean deliveries for primiparous women with midwife providers. CONCLUSION: A hospital-based doula support program is strongly related to improved breastfeeding outcomes in an urban, multicultural setting.
PMID: 17610053 [PubMed - indexed for MEDLINE]
martes, 4 de noviembre de 2008
domingo, 2 de noviembre de 2008
Pregnancy, depression, antidepressants
Pierre Blier, MD, PhD
University of Ottawa Institute of Mental Health Research, Ottawa, Ont.
“Pregnancy protects against depression.” This is a common
belief, perhaps based in part on some women experiencing a
heightened feeling of emotional well-being during pregnancy.
However, the evidence indicates otherwise. In particular,
pregnancy is a high-risk period for a relapse of depression.
A recent prospective study, conducted on 201 patients
who had been euthymic for at least 3 months, examined relapse
rates over the course of pregnancy.1 Women who discontinued
their medication had more frequent relapses when
compared with women who maintained their medication,
with a hazard ratio of 5.0. Moreover, in the women who discontinued
their antidepressant, the reintroduction of medication
decreased the risk of relapse, but to a much lesser extent
than if medication was continued throughout pregnancy.
Therefore, transient interruption of medication may still predispose
pregnant women to a negative outcome. In addition,
allowing major depression to occur during pregnancy may
result in a negative impact on fetal conditions. Because the
placental barrier is limited in its capacity to protect the fetus
against the systemic perturbations that depression can produce,
it appears imperative to prevent depressive relapses
from occurring. The endogenous substances that can be produced
in greater concentrations during depression, and
could have a negative impact, include cortisol and catecholamines.
The former can lead to increased corticotropinreleasing
factor production, which can induce premature
labour, whereas the latter can alter uterine blood flow and induce
uterine irritability.2,3 Finally, depressed mothers may
have a decreased appetite and may be more at risk of using
alcohol or illicit drugs, factors that can have a negative impact
on the fetus.4,5 Therefore, it is important to weigh the
benefits of not allowing depression to occur during pregnancy
against the risks of using antidepressants during this
period. The use of antidepressants clearly offers a protective
influence against such relapse.
“Antidepressants increase the risk of congenital malformations
and perturb organ development.” Again, the evidence
indicates otherwise. Reviews of the literature indicate that
antidepressants, especially selective serotonin reuptake inhibitors
(SSRIs), do not increase the risk of major and minor
malformations.6–9 However, there would appear to be a small,
but statistically significant, increased risk of spontaneous
abortions with SSRIs. The role of depression itself cannot be
eliminated as a contributing factor to this increase from 8.7%
to 12.4%.10 More troublesome is a recent study reporting an
increase of persistent pulmonary hypertension of the newborn
(PPHN) in babies whose mothers were exposed to SSRIs
after the first 20 weeks of gestation.11 This study reported that
14 infants with PPHN had been exposed to an SSRI (3.7%)
versus 6 control infants (0.7%). Nevertheless, it is important
to mention that the crude risk of PPHN at any time in pregnancy
was not increased by SSRI exposure. This seemed to
result from an apparent, though not significant (p = 0.08),
protective effect of SSRIs in the first 20 weeks. It is also possible
that the finding resulted from studying a small number of
subjects. As an illustration of the latter possibility, the number
needed to treat to obtain 1 PPHN was 200. This study
cannot establish causality, as pointed out by the authors
themselves, but it is well known that serotonin has mitogenic
and comitogenic effects on pulmonary smooth-muscle cells
that can produce pulmonary hypertension (PH).12,13 It was
thus postulated that elevated circulating levels of serotonin,
presumably resulting from reuptake inhibition by the SSRIs,
could be responsible for the proliferation of smooth-muscle
cells seen in PH.11 The problem with this hypothesis is that
SSRIs have been shown to protect against smooth-muscle hyperplasia
in the pulmonary bed.14 This is because serotonin
reuptake inhibition in the periphery decreases circulating levels
of serotonin, since platelets can no longer store serotonin
through reuptake,15 thereby decreasing any potential release.
Correspondence to: Dr. Pierre Blier, University of Ottawa Institute of Mental Health Research, Royal Ottawa Hospital, LG 2043,
1145 Carling Ave., Ottawa ON K1Z 7K4; fax 613 761-3610; firstname.lastname@example.org