It seems we are just now getting through the Covid-19 pandemic and now we have another concern. If you watch the news or scroll social media, it is likely you have heard of monkeypox. As a doula, what do you need to know about monkeypox and pregnancy?

As doulas, we are obviously non-medical and do not need a clinical understanding of concerns. However, it is important we can direct our clients to up-to-date, evidence-based information. It is also important for us to remember universal precautions in general for reducing the risk of illness.

Scientists are learning more. We know some information about monkeypox and pregnancy.

What is Monkeypox?

From the CDC:

“Monkeypox is a rare disease caused by infection with the monkeypox virus. The virus is part of the same family of viruses as variola virus, the virus that causes smallpox. Monkeypox symptoms are similar to smallpox symptoms, but milder, and monkeypox is rarely fatal. Monkeypox is not related to chickenpox.”

What we do know is that unlike Covid-19, this is not spread quite as easily through the air. However, it is still contagious and something to be cognizant of.

Monkeypox can be contracted a few ways, including:

• Direct contact with monkeypox rash, scabs, or bodily fluids from someone who has monkeypox
• Touching surfaces, fabrics, and objects which have been used by someone with monkeypox
• Contact with respiratory secretions
• Close contact during sexual intimacy
• Skin-to-skin or close contact via hugs, massages, etc.
• Prolonged face-to-face contact
• A pregnant person can pass the illness to their fetus

Monkeypox is contagious for up to 2-4 weeks. People are contagious from symptom onset until the rash is completely healed. As monkeypox lasts 2-4 weeks, this means they are contagious during the entire time.

What Do We Not Know About Monkeypox?

We know that it passes person to person as well as from animal to person. However, we are not certain how easily or frequently it spreads. We know the information above.

However, scientists as still researching how frequently it can be passed via respiratory secretions. They are also unsure if someone can be contagious despite lack of symptoms. While we know close contact and bodily fluids can cause infection, they are not certain which bodily fluids can carry the illness (e.g. urine, feces, etc.).

This is where, as a doula, universal precautions come into play. While we remain non-clinical, it is possible for us to come into contact with bodily fluids during a birth. Gloving up if needed, frequent handwashing, etc. are important ways to protect ourselves against a variety of potential illnesses.

Monkeypox During Pregnancy – Are There Risks?

Maternal health professionals are still learning more about monkeypox during pregnancy. Much like during the covid-19 pandemic, it unfortunately takes time to gather data.

What scientists and medical professionals currently know:

• Monkeypox can be pass to the fetus during pregnancy
• Newborns can become infected immediately following birth via close contact
• Spontaneous pregnancy loss and stillbirth, and preterm delivery, have been reported in confirmed cases – it is important to note that we do not have exact data to show causation. We see a potential correlation, but we do not know the exact risk level. Overall risk of loss likely remains low
• While monkeypox is related to smallpox, it appears to remain less severe in symptoms, short and long-term complications, and less likely to cause pregnancy complications

Monkeypox does carry risks associated with pregnancy. However, we do not know what the exact risk level is. It will take time to see if there is more than a correlation between having monkeypox and experiencing a loss. We will need more data to find out if there is a time period in pregnancy where the risks are higher or lower.

Overall, the best way to reduce risk is to follow current recommendations to reduce overall risk of catching monkeypox.

What Does Monkeypox and Pregnancy Mean For Doulas?

As doulas, it is important we stay up to date with current recommendations regarding pregnancy topics. At this time, monkeypox is not spreading at a fast rate like we saw covid-19 spread. However, it does seem to be a valid concern for pregnant people and those trying to conceive.

As a doula, it is important to reduce your risk of catching and thus missing birth or passing illness to your client. You should:

• Practice good hygiene
• Follow any local or national recommendations for reducing spread
• Avoid contact with anyone who is showing signs of any illness (fever, rash, etc.)
• Limit large crowds and travel around clients’ due dates if advised by your local government
• Continue to practice any local covid-19 guidelines
• Keep an eye on any local outbreaks in your area

You can also encourage your clients to follow any recommendations their midwife or physician has for them. Depending on their risk level, occupation, etc., their provider may recommend extra precautions. It can be important to encourage them to follow precautions while also reassuring them not to be anxious as overall risks remain low.

