labor nurse has been reborn and shares her experiences as a new nurse-midwife, woman, and blogger

Thursday, October 29, 2009

From The Other Side

What I've been finding interesting now that I have been working a few months on the labor floor is the differences in nursing care. Now, having been that bedside labor nurse for many years, I clearly understand the value in a good nurse. I'd like to think I was good at bedside labor nursing care, but now I often wonder what the providers I worked with prior to becoming a midwife thought of my nursing care.

But here is an example of what I mean. I was attending the labor of a young girl who I had seen for most of her prenatal visits. I had gotten to know her fairly well, and knowing that she didn't take any prenatal classes or even bother heading to the library to check out some books on labor, I knew she would definitely need a lot of support. She happened to arrive just as my call shift was beginning, which is the same time as the nurses' change of shift. So basically, she was getting the same provider and nurse for the duration of her labor and birth.

The nurse she was assigned to was Nurse Nikki- a personable younger nurse with decent experience but.... had no clue that the little nursing things are just as important to women in labor as having certifications in fetal monitoring interpretation and the ability to act quick in an emergency.

Nikki spent little time at the bedside, and hung out at the nurse's station most of the morning. When I could, I would leave this young laboring woman's room so I could finish postpartum rounds and frequently found Nikki sitting in the nursing lounge eating a snack or sipping coffee. Once my rounds were done, and I could focus on the woman in labor, I stayed by her side in the room. She had plenty of family there, so perhaps this is why Nikki felt her nursing care was not needed, but the woman frequently reached out to me for reassurance and help with each contraction. When she entered transition and started to be fearful of what was happening within her body, all she could do was say my name out loud while laying as still as a stone. Basically, the young girl needed professional, comforting support.

Then it became time to push, and Nikki was no where to be found. The first few pushes were very strong, but she became scared and fought the urge. I had pressed the nurse call button in the room to get Nikki in there, because I believe the nurse caring for the woman needs to be at the bedside for pushing. Perhaps it's just me, but the second stage of labor is an intense time that needs both the nurse's and provider's full attention.

Anyhow, about ten minutes later Nikki shows up. I tell her we started pushing about twenty minutes ago (basically so she can write that in her documentation). And then she wheels in an extra stool and plunks herself down by the monitor. She stays rooted there for the entire second stage. Even when the patient has pooped a significant amount (on the chux pad), moved around while pushing, and subsequently smeared it all over her butt cheeks.

So why didn't you just clean her up, Labor Nurse CNM, you ask?

I had been, but at this point I was gowned and gloved- and despite the fact vaginal birth is not a sterile procedure, I was not going to reglove with new sterile gloves a dozen times. It's wasteful, and at this point it only makes sense for the nurse to do this. I mean, is it wrong of me, a former labor nurse, to think the labor nurse's duties include cleaning up poop from pushing women?

And then there is Nurse Eileen. She was caring for another of my young primips in labor who was much like the first woman. Eileen stayed at the woman's side for just about her entire labor, with exception of an hour long nap the woman took after an epidural placement. She reassured the woman each step of the way. I could see that this girl really appreciated Eileen's care, and even shared the baby's name with her when they kept it a secret from everyone else. And the woman was kept clean and dry after her water broke and during pushing.

Now, I don't think Nikki thinks her nursing care is sub-par. I don't think she thinks that she ignores her patients. But I wonder what she thinks when she's sitting at the nursing station while all her coworkers are always stuck in the room?


Kimberly said...

Not a nurse. Am a mom:)

I know that in labor I wished my nurse had left me the heck alone. BUT - I was aiming for a natural birth and she was REALLY unsupportive of it. And her attitude (arguing against me to the doctor when the doctor and I were discussing whether I was going on pitocin is just a bit of it) stressed me to the point that my contractions SIGNIFICANTLY slowed every single time she entered the room.

However, had I made it to the pushing stage (never got past 8cm in 40 hours, including the pitocin, ended up with c/s) I would have really appreciated the poop cleanup;)

Anonymous said...

nikki sounds lazy. that's what. did you say anything to her? like "get your act together and do your job. this girl NEEDS you."

safebirthadvocate said...

