Birth Doula Blog
Why Exploring Your Unwanted Birth Matters
When it comes to labor prep you know to get your body ready for the big day. You will practice yoga, find a breathing technique that works for you, fuel your body with the right food, and become mindful about your body's mechanics. But did you know the most important labor work is mental?
The deepest work you will do in labor is emotional, mental, and spiritual. You will need to surrender to the great mystery that is childbirth. You will not know how or when baby will come. You will need to give up any time limits, expectations, and control in order to go deep within yourself and labor peacefully. Labor is not a time for holding back our primal instincts nor allowing fear to hold us back. It's a time of surrender and acceptance.
Limiting yourself to only one desired birth can greatly impact your satisfaction. If you are adamant on delivering vaginally, the thought of a C-section can be very scary. And if you are looking forward to an epidural, the idea of having contractions for hours on end might make you nervous. But, step back and remember that childbirth is not truly within your control. We can only plan but not demand. We can work with the knowledge and resources available to us. So, do you currently have those resources and knowledge if an "undesired" birth is your only option but you have avoided imaging that experience for yourself? Will you be certain you won't have a C-section, a failed epidural, a long labor? Why you...why not you?
Explore why you don't want medication, a C-section, to feel contractions, to labor at home or the hospital. Have a moment with those thoughts. What makes you uncomfortable about that experience? What fears do you have? What are the possible outcomes? If you had no choice but to give birth that way, what would help you feel better? Can you make room for the fact that the experience you don't want is sometimes necessary or empowering? It's true! There is no ONE way to give birth and even people who give birth completely opposite of you can still feel satisfied.
Finding the balance between hope and expectation will ensure you have a positive experience. Resistance will not grant you permission to accept any possible outcome, and believe me, there are tons of unforeseen outcomes! Now, if you imagine yourself in almost every scenario and gather the resources and knowledge necessary to give birth that way, you have eliminated the fear of the unknown. That fear is what holds us back from acceptance. Fear will put us into the fear-pain-tension cycle that we can't get out of. Fear eliminates acceptance which eliminates satisfaction.
Yes, create your birth plan and envision it, but make room for other truths. Plan for that other birth too and surrender to the great birth mystery.
Curious about doula coverage with Tricare? Read on to learn more and reach out if you have other questions!
Do I need a referral?
If you have Tricare Prime you will need a referral. Tricare Select does not need one.
How do I get a referral?
Find a Tricare approved doula and give her name, NPI, and contact info to your OB or midwife. I recommend you frequently check up on the status of your referral. If your provider is having a hard time creating one for you, speak to Patient Advocacy or contact your PCM.
How do I find a Tricare approved doula?
Log into Health Net or Humana Military. Be sure to search for In-Network and Non-Network doulas. Many newly approved doulas have not been added to the directory, so you could also run a Google search and ask the doula directly if she is Tricare approved.
What's the difference between In-Network and Non-Network doulas?
The main difference for you is that an In-Network doula should not be asking you for payment upfront. They will work directly with Tricare to get paid. Most Non-Network doulas will require you to pay them directly and they will create a bill that you can later submit to Tricare for reimbursement. Non-Network doulas may also charge 15% more than the allowable Tricare amount.
How much does Tricare cover?
The amount is specific to location, but the average total is about $966.
Will there be any out of pocket costs?
A Non-Network doula is allowed to charge up to 15% more than the allowable amount. However, if the total cost of any doula's package is more than that, she might give you two bills: one for Tricare and another for the difference that Tricare does not cover and it might include additional services. Ask up front what your out of pocket costs will be after reimbursement.
How do doulas bill Tricare?
All In-Network doulas directly bill Tricare as do a few Non-Network. However, the majority of Non-Network doulas will provide you with a bill that will itemize your number of visits and your labor details. You will see the total you paid her broken up amongst those visits.
Does a doula have to provide me with the six allowable visits?
No, she will likely provide you with the same amount of visits she offers to her non-Tricare clients.
