As she knelt on the hospital bed on all fours, an epidural was the last thing on Emily Farley's mind.

She felt comforting hands press deep into her back and hips. They were the hands of a woman Farley had grown to trust in just a few short weeks.

They were the hands of a woman with whom she had chosen to share one of life's most intimate moments.

"It just released all the horrible tension," Farley said about the down-on-all-fours position. Farley was a few hours away from delivering her second child and giving birth naturally without medication.

It's called the double hip squeeze, Sarah Blair said.

Blair owns those comforting hands Farley felt throughout most of her delivery. The double hip squeeze is just one of the many comforting techniques Blair knows to help expecting mothers.

Blair is one of Casper's few trained doulas.

A doula is a woman who is trained in childbirth and supports the family during birth.

Blair and doula Jennifer Bertagnole want to get more Casper women interested in becoming doulas. The doulas would like to hold a training hosted by DONA International, one of the largest doula organizations in the world, after the first of the year.

Bertagnole said women in Casper are becoming more aware of their birthing options.

"It's consumer-driven," Bertagnole said about the birthing business. "It seems like Casper's birth rate is jumping."

Since 2004, Births at the Wyoming Medical Center have been on the rise. That year, there were 941 births, according to hospital records. This year, the hospital is on pace to have more than 1,130 births.

History of Casper doulas

For thousands of years, deliveries have been attended by other women.

Bertagnole said mothers, grandmothers, sisters and aunts were there to help. Or a female neighbor might have assisted. In some cultures, elderly women in a community attended to a birth.

"While it is seen as a new concept, it's not really," Bertagnole said. "If you talk to most women, they had some women there. The word (doula) was just not known."

Blair said families are now more spread out and a woman may not have that female support available.

Bertagnole first became familiar with doulas about six years ago while living in Utah. She took a three-day course to become trained as a doula.

About four years ago, Bertagnole moved to Casper.

Few people knew about doulas in Casper then, and there were no other doulas that she knew of. The support of other doulas is paramount, she said, because it gives clients a choice in who they have as their doula. A backup can step in if the main doula is unable to be there.

Bertagnole got three new doulas trained, including Blair.

One of the doulas is a licensed massage therapist, while Blair works with a lot of teenage mothers, in part because she was one herself.

Blair had her son Malachi, 4, when she was 18. As soon as the birth was over, she began helping friends through labor.

Even before she took the training, she was tending to births at the hospital.

Worth the money

The doulas in Casper charge an average of $300 per birth. This includes prenatal visits, labor and delivery and several follow-up visits. Doulas most often provide the service on a part-time basis.

"We have to convince the husband this is something worth paying for," Bertagnole said.

Farley's husband, Justin, didn't need convincing.

He said hiring a doula was a great decision for the couple's second child.

As a father, it is difficult to remember all the calming mechanisms and breathing techniques, Justin Farley said.

"They are worth their weight in gold," he said of the doulas. "There was a world of difference between our first child and Jake being born."

The Farleys remember the birthing experience of their first child, Katie, 3, was terrible. The couple wanted to have a natural birth. Instead Emily Farley said she endured 24 hours of labor "jacked up" on drugs and stuck in a hospital bed.

"They had to induce me and that was the first drug," she said. "Then the nurses gave me an epidural, because I wasn't dilating."

When Jake, 1, was born with the help of a doula, Emily Farley endured only about eight hours of labor, spent the majority of the time moving around and didn't use drugs.

Blair saved the uninsured couple from having to pay about $700 for an epidural.

Casper doulas said they would never turn a woman away if she was unable to pay.

"Usually, the women who can't pay are the ones who need us the most," Blair said, "whether it be the teenager or the woman with four kids and a husband who works in the oil field."

When Tracy Gama-Moreno could not afford to hire a doula for her teenage daughter, Chalsea Geier, Blair said she would do it for free.

Blair helped keep the worried mother and scared daughter calm during the entire birth. She called every day leading up to the delivery, gave tips and connected with the teenager who was about to be a mother.

Geier had a baby girl June 4 without the use of medication.

"I thought she was awesome," Gama-Moreno said. "She was so kind."

Working together

Obstetrician Dr. Hugh DePaolo said he has been aware of doulas in Casper the past five or six years.

He said he lets women know about doulas because he feels they have the right to know all of their options.

"For the most part, I have had really good experiences," DePaolo said.

He said doulas have a place in the birthing process as long as they are not trying to provide medical care or impose their own beliefs on a patient.

Doulas can be beneficial, DePaolo said, because they support the mother, understand the birthing process and advocate for a patient's wishes.

The one instance he can think of where he had problems was when a particular patient was having a difficult time with laboring and pain.

The doula and family kept saying the woman did not need medication. DePaolo finally asked the patient if that was really what she wanted.

"She said, 'I want an epidural,'" DePaolo said. "She had the baby really quickly."

Bertagnole said some people think doulas will push mothers to have a natural birth, which is a misconception.

Doulas push for whatever birth the mother wants, even if it includes medications, Bertagnole said.

Blair said doulas are supposed to work with hospital staff and "harmonize with their efforts."

She works to complement the nurse, who might need to leave to do paperwork or has too many patients to give a laboring woman a 30-minute massage.

Monica Schulte, a registered nurse in the maternity ward at the Wyoming Medical Center, said doulas fill in the gaps nicely. She said a woman should have someone by her side every minute of labor. As a nurse she can't always do that.

"If you want to do it without an epidural, you need to do way more than just lay in bed," Schulte said. "As a nurse it is real easy to just let them sit in bed."

Though she has never seen a doula contradict a nurse, she said some nurses do not like to work with doulas.

The first time Blair went up to the hospital for a birth, she said people kept asking her what she was doing and felt threatened.

"It changed as soon as they saw I was here to work," Blair said. "Now doctors say, 'Oh, it's good to work with you again.'"

A passion for life

Being a doula is a calling, Bertagnole said. A doula can't fake a connection.

Doulas aren't in the business to make money. The $300 they charge per birth barely begins to cover the labors that can last 24 hours. Or the daily phone calls and false alarms all with unwavering support.

Doulas aren't in the business to make money. The $300 they charge per birth barely begins to cover the labors that can last 24 hours. Or the daily phone calls and false alarms all with unwavering support.

Besides raising her son, Blair runs her husband's business.

Bertagnole takes care of her five daughters and three stepsons. She is pregnant with her sixth girl.

Why are they doulas then? They have a passion for the miracle of birth and the power of motherhood.

"I still cry at most of the births," Bertagnole said. "It's a huge moment."

Contact health reporter Allison Rupp at (307) 266-0534 or allison.rupp@trib.com.