You can teach an old nurse new tricks

So, I'm on my third new nurse to precept now. My first night with her was last night... She comes from a state many states away from us... she used to work in a large hospital where they moved people through in an assembly line type fashion.. In the door, epidural in, pit going, baby out.. moved to post partum... next patient... She also typically cared for 2 laboring patients at a time. Well, we have the luxury most nights of having one-on-one nursing care for our laboring mothers.

When we came on our shift we were assigned to a woman who was 8cms. She had no pitocin and no epidural. So, I told my preceptee that we would be getting the woman out of bed and in some type of water... it could be the jacuzzi tub or the shower.. whatever.. no woman should have to do transition without an epidural OUT of the water... In my opinion... The new nurse was astounded... First of all when I suggested we get her out of bed to urinate she couldn't believe it... She said they never would have done that... Let alone get her out of bed to take a long hot shower... Well, we did it... we got mom in the shower and she was LOVING it....

This nurse who had been a L&D nurse for several years (in the teens) said she felt like a new nurse on the job last night... She said she never stayed with her patients in labor... we stayed in the bathroom with her spraying her back with hot water and massaging her .... She couldn't believe the way we practiced nursing.... And, when I went to get the patient in hands and knees she said to me she has NEVER had a patient in that position. Ever. In that many years of nursing. Wow...

Well, I guess she learned a few new tricks from this younger nurse last night... Nice healthy 9 pound baby born direct OP!

In charge

Initially when my nurse supervisor asked me to take the role of charge nurse, I hesitated and said I didn't feel comfortable. Which is the truth. But, then I looked at my reasoning. Why? I like having my own patients and being involved in their care.... keeping busy and not worrying about everybody else. I didn't want to be in charge of all of the nurses. I didn't want to have "the buck stopping with me." If we have to transfer a patient to a higher level hospital.. it is me who would have to arrange for helicopter transfer, etc... If we have an emergency c-section, guess who has to call all of the appropriate people, make all the arrangements? If we don't have enough staff in the morning for the 2 section, induction and 2 leftover labor patients, guess who has to make it work?

But, then I realized it is my nurse manager who will be making referrals for me when I leave. And, if I balk at the chance to take on more responsibility, how will that look? So, I caved in. I told her I would be the charge nurse - ON occasion when no else is scheduled who usually does it. I've done it once so far... and we did have to transfer a patient in from another hospital and we did have an emergency cesarean section... both on my first night of being in charge... And, it wasn't so bad... I'm in charge again tonight... We'll see how it goes... But, if nothing else, it looks good on the resume, no? :)

Week of Certifications

While working in OB, you need to maintain various certifications... Most of which you don't use on a daily basis.. some of which I've thankfully never had to put into practice... However, this past week I had to use my most recently obtained certification - TWICE...

A couple months ago I went to an ALSO conference and became ALSO certified. ALSO stands for Advanced Life Support in Obstetrics. and it covers various OB emergencies that arise occasionally that require additional training. Some topics covered include CPR in the pregnant woman (different than basic CPR), Perimortum C-Sections, Breech births, Postpartum hemorrhages, Shoulder dystocia, etc. Things you never want to have to deal with... But need to know how.

It was great to have the certifications "In my pocket" so to speak and know exactly what to expect/do when the situations arose. Not all of the nurses on our unit are ALSO certified, so not all of them knew exactly what steps to take... and it was reassuring to me that I did and was able to help others through the situations...

Everything went well with both situations and I wouldn't want to have to have them happen again... But, I'm glad I was there when they did happen, so that I could have the hands on experience under my belt and learn from them. I was in on a postpartum hemorrhage and a true shoulder dystocia.

In the postpartum hemorrhage situation, I was lucky enough to have a doctor there who is interested in my continued learning. He included me in the process the whole time... Took my suggestions and input and used it. And, afterward, he sat with me to process the situation so when I am there alone one day, I will be able to move quickly to the necessary steps.

All in all, certifications are a pain the butt to get and keep up on.. But in the rare cases they are needed... It feels good to kind of be on "automatic pilot" in an emergency and know exactly what steps are needed.