Are virtual prenatal visits covered?
Will I be reimbursed for virtual labor support?
No. Ask your doula what your financial responsibility is if labor support becomes virtual
What if a backup doula is used?
Only a Tricare approved backup doula is eligible for reimbursement. If a non-Tricare doula is used, you might have to pay out of pocket for her service. It is illegal for your original doula to bill Tricare for a labor she did not attend. Ask if your doula's backup is also Tricare approved.
If you are on Prime, you might have a tricky time getting reimbursed for that Tricare approved backup because your referral has been made to only one doula.
If you are on Select, both Tricare approved doulas should be covered as you do not have a referral with only one name tied to it.
Will I be reimbursed if labor ends in a C-section or loss?
Tricare will reimburse the cost of labor no matter the outcome as long as the doula provided any amount of in-person support.
What if I no longer need doula support or she fails to make it?
If you schedule a C-section and choose not to have a doula, if you fail to call your doula, or if she doesn't make it in time to provide in-person support, you may incur out of pocket costs or she could offer additional services in lieu of reimbursement. Make sure your contract details both of your financial responsibilties in the event of failure to provide services.
Will the demonstration cover postpartum doulas?
No. However, an approved labor doula may choose when to use her six allowable visits.
When can I set up visits with a doula?
You may hire a doula at any point during your pregnancy but Tricare will not cover sessions before 20 weeks.
How do I submit a bill for reimbursement?
Most Non-Network doulas will provide you with a super bill that will include codes and fees. You will need to mail this along with DD Form 2642 to the appropriate address. You have one year from date of service to submit your claim. If your claim is denied, reach out to your doula ASAP so she can make any corrections. Most claims are processed by Tricare within 30 days (but could take up to 90) and a check will be mailed to you. You can check the status of your claim by logging into your Tricare portal or giving them a call.
How to Have a Successful Hospital Birth
Tips From a Doula Who Knows What Works
Maybe the hospital amenities or sense of safety have drawn you in. Or maybe you can't imagine delivering without your rock star team. Or maybe hospital births are just the way things are done. Whatever the reason, I'm sure you want to make it the best possible experience and avoid any unnecessary interventions.
BEFORE YOU GO
•Read up on your hospital's policies and discuss the ones you aren't comfortable with to try and find a compromise or alternative with your care team.
•Tour the hospital and learn how to enter the labor and delivery department (after hours too). Find out what the in-processing procedure looks like, what you can sign ahead of time and what is done during triage. Ask what signs you need to show before being admitted.
•Take a birth class so there are no surprises when you go into labor. You'll be able to speak the lingo and understand your options.
•Find out what your hospital offers for pain medication and learn about their risks and benefits.
•Pack light! You don't want to clutter the already small labor room with stuff you truly don't need. The most unnecessary items I've seen are excessive clothes for parents/baby and tools that parents were hoping to use during active labor but didn't even use during early labor or pregnancy. Find out what your stay already includes. See here for what to bring.
•Stay home as long as possible. The goal is to check in to the hospital at no less than 6 cm when labor is well established. Early labor (0-6 cm) is the longest part of the whole event and can easily be spooked away. You don't want to extend your hospital stay by going in too soon. Also, the longer you're there, the more prone you are to having unnecessary interventions.
AT THE HOSPITAL
•Become an informed decision maker! Understand your rights as a patient and know when you can opt out of anything that doesn't sit right with you even if it seems "mandatory." And speak up if you have questions. Nurses can be flexible but they won't know you disagree or aren't comfortable unless you say something.
•Bring a sign that has your top 3 labor wishes and tape it to the door so all the nurses are informed and you don't have to keep repeating yourself.
•If you don't have any IV meds, choose intermittent monitoring. Did you know continuous monitoring increases your chances of having a C-section?!
•If you need continuous monitoring, opt for a wireless monitor to retain your mobility. Movement is a huge part of successful delivery!
