No One Likes A Purple Baby

You can’t always tell a “bad” baby by the fetal heart strip.

That is to say, some babies look fantastic during labor and all the way through pushing, but when kiddo is born and the big moment comes, they just can’t seem to get the hang of “life on the outside”.

The majority of babies transition well.  When L&D nurses talk about babies “transitioning”, we mean the process that takes place immediately after birth where baby goes from being in-utero and fully dependent on mom’s body to breathe, feed, and remove waste to suddenly having to do all of that for himself.

Like I said, most babies figure it out on their own within moments of being born.  They take a surprised breath, and with a bit of drying and physical stimulation, they start to cry, their skin turns pink, and wa la!  Life doesn’t really begin as much as it just continues.

Still, my hospital requires that at all births, there is a nurse present for mom and a second nurse present for baby.  This ensures that if there is an emergency with either, both have their own dedicated staff member present and fully in-tune with their history and their treatment. The last night I worked, I got a great reminder of just why we require two RNs to be present at all births.

The Scenario

The nurse who had the patient in room 2, Barb, was an experienced L&D nurse who had an orientee, Marcy, working with her.  When one of my other coworkers mentioned that Barb and Marcy’s patient was about to deliver, I took a look at the strip and started heading down the hall.  As I was “up”–patient-less and waiting for an assignment–I was ideally free to help in the meantime.

“Well, I dunno, Sophie.  She should be good.  She has Marcy in there with her, and she’s almost off orientation.”  Breanna called from the desk.

“Oh, it’s no problem.” I replied, keeping in mind the happy FHR strip I had just seen on the monitor.  “You never know, after all.”

“True.”  Breanna agreed plainly.

As I arrived in the room with the doctor and the surgical tech, I prepared the bassinet, laying out the blankets, placing a blanket on mom’s chest, and making sure that suction, oxygen and my emergency equipment was functioning and turned on.

Barb and Marcy were helping their patient push, which was taking longer than they had expected for the first-time mom, but baby was clearly at about a +2 station and making progress with each push.  About five minutes later, baby’s head emerged, followed by the rest of his body with one last push.

As the doctor cut the cord, I stepped up at the bedside, drying and stimulating the baby as he was placed on mom’s chest.  APGARs are a little low on this one, I noted as I realized the baby wasn’t crying, had central cyanosis, and he wasn’t moving much.  Moments later, I heard the distinct sound of grunting on the end of each breath and retractions appeared around baby’s sternum.

Seconds into meeting this new little boy, it became obvious that he would require a little extra attention.  I kicked my assessment skills into high gear as I reached for my stethoscope to take a closer look.

Drying, Stimulating and Crying

Drying a baby is important as babies have difficulty maintaining their own temperatures, so the longer baby stays wet, the more likely it is for him to get cold and potentially experience some of the consequences thereof: dropping blood sugar, lethargy, and low blood oxygen to name a few.  While some of the “goop” (AKA: vernix) that baby is born in has been shown to protect baby against infection and help regulate baby’s temperature, making sure baby is dry is of paramount importance immediately after birth.  It is important to note that while some of the vernix will come off with drying, enough will stay on the newborn to provide the benefits associated with delayed bathing (which is a topic for another post!).

A natural result of drying baby is the stimulation that occurs when the blanket makes contact with his skin, and this stimulation usually causes babies to cry.  Crying will naturally help to clear any fluids that baby might have gulped on his way out, therefore opening his lungs and getting him used to the idea of breathing on his own.

Skin Color

Cyanosis is a general term that refers to a bluish coloring of the skin due to a lack of blood flow or poor oxygenation.  A little cyanosis of the hands and feet actually isn’t uncommon in newborns and is called acrocyanosis.  Acrocyanosis occurs normally as baby transitions from being in-utero to having to breathe on his own after birth: slower or decreased blood circulation to the extremities is normal as baby’s body learns to support itself through breathing.

Central cyanosis means that a baby looks purple or blue in his or her trunk.  When the infant’s chest, abdomen or face appear purple, it can be a sign that baby isn’t getting enough oxygen all around.  Though central cyanosis isn’t in and of itself indicative of decreased oxygenation, it is an indication to place an SPO2 monitor on baby’s right hand and make sure that the discoloration you’re seeing isn’t from low O2 levels.