2 Years

This week marks 2 years that I have been working as a Labor and Delivery Nurse. The time flew by... I know it's so cliche to say so... But it feels like it!

I have had many experiences in the short 2 years I've been doing this and I've learned a ton. I've cried more than a couple times... some times out of joy sometimes out of sadness and even out of frustration.

Some of the memories I've made will stay with me forever - I hope.

I remember my first medication error. I thought I would just die... I administered someone a percocet instead of a Tylenol with codeine. Thankfully, it wasn't a grand error in the scheme of things... But it did make me a better nurse. I became even more vigilant when administering medications to patients. The best way for me to learn, I've found is to actually get in there, do it and learn from my mistakes. Our hospital's medication administration system is antique to say it nicely... and this coming year we will be updating it to the "bar-code" system... which will aid in preventing further errors like this one that devastated me as a new nurse.

I remember the first time I had to resuscitate an unresponsive newborn. I've gone through many certifications as a new maternity nurse, but the one I use most often - even daily - is my neonatal resuscitation certification.... That combined with my ever available co-workers make "catching a baby" one of my favorite things to do.... Thankfully it is few and far between that I actually have to put into action the resuscitation measures ... but it has happened a couple times... all with good outcomes.

I remember the handful of times I got the privilege of delivering the babies - when the doctors didn't make it to the birth in time. It is an awe-inspiring event for you to be the first set of hands that touch the fresh, new baby... Yours are the hands that check for the nuchal cord... that gently guide the head and shoulders over the perineum... It is just awesome and part of what motivates me to keep moving forward towards my ultimate goal of being a midwife.

I remember with sadness the few fetal demises I had the opportunity to be a part of. The heaviness in that room when the breathless baby enters the world... Never to take it's first breath or cry its first cry... It stays with you forever.... Peace little ones...

I remember the joy of attending my first VBAC and first vaginal breech birth with our new rouge, trail-blazing physician, whom I absolutely LOVE!!!

I've been blessed to have been led to this particular place of employment as my first experience as a labor and delivery nurse. I kind of thought I would find aspects of this job I liked... But overall I thought it was going to be a necessary step towards the direction I feel compelled to head into; But, I have honestly come to absolutely LOVE being a labor and delivery NURSE.... Yes, it is still a necessary step towards my goal of becoming a certified nurse midwife... But it is a step I will cherish forever and one I could honestly be very happy at for a long time.

Open Letter to Medical Students

This is a open letter to all Medical students thinking about a career as an OB/GYN from a L&D nurse.

Please think long and hard about your decision. Consider all of the factors that there are to consider. Do not be swayed easily into this profession by beautiful bellies and babies; because if you are, you may end up regretting your decision for a long, long career. Your happiness and that of the nurses around you demands that you think LONG and HARD about the realities of being an OB/GYN.

Some of these realities include:
- Pregnant women - AKA your patients - have babies at ALL hours of the day and night.
- You will be expected to be on call during ALL hours of the day and night.
- When pregnant women - AKA your patients - come to the hospital in the middle of the night to have a baby it is not because they have an evil plan and were waiting for YOUR night on call to do so.
- When your patient needs orders or procedures nurses are not able to provide alone, you - the doctor - will be called during ALL hours of the night.
- You will be expected to work the day after you are on call all night and your patients will still need things that day - again, there is no evil plan to make you miserable.. they just need medical attention.
- Nurses are not allowed to make treatment and diagnostic decisions without the guidance of a doctor... that is you... and yes, this will happen at ALL hours of the night.
- You are no better or higher of a person than anyone else. You have no right to take out your frustrations with work or lack of sleep on anyone who needs your assistance (including your patients or their nurses) during ALL hours of the night.
- You make significantly MORE money than the nurses you are rude to when they wake you up in the middle of the night.... and YOU decided to choose this profession.
- When nurses order chinese food: watch out. (Yes, they may be the ones with the evil plan....)

Did I mention you will have to work during the night time - and it is not the end of the world?

Just sayin...

Standing up for Myself

Just to follow up on my previous post about a certain "Dr. Hostile" and my need to address his behavior in order to respect myself. Well, I DID address this particular doctor. I clearly outlined his behavior, attitudes and actions and the affect they have on me as a nurse. I told him his actions - regardless of intentions (because he supplied a few excuses such as being busy, etc.) - were rude and disrespectful to me as a nurse. I was true to myself and addressed every issue I felt I had with this doctor.

