Statement on physical assessments; introduction to palpation, fetal heart tones, and vaginal exams in the ALACE Labor Assistant/Birth Doula Workshop.

Philosophy

The ALACE three-day Labor Assistant/Birth Doula Training Workshop has two experiential exercises which also serve as an introduction to three physical assessments: palpation, fetal heart tones, and vaginal exams. Although the majority of ALACE labor assistants/doulas do not choose to offer these services in their practices, these two sections of the workshop are by and large people's favorites. Workshop evaluations continuously reflect that participants found these exercises to be extremely useful in helping them synthesize information from reading, lecture, and discussion. As one woman wrote on her evaluation, "By feeling with my hands I was able to get a better picture in my head and understanding of what I was doing rather than reading about it in a book."

We include these exercises for exactly this reason. By actually palpating a pregnant belly, listening for heart tones with a fetoscope, and feeling a cervix, our workshop participants learn about fetal positioning, pelvimetry, dilation, and station in a way that engages them more thoroughly than if these things were simply discussed. In addition, the palpation/fetal heart tones exercise provides an opportunity to interact with pregnant women at the workshop, which is extremely valuable for learning about appropriate touch and communication with clients. The vaginal exam exercise is another way to practice appropriate touch and interaction, and a good introduction to providing sensitive support during an intimate time, an essential skill for labor support.

ALACE certification does not cover clinical or assessment skills such as palpation, fetal heart tones, or vaginal examination. All ALACE labor assistants/birth doulas are required to sign the ALACE Scope of Practice Statement, which states that ALACE provides only an introduction to these skills.

ALACE supports the right of labor assistants/birth doulas to perform assessments if they are already a midwife, physician, or labor and delivery nurse or have received further training.

However, we discourage routine or frequent vaginal exams in any setting, and by any caregiver. Labor support professionals should never offer assessments while in a hospital or birth center, unless it is at the request of the mother's primary caregiver and with the permission of the mother.

Practice

In our workshops, the palpation and fetal heart tones exercise is done by inviting 4-6 women who are over 30 weeks pregnant into the workshop for about an hour. After a demonstration by the instructor, the group breaks into small sections, who alternate palpating for position, listening for fetal heart tones with a fetoscope, and massaging the woman's feet and/or scalp and neck, if she desires.

The vaginal exam exercise is done on the last day of the workshop, after participants have been together for two full days and feel comfortable with each other. It is an optional part of the workshop, and women who decide not to participate either take an early lunch or, if space allows, watch a video in another room. Men are not invited to participate in this portion of the workshop.

After a demonstration by the instructor, those participating pick partners and break into two groups. The exams are done in such a way as to create a very safe space. Participants wear skirts to protect their own modesty, and the exercise takes just a few minutes. Participants feel for the cervix, ischial spines, sacral curve, and pubic arch. Examinees are asked to perform a Kegel exercise during the exam, which illuminates for both the examinee and the examiner the strength and location of these muscles.

As an additional benefit, after participating in the exams women comment they understand their own bodies much better, and feel empowered by the experience. Many women also express a deep appreciation for the exercises in helping them understand that pelvic exams do not have to be painful, and tell us that this is the first time they have had a painlessexam.

We are very sensitive to the reasons women choose not to participate in the vaginal exam portion of the workshop, and always respect a woman's choice about whether to do so. We exclude women who are pregnant or were recently pregnant from having an exam performed on them, although we will try to accommodate them if they wish to perform an exam on someone else.

ALACE reviews this policy yearly, and is proud to be the only labor assistant/birth doula organization which continues to offer these incredible experiences in our workshops. We believe it provides valuable and diverse skills for our trainees, and is an important part of our ongoing contribution to improving women's health and empowerment across the US and Canada.