Muscle Tone and Startle

Decreased movement is another potential sign of trouble.  When babies cry, they naturally tense their legs and arms.  In general, crying is a whole-body experience for a newborn.  Also, in addition to the stimulation of having been born, the noise and light associated with birth often triggers baby’s startle reflexes, and if baby doesn’t have good muscle tone and good reflexes pretty quickly after birth, this can point to trouble.

Of note: this can be a sticking point for babies born by C-section.  Vaginal birth and the process of emerging from the birth canal–and all the squeezing that entails–can naturally stimulate a baby as he’s being born and also force fluid out of baby’s lungs.  C-section babies aren’t privy to this particular set of benefits, however, and as a result, sometimes babies born by C-section require a little extra attention to get them to perk up after birth.

Retractions and Grunting

Retractions are a fancy term for when the skin pulls in around baby’s ribs and sternum as he tries to breathe.  The direct result of a baby working extra hard to pull in air, retractions are a sign of respiratory distress in newborns.

The same goes for grunting, which initially sounds like baby is humming a song.  As baby exhales, he closes his glottis (which normally covers the airway when you’re swallowing food or fluids), which causes a distinctive “ah-ah-ah-ah-ah” sound.  In doing so, he causes a change in pressure in his chest that helps improve his oxygenation.  If a baby is resorting to grunting, chances are, he will need some assistance in the breathing department, whether that be suctioning, oxygen administration, chest percussion, or a combination of all three.  Grunting can be a last-ditch effort to open baby’s lungs before things go south, and I’ve seen grunting babies decline from grunting to assisted ventilations (bagging) to intubation (ventilator) depending on the source of their respiratory compromise.

*Of note: breathing is a big deal.  I know that sounds like a given, but in most babies who require resuscitation, breathing is the culprit of their distress.  Say you have a baby who’s born at term with central cyanosis and a no heart rate.  Even before you consider starting chest compressions–even if baby didn’t have a heartbeat at all–per Neonatal Resuscitation Guidelines (NRP), you must give adequate assisted ventilations (bagging) before starting chest compressions.  Most of the time, correcting problems with baby’s breathing will correct everything else.

APGAR Scores

At one minute, five minutes and ten minutes after birth, nurses assess something called an APGAR score.  This quick, objective assessment looks at five categories: skin color, heart rate, breathing effort, muscle tone, and reflex irritability.  At most, baby can get a “2” in each category.  At the least, he can get a “0”.  So on a scale from 0 to 10, an APGAR score tells a provider quickly how a baby is transitioning.

At one minute, my baby scored as follows:
Breathing: 1 -irregular, discoordinated breathing efforts
Heart rate: 2 -pulse is 150bpm, normal range
Muscle tone: 1 -baby has some muscle tone present, but less than normal
Reflex irritability: 2 -baby’s reflexes are normal
Skin color: 0 -baby has central cyanosis

Total APGAR: 6
(As a reference, most babies are born with APGAR scores of 8-9.  A score of less than 7 indicates a need for medical attention).

Back to the Scenario

With baby’s physical assessment looking borderline, I took the baby to the warmer with his mother’s enthusiastic permission.  I placed an SPO2 (blood oxygen) monitor on baby’s right hand and looked for a baseline.  Heart rate was in the 170’s–up from when I had listened to him on mom–and his blood oxygen was lower than normal.

With audible gurgling and coarse lung sounds, suction was in order.  I suctioned baby’s nose and mouth quickly, immediately pulling out some thick, clear secretions.  Suctioning can be an irritating process to a baby which can have the added benefit of making baby cry.  My baby did just that.  He cried immediately after I suctioned him, producing more fluid from his mouth and nose.  A few suctions later, baby’s heart rate came down, his O2 went up, his retractions stopped and grunting significantly decreased, and we were looking at a much happier boy.

In the end, this baby did well.  He was brought back to his mother and monitored for the rest of his time in L&D, but he transferred to postpartum without issues and was discharged normally with his mom a few days after he was born.

However, this scenario just goes to show: a happy strip doesn’t mean a happy baby, and it pays to stay on your toes at all times!

That Awkward Moment When…

I know.  There are a lot of awkward moments in my job.  So I’ll be quick to clarify.

That awkward moment when…you save someone’s life and no one else* knows it.
(This does not include the responding nurses/physician!)