To my surprise he actually heard me. I doubted that things would change significantly; however, in the several weeks since our conversation, his actions and attitude has been more than appropriate. He includes me in the decision process, asks for my professional opinion and has not once been rude or disrespectful towards me.

I am not the only one who has witnessed a change in him since our conversation, either. Multiple other nurses have expressed their pleasure in his new efforts to not be a "PITA." Whether these changes will be long-term or not is still questionable. But, at least I feel like I stood up for myself and proved to him that I was not going to be disrespected "just because."

Good Experiences

There are many things that happen and I think, "Boy, I should write that down because I want to be able to remember that." But, rarely do I... My hubby is good... he has a journal... I don't.. I have one but it rarely gets written in and I am sparse about my posts here...

Like two weeks ago when I finally told my nursing supervisor about my plans to apply to graduate school for my masters in midwifery!! I was so nervous and felt like I would be disappointing her because of all of the training she poured into me fresh out of nursing school to become a fully functional L&D nurse... But, she was genuinely happy for me and truly excited for this opportunity! She said many wonderful things I wish I had written down... Like she said when she met me she knew I had great potential for things beyond a staff nurse... and that she was glad to have had a part of my training... And she just knew I would make a fantastic midwife! She was awesome....

My last night at work is another situation I hope I remember for a long time.... I was kind of in a slump emotionally when I got there... I hadn't slept well that day and was kind of off my A-game.. I was assigned an out-patient rule/out labor. Well, it turned out she was a keeper and was indeed in labor. My mood brightened after that because the expectant couple were super nice and the mother intended to labor actively without medications (My favorite type of patient!).

So, it was a lovely night... she progressed slow and steady... I was able to take my time and get her admission done, IV started, etc... Because she was not in a rush to get an epidural ASAP. She warned me that she "transitions and pushes quickly" so I made sure everything needed for delivery was ready by 6cm.

It was coming close to change of shift time and she was not delivered yet but was close to 8cm... Our unit was short staffed and the charge nurse was calling everyone to ask if they could come help - without any luck... So, having bonded with this lovely couple and feeling like she would deliver soon, I volunteered to stay past change of shift and finish out her labor and recovery.

That's when it got a little tricky. The lady's doctor was scheduled to do 2 back to back cesareans that morning and there I was sitting with a multip who "transitions quickly." I was a little nervous. The doctor checked in on us before and between the cesareans, but I was nervous as all heck. Not nervous particular about the possibility of attending a delivery without a doctor present but nervous about the politics of doing so.... Filling out an incident report...meeting with my supervisor... explaining why I was unable to ensure the Dr. made it in time...etc, etc... Plus, my patient was active during all of this... walking the hallways, etc... at 9cm, pausing and squatting, etc, etc... I almost felt the need to follow her around with some kellys and a cord clamp in my pocket.

I agreed to stay until a certain time and it was nearing that time and she hadn't delivered yet.... So much for "transitioning quickly".... I was then happy because she finally delivered after being stuck in transition for hours one half hour before I had to leave... It was wonderful... It was with my favorite doctor to work with and I was able to be with her from start to finish - at a natural medication free birth.... Something I usually don't get to do since giving up my doula practice to turn RN... I felt like I was in the good-old doula days again!!!

Then, after the delivery the doctor and I were talking and I confided in him that I was going to graduate school to become a CNM. He responded wonderfully as well. He said he used to work with 7 CNMs in another state years ago... and he would love to work with a CNM again but doubts that he would be able to in this area... I sadly agree.. But it was great to be able to talk about it... He said the next delivery I have with him where I've bonded with the patient and feel comfortable he wants me to gown and glove up and do the delivery with him as my guide. Pretty awesome, huh?

The card

I haven't posted in a while....  But, things are still going well at work.  I love working but am glad to have a break when I'm not...  We have some really interesting antepartum patients currently that I've been learning a lot from.  One patient has a complete placenta previa.  My stress level goes up 100% when I go in and see my name next to her room number indicating that I'm her nurse for the shift.  