As a doula, you do not need clinical level understanding of any illness. Neither do you need to understand every aspect of public health to support your clients. However, being aware of current issues, recommendations, and hospital policies can be an important part of supporting your clients.

Many of us jump into doula training with a passion for supporting families. We know the benefit of doula support and we expect others do too. However, many of us end up wondering, “How do I get my first doula client?”

We talk to our family and friends about our training. We put up our social media pages and website. And then we wait. We wonder where our first client doula client will come from. Won’t we immediately get clients by simply becoming a doula?

At IDI, we strive to ensure our doulas are fully prepared to work as a doula. We do not simply train regarding birth support. We provide additional business training. Still, it can be difficult to jump in with your first doula client.

What’s The First Step In Finding Your First Doula Client?

One of the most important things for new doulas to do is network. It can be scary and vulnerable to share your new career and passion with people around you. However, the more you talk about your training and work, the more potential first clients you will encounter.

As soon as you begin your training, it can be important to share about your work. Have some cards and pamphlets made. Begin your online presence. This way, when someone is pregnant and looking for support, they will know who to go to with questions. From there, you can share about your services.

Establishing Yourself as a Pregnancy and Birth Expert

As a doula, you will be non-clinical. However, you become a valuable resource of information about everything pregnancy and birth. How? Through our comprehensive doula trainings as well as being committed to self-education.

When you are looking for your first doula client, you need to already be seen as an expert. Taking time to focus on your training, the required reading, and seeking out other evidenced-based sources is vital.

As you begin to learn, be sure to share all you are learning. Answer people’s questions objectively and with evidence. It is okay to have personal preferences and opinions about birth, however, that is not something you want to lead with when answering people’s questions about birth.

Take time to add evidence-based information, resources, etc., to your social media and websites. This will encourage people to come to you when they are pregnant. It will also encourage people who know you to share your information with people they know are pregnant.

Network With Other Professionals To Get Your First Doula Client

One of the best ways to establish a steady client base is to get referrals from other professionals. As you begin your doula training, it can be vital to network with a variety of birth professionals.

Take time to learn about and connect with:

• Midwifery and OB practices in your area
• Chiropractors
• Prenatal massage therapists
• Contact therapists specializing in perinatal mood disorders
• Fellow doulas in your area
• Childbirth educators
• Lactation consultants
• Specialty service providers such as event planners (for baby showers), boutique baby stores, etc.

When you establish a positive rapport with professionals, eventually, this can lead to referrals. It takes time to establish relationships in a way a provider might trust to refer a client to you. Beginning to establish relationships before you are ready to take your first client will make it easier to find a first client when you are ready.

Be Confident!

Every doula must start somewhere. We will all have our first client. It can be difficult to truly trust your skills before you attend a few births. However, the more confident you are, the easier it will be to get hired.

Take time to practice skills with friends. Do all the role-playing activities in your training. Continue to role-play interviews, prenatal visits, etc., so it becomes second nature. This way, once you are ready to seek out your first doula client you will be completely confident.

You do not need to have attended fifty births to be an amazing doula. Yes, we will gain valuable experience with each birth. However, your comprehensive training will give you the tools necessary to support your first doula client in a perfectly professional way.

Taking time to prepare now, before you complete your certification, will make finding your first client much easier than if you wait. Be sure to join our student Facebook group (link is in your student portal) for even more support as you navigate the early part of your doula career.

Half a century ago, continuous fetal heart rate monitoring became the norm with the hope it would improve neonatal outcomes. At the time, we were not sure of the causes behind many cases of cerebral palsy, intellectual disability, and more.

Professionals believed hypoxia, or lack of oxygen, during birth caused poor neonatal outcomes. Making continuous fetal heart rate monitoring standard care, providers hoped to improve outcomes. It made sense, keeping an eye on fetal heart rate. Much of medicine is simply trying new things and observing the results.

Decades later, that has not proven to occur. Continuous FHR monitoring for all does not improve neonatal outcomes. It is, however, associated with an increased risk of c-section birth. What do you need to know as a doula? Read on to learn more.

How Does Continuous Fetal Heart Rate Monitoring Increase C-Sections?

As doulas, it is important to understand that there is a role for FHR monitoring, whether intermittent or continuous. There are specific circumstances where continuous monitoring is safest for baby.

However, what evidence shows for the general population is that continuous FHR monitoring increases the risk of c-section without decreasing poor neonatal outcomes on a population level.