•Put off any pain meds until you're at 6 cm (active labor) to avoid a potential stall.
•If you opt for an Epidural, have it turned off or greatly reduced at 8-9 cm so that you have enough feeling to be able to actively push in order to avoid tearing.
•If an intervention is mentioned, ask if you have time or options...you almost always do.
•Change position every 30 minutes, even with an Epidural.
•Pee often. A full bladder gets in the way of baby's path.
•If unmedicated, opt out of directed pushing and go for spontaneous pushing in order to avoid tearing.
One last tip! I know you think you'll remember this day forever, but trust me, write it down. Take a few minutes to type or voice record your story. Life happens, birth stories blend and before you know it it's gone.
Is This Thing On??
A few weeks ago I was invited to be a guest on Julie Jacobs's wonderful podcast Goddesses Gather Here. And like the name implies, this is a podcast for amazing women to lift each other up, share their journeys, and offer advice so you too can become a goddess.
I met Julie at a meeting for military spouse entrepreneurs. I was seated quietly at the end of the table (as I had arrived late) and Julie was actively taking part in the conversation. I knew she was a force of a woman by the look of her bold red lips and when she mentioned the name of her podcast, I just knew I had to meet her! There is something so special about women recognizing, creating, and supporting other strong women.
And that's what I do as a doula...I get to witness strength being born. I help women find confidence during their pregnancy so that they can have an empowered birth.
Listen here to learn more about why I got into doula work, what my favorite part is, and what lies ahead for me.
Happy listening, friends!
Tricare Doula Coverage
On January 1, 2022, Tricare debuted their Childbirth and Breastfeeding Support Demonstration which will run until December 31, 2026. This demonstration seeks to study the impact birth doulas and lactation counselors/consultants have on the services of cost, quality of care, and maternal and fetal outcomes for the Tricare population.
In order to get reimbursed for doula services, you must:
•Be at least 20 weeks pregnant upon our first prenatal visit
•Be enrolled in Tricare Prime or Tricare Select
•If you have Tricare Prime, obtain a referral from your PCM to see a provider for the management of your pregnancy AND for doula services
•Choose prenatal care with a Tricare authorized OB/GYN or a Certified Nurse Midwife (CNM)
•Choose in-person labor support. Prenatal and postpartum visits may be in-person or virtual
•Use Tricare as your primary insurance
If you do not meet the above requirements, Tricare will NOT reimburse you and you will be financially responsible for any services provided. It's important to note that virtual labor support or births that take place at an MTF (military hospital) are not covered under this demonstration.
Most doulas, like myself, are participating, non-network certified providers for Tricare, which means you will likely pay out of pocket for services and will be reimbursed by Tricare when services are rendered. You will likely follow the fees and payment schedules outlined in your Birth Doula Services Contract. The doula will be responsible for creating one itemized bill after the postpartum visit or individual ones after every visit that you can submit to Tricare for reimbursement. My specific bill will include dates, location and codes for all of the prenatal visits, birth and our postpartum visit. Itemized bills will total what I advertise on my website for the package you have chosen and I will not bill you more in order to get the maximum allowed fees from Tricare. I do not intend to take advantage of my clients or Tricare.
The allowable reimbursement fees under the demonstration are as follows:
•Up to six antepartum and postpartum visits at a rate of up to $46.00 per visit. Visits are untimed and only one is allowed per day.
•Continuous labor support at a rate of up to $690.00 regardless of length of time and outcome.
Tricare approved doulas have met all of the following requirements to be a Certified Labor Doula under this demonstration.
•Attended a training curriculum of at least 24 hours for doula training
•Attended a breastfeeding course
•Attended a childbirth course
•Provided continuous labor support for at least three births in the last three years, with a minimum of 15 hours over the three births
•Provided antepartum and postpartum support for at least one birth
•Hold a current child, infant, and adult CPR certification
•Have a NPI
The reimbursement and billing process is very new to doulas and Tricare, but I will do my best to work with you and Tricare to ensure you get reimbursed through Humana Military. Every doula has chosen their own conditions when it comes to accepting Tricare beneficiaries. Contact me if you'd like the specific details of my contract.