I've had some good births and some not so good ones...  One night in particular was a difficult one.  There were several things brewing on the floor that night...  Another nurse had a postpartum patient who had to be transferred to ICU.  At the same time my pitocin induction patient started to have late decelerations.  I felt like I was walking a tight rope all night ..  trying to up her pit so she could deliver but not up it too much so the infant wouldn't become distressed in utero.  

It was stressful to say the least and the doctor on call for the night was one who does not handle stress very well... he just makes the situation more stressful, usually, and is NOT calm under pressure.  Then there was an incident where I called the anesthesiologist to place an epidural for my patient and when he arrived I was starting an amnioinfusion, so I told him he wouldn't be able to start it until after I finished the amnioinfusion set up.... Well, that didn't go over well at all.  

By the end of that night one doctor actually yelled at me (for waking him at 2am and then not being able to start the epidual immedicately when he showed up) and the other doctor was borderline rude and short with me all night....   I did break down at one point in the break room and cry.....   But I pulled it together and made it through the rest of the night with the patient - ended in an emergency cesarean section that we all saw coming.  I think the stress got to everyone that night....   And, in the morning, one of the doctors actually apologized to me for his actions and told me I did a good job handling the difficult induction.

As nice as that apology was, is wasn't nearly as nice as the card I received about 3 weeks later.  The patient who I was caring for that long and stressful night mailed a card to the hospital's maternity unit for me.  She handwrote a lovely message telling me how much she appreciated all the efforts I made to care for her and make sure she and her son had a safe and special birth.  It meant the world to me that she would take time from being a new mother and address a thank you note to me....  After all the sweat and tears that night brought me... to know that the mother appreciated my care and that I was able to shield her for the stress of that night and make her feel safe and special.  It was a simple gesture from her...but one that really touched me.  

I do not remember my labor nurses at all.  I'm not sure why...  But, I know I will remember some of my labor patients for ever.  

Deliveries

This past week I delivered a baby! The doctor didn't make it in time and it was up to me to handle the situation. It was only my second night off of orientation..... Mom and baby did well and I realized I was capable of more than I imagined.

It wasn't the first time I was present at a birth the doctor didn't make it to... But previously, I was on orientation and I always had a preceptor with me and I wasn't directly in charge of the safety of the mother and baby. This time was different. It was a very good experience.

It is amazingly more common than I thought that the doctors miss deliveries. In fact, the night I delivered the baby, there was another birth the same night that another doctor missed as well.

It is really a balancing act that the RN is asked to preform. She must be the eyes and ears of the doctor. Manage the labor and inform the doctor of the progress and any complications. Carry out all orders. Then, when it comes time to deliver, the RN has to get the doctor there at precisely the right time. Doctors do not like to come too soon or too late.

The optimal time for a doctor to enter the room is sometime between +3 or +4 and crowning.

One tip I'll pass along to L&D nurses in training: DO NOT break down the bed until the doctor has committed to being in the room. If the birth does happen without the Dr, at least you have the bed there for the baby to slide out onto. It helped a lot not to have to worry about holding onto a slippery wet squirming newborn as I was worried about checking for a nuchal cord and delivering the shoulders, etc.

Night of Competencies

I had an unbelievable night a few weeks ago.... I did nearly every job to do on the floor - in ONE night.... I could have had almost all of my yearly competencies signed off in that one night!

I started out with 2 outpatients, which I evaluated and subsequently sent home.

Then, there was a birth where I was assigned to "catch the baby." After the baby was stabilized, I accepted the mom and baby as a post-partum couplet and cared for them for about 3 hours or so.

Then, a cesarean section was called, and I was asked to be the scrub nurse for it, which I did.

After that, I said to one of the nurses, mistakenly, "About the only thing I haven't done tonight is labor."

Yep, you guessed it. In walked a mom in active labor, 8cm dilated at around 5 am. Do I need to say who was assigned to take this labor patient?

She had a very quick labor, as she was a gravida 6.... And she ended up having an "unattended" childbirth - which means her labor nurse - me - delivered her baby.

Well, that, thankfully, was the end of my 12 hour shift.

Unbelievable!!!!!