“Only two randomised trials, both published more than 25 years ago, have compared cerebral palsy rates in births monitored electronically or by intermittent auscultation. Cerebral palsy cannot be diagnosed at birth, so infants have to be followed for several years, until a diagnosis can reliably be made. In a trial in 13 079 births in Dublin, evaluation at age 4 years indicated that the rate of cerebral palsy was not lower in children whose births were monitored electronically. A multicentre randomised trial in the US compared 93 singleton, vertex presenting infants with birth weight ≤1750 g whose births were monitored electronically with 96 comparable children monitored by intermittent auscultation. At 18 months of age, the cerebral palsy rate was significantly higher in the electronically monitored group.”

You can read the full publication on the NIH website, published in 2016. Meaning, we have had evidence for years showing fetal monitoring does not necessarily reduce the rate of cerebral palsy. This was one of the main reasons for the initial development and push for continuous monitoring.

Increased C-section

So, what does that have to do with the increased risk of c-section? Well, the variations in heart tones picked up in continuous monitoring can lead to c-sections for fear of fetal distress. True fetal distress does occur. However, normal, temporary, variations in fetal heart tones can show up. This leads to misinterpretation for true fetal distress.

With intermittent monitoring, along with looking at the overall picture of the birther and baby, can reduce c-section rates without increasing poor neonatal outcomes. It is important for providers to begin following evidenced-based information. New guidelines aim to support that.

Do Fetal Heart Rate Variations Always Mean Fetal Distress?

The study mentioned above also states:

“Use of electronic fetal monitoring to prevent cerebral palsy was based on several erroneous assumptions. Firstly, fetal heart rate decelerations are commonly associated with peripheral chemoreflex rather than compression of the fetal head or umbilical cord and may be relatively unthreatening. Furthermore, studies consistently show that most cases of cerebral palsy in babies born at or near term are not caused by birth asphyxia but associated with congenital malformations, fetal growth restriction, intrauterine exposure to infection or inflammation, and other unknown factors.”

Simply put, we are still learning:

• To properly interpret fetal heart tones
• About the cause of poor neonatal outcomes in near or at term babies
• And what all this means in terms of clinical practice

What Are Current Recommendations?

Many birthing facilities have varying policies in terms of continuous fetal monitoring or intermittent fetal monitoring. These policies can vary quite significantly.

However, a new 2022 publication in the Journal of Obstetrics and Gynecology summarizes a new recommendation saying in brief:

“Evidence-based medicine should replace tradition in the use of electronic fetal heart rate monitoring.”

Continuous fetal monitoring use had good intentions. Unfortunately, continuous fetal monitoring showed little benefit across the board. However, tradition remained over evidenced based policy.

In more detail, the journal states the following:

“…after a half century of use and millions of cesarean deliveries based on FHR monitoring, evidence for such improvement remains absent. This dichotomy appears to be related to widespread misconceptions regarding the physiology underlying various FHR patterns and the developmental origins of cerebral palsy. These misconceptions are strengthened by a reliance on anecdotal experience and tradition in lieu of evidence-based medicine, the confusing “category II” FHR designation, medical-legal considerations, and our tendency to view fetal monitoring, as originally conceptualized, as a single, indivisible entity whose concepts must be accepted or rejected en bloc. Ill-defined and largely imaginary conditions such as “depletion of fetal reserve” are particularly harmful and their use in clinical medicine uniquely not evidence based.”

What Does This Mean For Doulas?

As doulas, many of us have long been aware of the risks of continuous fetal monitoring for all births. This means more than just one’s with medical necessity.

There is evidence to support the use of continuous FHR monitoring when baby is at risk of fetal distress. Some examples of that include due to prematurity, congenital birth defect, or the need for Pitocin.

However, for typical birth situations, especially unmedicated ones, continuous fetal monitoring can:

• Increase the risk of c-section
• Discomfort increase
• Limit mobility which can potentially prolong labor
• Increase stress for parents listening to normal heart tone variations

During prenatal meetings with clients, it can be helpful to educate them about birth options. Encourage them to have conversations with their providers about continuous versus intermittent monitoring. Doulas need to take time to provide clients with many resources. Point them to evidenced based resources so they can make informed decisions about their care. Finally, support them in whichever decision they make.