Sometimes the amount of info out there regarding VBAC can be overwhelming, confusing, and at times plain false! It can be tricky navigating through all that noise, so I've narrowed it down for you. Read on to learn how YOU can stay informed and in control of your care.
Your provider is a key person in the success of your VBAC and it's very important to find someone who is supportive, not just tolerant. Remember that yes, no one can legally force you to have a C-section nor deny you care even if the hospital has a VBAC ban, but it's also important to know ahead of time if your hospital has the tools and staff to support a true C-section emergency. You really can't force a hospital to treat you if they don't have the means. And if your provider is suggesting a repeat C-section, don't dismiss the advice so quickly. Really talk to them about their concerns to find solutions and compromises. Sometimes having a repeat C-section is truly medically necessary and your best option.
Next time you see your provider ask:
•How long will you allow me to remain pregnant? Why do you prefer that date?
•Will we attempt an induction? Which methods will be used?
•How will I be monitored during labor?
•How do you feel about me laboring as long as possible as long baby and I are doing well?
•At what point during labor will a C-section be needed?
Also, ask yourself:
So, you've decided on getting a doula, what now? To give yourself a few options, interview at least three candidates and choose based on the connection, not just on the fee, experience, or reputation. A pricey doula doesn't necessarily mean she's giving you quality support. An experienced doula doesn't always mean she's right for YOUR experience. And a popular one is simply one who's talked about, but there might be another one who could be a best kept secret. Ask the following questions to get to know the person she is, her values, work ethic and client-doula relationship. Make sure you and your partner both get the same positive vibe and that she meets your individual priorities.
P.S. If you decide to pass on her, be courteous and let her know. It's just the nice thing to do!
ALL The Doula Questions
•What doula education or training do you have?
•Do you carry liability insurance?
•What is your philosophy about birth?
•How do you feel about my desired birth? What are your favorite and most challenging aspects of a labor like mine?
•What sets you apart from other doulas?
•How soon do you reply to messages and emails?
•How many births do you attend a month?
•Do you have a backup and can I meet her?
•Do you have experience at the place I'm birthing and what do you think of it? *If a doula isn't quite comfortable at that place, ask why.
•What do your refund policies and contract entail?
•Do you have any beliefs that will prevent you from being 100% supportive of my labor and newborn wishes?
•How many times will we meet? What if I need more visits?
•What does labor support look like with you? Do you bring tools?
•When should I call you for labor support?
•Do you offer a postpartum session and what's included?
•What do you love the most about being a doula?
•What is the hardest part of your job and how do you handle that?
•Why did you become a doula? (My personal favorite to answer!)
All About Epidural
'I'm a straight shooter so I'll start by saying that there is a time and place for an epidural. Personally, I believe its overused, rarely necessary, and not fully understood by laboring people. If the immediate and future benefits and risks are truly considered then I see no problem with the use of an epidural. My biggest issue with it is that the promise of quick pain relief overshadows the uncomfortable prep work that is needed prior to administration, the potential risks during its use, and the effects after it's been removed. That being said, there are actual circumstances in which the benefits outweigh the risks.
But, Do I Really Need a Doula?
So, maybe you are new to this doula thing or all of your friends have gotten one for their labors and swear they couldn't have done it without the help of a doula. Now you're wondering if you should get one too. I mean, all the cool kids are doing it, right?
Even though I'd love your business, I'm not going to lie to you. Doulas aren't the only ones who can can improve your birth experience. I say it all the time, surround yourself with the RIGHT people! Studies have shown that having doula support during pregnancy and labor can decrease your chances of a C-section, need for pain medication, and assisted delivery. We can also increase your overall satisfaction with your birth experience and improve breastfeeding and bonding outcomes. But how does a doula have that effect and can anyone else give you those amazing outcomes?