I had my first postpartum hemorrhage the other day.  It was terrifying.  Again, I don’t tell you that as a new nurse whose experience barely extends beyond the imaginative, scenario-based world of training.  And while the scene was unforgettable–arguably, indescribable, as after several edits, I still don’t feel I’ve captured the full chaos of the situation–one thing will always stick with me.

I was the only one who realized what was going on.

I’ll set the stage for you.  I’m about at the end of a recovery after a fairly difficult vaginal delivery.  The patient is doing fine.  Baby is doing fine.  The mom has some visitors in her room and they’re casually chatting while I’m giving her some pain medication.  However, as I’m pushing the med, the patient starts to feel sick.  I hand her a bucket and she is very clearly nauseated, retching but unable to produce anything.  I think to myself, perhaps she’s simply naïve to narcotics.  That could be the case.  Some folks are extremely sensitive to narcs and will become sick quickly after an IV push.  However, it was just as I was starting to think that this was pretty intense to be a reaction to a narcotic, it happened–

A loud splash, as if someone had thrown a bucket of water on the floor.  I look down to see the biggest puddle of red I’ve ever seen creeping rapidly toward my shoes.  And then, a family member’s reaction so misplaced, I can barely believe what I’m hearing…

Hemorrhage 1

Now, let me pause here to explain to you how delivery beds are made.  They have a bucket underneath them that is specifically designed to catch blood during a delivery.  That bucket was in the path of this gush.  Delivery beds aren’t thin, either, meaning there is a lot of distance, including mattress and metal pieces, to travel through in order to reach the floor.  That’s a lot of stuff between the patient and the floor–plenty of material to slow down a fluid spill.  For blood to have hit the floor hard enough to splash…wow.  That’s a lot of blood.

All of this crossed my mind in the span of a few milliseconds before I reached for my poor patient’s boggy uterus and hit the emergency bells.

Hemorrhage 2

If, by some strange coincidence, you realize as you read this that you were among the family members who were sitting in the room when this happened, I really didn’t mean to be rude.  Let’s just say I was stunned–flabbergast–appalled at the thought that you were sitting at bedside during a massive postpartum hemorrhage and laughing as your family member was bleeding to death.

Don’t get me wrong: I don’t expect those guests to be medical experts.  But there is something strange and unsettling about people who laugh at of a volume of blood that is rarely shown in appropriate circumstances on TV, much less seen in a real-life situation involving a loved one.  I argue not for the medical proficiency of her guests, as this was not necessary to deduce that serious trouble was amiss.  Rather, there was a sickening lack of basic concern for the crimson pool that grew by the second and the simultaneously dwindling consciousness of the woman in bed.

At any rate, after an initial moment of stunned silence, the family members left the room, and in a matter of seconds, the cavalry arrived.  The patient was barely conscious, her blood pressure so low that the machine couldn’t read it.  I had pulled back the blankets to reveal a pool of blood in the bed, soaking the mattress and sheets from foot to waist.  One nurse was starting a large bore IV while another opened up the pitocin and fluids that were already running, infusing them in at full blast.  Another nurse put an oxygen mask over my patient just as the doc came running in, slid a hand into my patient’s uterus and pulled out some of the biggest clots I’ve ever seen.

In all, we estimated somewhere around 2.5 liters of blood lost in less than a minute.  Really, 2.5 liters.  Consider that te average human adult has somewhere in the neighborhood of 5 liters of blood circulating.  Approximately half of my patient’s blood had exsanguinated and now lay in the bed or on the floor.

After stabilizing my patient and cleaning up the veritable mess that remained, we let the visitors back in at her request.  I felt bad for the poor girl.  She had been up for over 24 hours, had gone through hell in labor, and now looked like death warmed over (and that is no exaggeration).  Her blood levels, even on the CBC immediately after the bleed, were low.  I expected she’d receive a blood transfusion before my shift was up.

But when her visitors came marching back in, to my amazement, they seemed to have forgotten the events that led to their abrupt eviction and instead, peppered my patient with comments like this:

Hemorrhage 3

Hemorrhage 4

I know what you’re thinking.  They’re probably just being nice, you’ll say.  They’re probably trying to make her feel better, you reason.

No.

Simply put, no.