I think many nurses practice "virtual nursing". Central monitoring enables some nurses who don't "get it" to sit at the desk and spend less time in the room. If we can't get rid of continuous fetal monitoring, maybe we should get rid of the central monitor to make nurses spend more time at the bedside!

Heather Griffith Brewer said...

Do you think the extensive use of monitoring contributes to this sort of behavior? Perhaps it's given some nurses the means to indulge their laziness.
I have to say though, even though my hospital delivery sucked, my L&D nurse was very supportive. I felt at times that she was a bit torn between wanting to help me, and feeling like she needed to back up my OB. I didn't feel like she was burdened by my care.

Tiffany said...

I'm glad I'm not the only one to have found myself in this situation, where perhaps the nursing care being given is not the care we would have provided in the same role. In fact I find myself doing some of this care depending on who the nurse is. Some nurses seem to have an expectation that because you are a nurse-midwife, you should therfor being doing both jobs. There is a lack of understanding that we are working as a midwife...not as a nurse, sometimes. Other times, it may just be laziness!

I think it's interesting because physicians don't have a clue what kind of care their patients are getting...because #1 they aren't there until the end and #2 they haven't ever been a labor nurse. They rely on the nurses - and we all know that sometimes this is a really bad thing.

I don't mind being a teamplayer and helping out the nurse, but not if she exhibits a pattern of that sort of behavior.

mitchsmom said...

Yeah, it definitely sounds like nursey should have been around.

Actually we usually DO clean up poop the majority of the time because our MD's refuse to enter the room until the baby is crowning anyway...(they come at crowning, deliver, then open the pit and pull the placenta out immediately... usually in the room for about 10 mins on average I'd say, occasionally longer if more pushing needed but in that case they usually give us a dirty look & walk back out to play on the computer until the baby is "falling out")- anyway if pt is pooping at that point, obviously the MD can't move out of the way for us to get it (they usually cover it if a little bit and delivery is coming soon). We usually do the majority of the pushing and everything involved therein, on our own with the patient. The only other time the MD's are likely to see the patient AT ALL is when they make AROM rounds in the morning, that's about a 3 minute visit.

On the amount of time in the room with patients, I will say that I really play this by ear depending on the patient. Sometimes the patient needs my help (as it sounds like yours did) and sometimes not.

When I was in labor with my three babies, I did NOT want anyone but my husband in the room, whenever possible. It felt like an invasion of privacy and irritating to me to have more interruptions than necessary. But everyone is different.

Plus, not to mention that we usually have two patients, so we have to divide our time, at least until pushing. I wish I had the luxury of a single patient more, and less paperwork to do at the nurses station. One little example out of 100, we write 99% of our MD orders for them. It all adds up. I am not lost on what you're saying but it does hit home because there are times when I probably don't spend enough time at the bedside, but I also RARELY get to stand around sipping a drink, etc. I VERY RARELY even get to eat lunch period.

All that said, there are good and bad everywhere - nurses, providers, whoever...

safebirthadvocate said...

Bedside midwifery care is very new to my community and the some nurses are very confused about what their role is...I tell them to do what they would normally do when I'm not there; we are a team.

Adding to Tiffany's comment about physicians not knowing about the care their clients receive, I actually had an "incident" a couple of years ago as a brand-new CNM. I had a woman in early labor who was already exhausted so we did a little therapeutic rest. She slept well for several hours and woke up with some very strong contractions. She requested a little more pain med and I couldn't find the nurse to see what time her last dose was given so I looked it up in the computer myself (I don't think I have ever seen a physician do this) and saw that she had some about an hour earlier. When I questioned the mom she said she had not been given anything. I talked to the charge nurse and they questioned the nurse. Come to find out this nurse had recently returned from rehab and had fallen again. I felt bad about it but had to protect others from this sort of thing. I thought to myself, "why would she pick a midwife mama to do this to, when I am involved in every aspect of my client's care?" I wondered how often this had happened with her physician patients. Sadly, this nurse lost her job that day.

That said, there are so many wonderful nurses who give great care!

Reality Rounds said...

Our hospital "policy" is that the L&D nurse stays at the bedside at all times while a mom is pushing. If the L&D nurse needs a break, she must find coverage, usually the charge nurse, to be at the pushing moms side. It does drive me crazy when the L&D nurse focuses more on the computer than the mom. Gotta get that charting done! *I must say though, that you should have confronted Nikki.