Well, lean in and I'll tell you a secret. Doulas aren't magical beings who also happen to be good luck charms in scrub pants. We are just people who know, care, and do! What sets us apart from nurses is that we provide continuous labor support (something nearly impossible for hospital staff) and we've also established a relationship with the parents during pregnancy. And what sets us apart from your partner is that we have lots of birth knowledge and experience.
You might be wondering, "Can't my husband or my sister be my doula?" Answer: Absolutely yes, but there is a big but! There's nothing more powerful than love and safety during labor and no one can provide it better than your partner. Deep gazes and physical touch from your partner or close friend increase the oxytocin levels responsible for strong, effective contractions. They likely have me beat in the love department and I am thankful to have them on the team. But, this is where the big BUT comes in...your partner/sister likely doesn't have the knowledge and experience a doula has. I wish love alone could carry you through labor, but you need someone who will tell you things straight up, offer solutions and options, and help you make sense of the process.
Here's the good news, though. If you have a partner/friend who is feverishly committed to taking an active role in the birth experience, then they definitely can help! Having a partner or friend present at birth can still give you similar results to a doula. Here are my recommendations to having a rockstar experience with a loved one as your doula.
Your support person should:
• Read The Birth Partner by Penny Simkin to learn how to physically, emotionally, and informationally support you
• Attend a birth class
• Discuss your birth wishes to truly understand what you want, why they're important, and how they can support them
• Practice touch techniques with you and use birth tools during pregnancy
• Watch YouTube videos that show the kind of birth you're hoping for
• Understand what your options are if things don't go as planned
• Be willing to offer you non-judgmental advice
Truly ask if your partner/mom/sister is willing to meet ALL of these requirements. Doulas are effective because we are prepared and educated. You need to make sure your partner is as well. If you're still on the fence on whether or not they've got what it takes, you can still hire a doula and have her take a different role to help guide your partner and step in when needed.
Down There Prep and Care
\Let's talk perineal prep and care! Many women wonder if they will tear during a vaginal birth and if they can do anything to prevent it.
WHY DO TEARS HAPPEN?
Contrary to popular belief, a baby with a larger head isn't always the cause of tears. They typically happen when the perineum doesn't have enough time to gradually stretch due to a baby who's emerging very quickly or if the skin doesn't easily stretch even with a slowly emerging head. During the pushing stage, you might have a provider tell you to slow down your urge to push if they believe the skin hasn't fully stretched. This is easier said than done, but some controlled breathing, small grunts, or laying on your side can help slow down the process.
Tears may also occur if baby is malpositioned. Getting in certain positions can encourage baby to turn into an ideal position to prevent a tear. Laboring upright for too long can also apply too much pressure on your perineum. I suggest you switch positions every 30 minutes. Pushing with an Epidural means you may end up with directed pushing, where the nurse tells you when and how long to push. Directed pushing could sometimes be ineffective and exhausting because you can't properly feel the urge to push or recognize the muscles required to push. I recommend you turn down/off the Epidural at 8-9 cm. so that you can feel your pushing urges and listen to your body. It'll know how and when to push.
Lastly, you're more likely to tear for your first vaginal delivery than subsequent ones.
CAN TEARS BE PREVENTED?
While no one can predict if you'll tear, you can definitely help yourself during labor by forgoing numbing meds such as an epidural or getting a low dose of them. If you are unable to feel your urge to push, the staff will likely direct you to push before your body is ready, before your perineum is ready. This unnecessary pressure against your perineum can increase your chances of tearing.
During labor, a warm compress to the area can help relax the muscles, provide counterpressure, and help you focus on where your pushing muscles are.
Studies have also shown that laboring with a midwife or at a birth center/home setting reduce your chances of tearing. Midwives are known to do less interventions, which can lead to tearing. And laboring in a comfortable environment such as your home leads to better outcomes due to your relaxed nature.