The following post is a reprint of an article as it appears DONA International monthly publication, International Doulas.’ Originally published in December 2014 issue.

In some parts of the country, introducing a Doula to the birth experience is as natural as the sun shining in the sky. The relationship of mom / partner / doula is so common that those of us in the birth community do not even bat an eyelash.  But what happens when the family being supported is nontraditional?  How does the doula work change? Gestational surrogate, a woman choosing to carry and deliver a child for another couple.

This spring Vonda Boyd had the privilege of working with an experienced surrogate that wished to have a very specific type of birth.  After four previous surrogate pregnancies, this woman knew her body very well.  She knew how to carry, how to labor,  and how to deliver in a way that best suited her, but the intended parents for this birth were culturally very different so she contacted us for support in navigating the relationship with them.

As a birth professional of sorts, the surrogate had an understanding of doulas and wished to connect with someone experienced, having a broad range of talents. The surrogate wanted to confidently handle any scenario that would arise in this delicate process, so she called upon certified birth and Postpartum HypnoBirthing® instructor, Vonda Boyd CD(DONA),CPD(DONA),HBCE. The surrogate was particularly drawn to Vonda’s postpartum work because of the special task of transferring the baby to another couple.  BOTH parties would require emotional and logistical assistance, and a postpartum doula is uniquely qualified in those types of transitions.

The Doula Perspective

From the doula perspective, Vonda handled the gestational surrogate as she would any other client.  She attended prenatal appointments, shared information appropriate to the woman’s stage of pregnancy, and was simply a good friend.

Initially, the surrogate’s expectation was that she would contract a doula, have the baby, then — to protect herself from connecting to a child that would soon go home with another couple — the doula would step in to facilitate newborn bonding with the intended parents.  However after connecting with Vonda, as the days progressed, the surrogate realized just how supportive a doula could be!  She could lean on the doula for information, have company at doctor visits, receive assistance with communicating with the intended parents, and so much more.  Rather than travel this unique experience alone, now both the gestational surrogate and the intended parents had an ally!

Unique Circumstances of Pregnancy

What would a doula need to prepare for when working with a surrogate or intended parent?  What circumstances might arise above and beyond a traditional client?

•     Geographical distances. Many times, the surrogate mother and intended couple do not reside in the same city.  This doesn’t cause difficulty since the roles are typically quite independent until the birth, but it does create a logistical hiccups.

•     The child the surrogate is carrying will go home with another couple. As much care as is taken during the process, there is always a special emotional component to this experience.

•     The surrogate has their own life and family. Surrogates still maintain husbands, kids, and jobs outside of this process, and the doula needs to connect with them all.

•     Distance by surrogate’s natural family. While not the case with this client, some surrogates contend with a spouse’s desire to remain distant in order to stay detached from baby.  In this case, the surrogate’s spouse was totally supportive but unavailable due to work commitments.

•     Information exchange across many levels. Whereas a traditional birth only includes mother and partner a surrogate birth includes more than one couple, a surrogate’s biological family, typically larger medical provider and hospital teams, legal counsel for surrogate and intended parents, and often a surrogacy agency.  This exponentially increases the number of people that must remain informed. It is easy for the surrogate to become overwhelmed.

•     Multiple birth plans. Similar to the typically simple information exchange, surrogates must prepare their own birth plans but also take into account the wishes of intended parents.  This could range from food and lifestyle preferences to laboring and birth techniques.

•     Induction and interventions. If the birth is induced in order to ensure all parties are available to attend the birth, a doula will need to be prepared to support that process and possibly other interventions. This is an important note for doulas that primarily work with unmedicated birth clients.

•    Increased support system for doula. Every birth is both exciting and exhausting for a doula. A surrogate birth, however, can be increasingly more so due to the additional number of people and heightened emotions involved. It takes a unique individual to navigate the experience and still remain neutral.

•     Lactation support. If the intended parents opt for breast milk following the birth, this circumstance also has to be approached with care.  In order to balance the new parents’ desire for a strong milk supply and preservation of the surrogate’s privacy and feelings, much thought and sensitivity is required.  Logistics must also be considered.

Two Clients one Doula

At the second prenatal meeting, after the surrogate had really clicked to the idea of how supportive a doula was and how smooth she could make the birth experience, she introduced Vonda to the intended mother.   Contractually, the doula’s relationship is with both parties, so at that time and with the surrogate’s permission Doula Vonda became a free-flowing conduit of information. She kept both women informed on the other’s preferences.  The surrogate connected with Vonda on her labor birth plan while the intended mother connected with Vonda on her birth and postpartum plans and handling a newborn. Vonda’s role was to ensure those two pieces met seamlessly.

A testament to Vonda’s skill as a doula is the fact that BOTH women felt completely comfortable sharing this experience with her.   Vonda gracefully alternated between the two sets of needs and the two differing viewpoints without anxiety of any kind.  Her diplomacy provided a level of privacy for both sides and eased the transition.

The Birth

To ensure the intended parents could be in town for the birth, all parties agreed labor to induce labor.  When Doula Vonda arrived at the hospital, the surrogate’s biological children were present but left before the induction began to preserve the intended parents’ privacy.  This is not uncommon.  That placed the doula in the role of sole companion.

Considering the special circumstances, this birth drew a lot of hospital staff attention.   Their legal counsel made an appearance prior to the induction getting underway and again after the birth.  There was also a steady stream of nurses throughout.  Other than being presented with two birth plans, things were quite routine.  The surrogate labored beautifully throughout the day.  She REALLY knew her body and how it responded to each stage.  The doula alternated between supporting the surrogate and preparing the intended parents for what would come next.

As the pushing phase neared, the nurses did a wonderful job of staging the room so, logistically, each party could best perform their role: doula could easily comfort, nurses could easily access their patient, and the intended parents could receive the child and stand by for immediate skin-to-skin as outlined in their birth plan.

When the baby arrived, he went directly to the intended parents.  Doula Vonda remained with the surrogate.   Since she had been through this process before, the surrogate knew what to expect and demonstrated very little emotion during the transfer.  On the other hand, the intended parents were quite excited and needed lots of support to feel comfortable.  Doula Vonda remained much longer than is typical in order to settle all parties.  Luckily, the hospital provided the intended parents with a room across the hall, and the doula was able to easily move back and forth.

Closing the Loop

In addition to continued emotional support for both parties after birth, there also came the work of establishing lactation.  Late in the pregnancy, as both women saw the strength of Doula Vonda’s support, they agreed they would establish breastfeeding with the surrogate before moving to pumping.   Understanding the benefit of having baby nurse first to increase milk production then pumping, the baby went to the surrogate’s breast shortly after birth. The doula would remain onboard in a postpartum role because — with her help — both women trusted it would be a smooth, effective process.  Baby remained on a consistent feeding schedule until a good flow was established.

The doula’s contractual relationship ended with the intended parents first.  They returned with the child to their homes in another city, and that was that. The doula had thoroughly prepared them with information on what they would need and should expect in the coming days. Being armed with that, they left.  On the other hand, the contractual relationship with the surrogate continued through the postpartum period as she worked through common issues like physical recovery, pumping, hormonal changes and the baby blues, and transitioning back into her family.

A surrogate birth is a long, winding road through gentleness, diplomacy, effective communication, strong command of the birth environment, and a non-judgmental heart. However, as simply it begins, it ends — one woman comforting another through a birth.