Lct4j said...

It seems to me that a smart, hardworking nurse will assess what the patient's needs are. Some women, like me, needed very little labor support. Other women, like this patient of yours, needed a lot more. A good nurse will observe, ask questions, and assess what her patient needs. Nikki just sounded lazy. And, I really would've appreciated it if my nurse had NOT told me that I needed to be cleaned up after delivery. was embarrassing.

Yehudit said...

From a UK perspective - where midwives provide both labour care and catch babies - this is really incomprehensible to me.

If the midwife does not provide the labour care, then how does she differ from the doctor at a spontaenous vaginal birth?

If the L&D nurse does not provide the labour care - well that's even worse! Who is providing the labour care?

What is the reason that midwives are not providing both labour care and catching babies?

Best tip for having sterile gloves for a birth is to double-glove, and then take off your top gloves at the last possible moment.

Ciarin said...

Yehudit - I think the confusion is that we midwives provide labor support while the nurse does nursing care such as meds, listen to FHTs (although many of us assist with this I'm sure), changing linens, documenting the labor, etc. Nurses are rarely available to sit at the bedside providing one-on-one care. In my practice, we are able to commit to labor support such as sitting with women, providing guidance, doing massage, etc. However there are midwives out there who must practice as doctors also...all depends on the setting.

Yehudit said...

Is it really difficult to provide labour care and in addition do meds, intermittent ausculation/CTG interpretation, change linens, documentation?

That is what is expected of labour ward midwives in the UK.

Labor Nurse, CNM said...

Yehudit- the labor nurse is primarily responsible for the basic labor support and fetal monitoring on the labor floor, giving meds, etc. If a woman wants an epidural, many nurses will find this a blessing because she won't be needed at the bedside quite as much. However, if a woman is having an unmedicated birth and is needing a lot of 1:1 support- then it takes a lot more time and effort from a nurse who may be also caring for 2 or more other laboring women. It is a lot, and having been that labor nurse trying to give good care to multiple laboring women at one time can tell you it feels next to impossible. The epidural and continuous fetal monitoring allow the nurse to step away from the bedside- and frankly management is fine with this because it means that they can staff less nurses on any given shift. I certainly am not agreeing with this, but it is a strong reality on many labor units here in the US.

As far as nurse midwifery care here in the US, most CNMs are responsible for multiple things during their call shift. For instance, I am responsible for triaging all patients from the practice (including the doctor patients), admitting them, while also doing postpartum rounds, discharges, as well as heading over to the office to see patients! Sure, there are times where I can be right at the bedside (or tub side, whatever) with a laboring woman, but many times we must rely on the nurses to provide the support women need.

And the system is just not set up for this.

I don't know how the system works in the UK or how many laboring women the midwives care for at one time. Perhaps the system allows for continuous 1 to 1 support provided solely by midwives, which unfortunately is not the case in most US hospitals.

Yehudit said...

Our system demands one to one care in active labour. Since intermitent monitoring every 15 minutes for one minute after a contraction is standard in normal active labour (i.e. without synto induction, epidural or other risk factors) it is basically impossible to provide labour care without having someone with the woman the vast majority of the time. And you certainly couldn't look after two labourers with that standard of care (whether you are a midwife or a nurse).

Now, that doesn't mean that every hospital on every shift is able to provide that - but it is certainly regarded as a staffing crisis if you can't provide that, and we don't plan our staffing around the idea that midwives look after more than one woman in active labour. (Of course, you can assess many women in latent labour/?SROM. And you can look after several postnatal women, or several woman being induced and not yet in active labour. But once a woman is in active labour, then it is regarded as absolutely necessary that she have 1-2-1 care.

Yehudit said...

If a woman wants an epidural, many nurses will find this a blessing because she won't be needed at the bedside quite as much.


Who is getting her to move (and possibly helping her to move, depending on how dense your epidurals are) every 30 minutes or so?

Ciarin said...

It is when you frequently have more than one patient laboring at a time. It's difficult if you a mix of high risk and low risk.

DarellCarey said...

Not sure Nikki sounds like she's cut out to be a nurse. Surely patient care is a major part of the job? Especially in your area of nursing. I think you need to give her some sound advice!