I only wish their reaction could be attributed to some benevolent desire to make this patient feel like less of a train wreck than she was.  In fact, I made every effort to believe they were only being nice until I was eventually confronted by the uncomfortable facts: they were nothing short of completely sincere.

To boot, even my patient didn’t seem to understand the fact that she had done the Texas two-step with death that night and come out on top, even when I explained to her the extent of her bleeding, the meaning of her CBC results, and the fact that she might get blood to prevent spontaneous bleeds that could result from extremely low blood counts.

So it was an odd night to say the least.  I headed home feeling a bit off, knowing that I had done something incredible, but with very little acknowledgement.  It’s happened before, and I know it will happen again.  It’s just strange to be the one who experiences it in full: the crash in vital signs, the blood, the near-fatality, the incredible response of the staff…

…and to go from all that adrenaline, action and real-life heroism to a patient and family whose biggest concern is…when the mom can have something to eat.

However, as one of my more thoughtful coworkers pointed out, maybe it’s better that way.

A Cruise to Sciatica

This post is admittedly a little random, but it focuses on two major features of working as a nurse on my unit and working nights: first, the randomness that defines the hours between 0300-0600 (commonly known in my workplace and many others as “the wall”, wherein everyone is so tired and so slap happy that you never know what the conversation will bring) and second, the long-running tradition of teasing the charge nurses.

Charge nurses have a tough job.  I’ve been a charge nurse before, and it’s certainly not a job I envy.  In charge of organizing the other nurses, making patient assignments, and keeping the floor afloat, charge nurses are used to rolling with the punches, especially the ones that come from their own staff.

Enjoy a sample of a typical discussion right around 0400, when most of us are actively “hitting the wall”.

Sciatica, Greece 1

Sciatica, Greece 2

Sciatica, Greece 3

Sciatica, Greece 4

Sciatica, Greece 5

Sciatica, Greece 6

To all the charge nurses everywhere…thank you for what you do!  And remember, we only tease the ones we love!

The L&D Perspective in a NICU Habitat

L&D nurses and NICU nurses see babies differently.  It’s something I’m thankful for every time we send one of our kiddos to the unit.  However, it’s only when the NICU is overflowing and it’s my turn to float that I begin to realize exactly how big the divide is between the NICU and L&D perspective…

NICU vs LD 1

NICU vs LD 2

NICU vs LD 3

NICU vs LD 4

NICU vs LD 5

NICU vs LD 6

NICU vs LD 7

Punting the Pain Scale

If you’re even remotely trained in anything related to medicine and/or if you have ever received any medical care of any kind, chances are, you’ve encountered the 0-10 pain scale that medical professionals use to assess the presence and intensity of pain in adults and older children.

Up until I worked in L&D, this scale worked pretty well to guide my practice in terms of treating and controlling pain.  In oncology, I had plenty of experience not only in using this scale, but understanding the nature of oncologic pain and keeping my patients comfortable despite their cancer, chemotherapy, radiation, surgery, and often rather dismal states of mind.

But when I moved to L&D, the way the pain scale–and indeed, pain itself–was approached was completely redefined.

On the medical units, pain was the enemy.  It was something to be kept at bay.  It was to be treated immediately, reassessed constantly, and warded off with some of our strongest drugs.

But on L&D, pain is an entirely different entity.  While some pain in L&D can be pathophysiological in nature, the vast majority of pain in L&D is not only normal, but it’s a good sign.  It’s a sign of a healthy and steadily progressing labor that will eventually lead to the birth of a baby.

Long gone were the days of running down the halls for pain medication.  If a woman wanted an epidural, she faced a 1-hour wait, assuming the anesthesiologist wasn’t in surgery.  If she wanted IV or oral pain medication, that was at the discretion of the OB and myself as the nurse in charge of her care.  Indeed, pain is part of the program on my new unit, and while it is arguably some of the most intense pain a woman will experience in her life, it is also universally accepted by the professionals on my unit as all in a shift’s work.

Along with understanding this new place pain had in my practice, I also began to understand the varying levels of pain tolerance in women and what these different levels and tolerances can mean when attempting to reconcile the subjective information the patient is giving you with the objective data you can gather on physical assessment.

A true story from my orientation experience: my preceptor, Melody, and I were finishing up a recovery on a patient who had recently delivered.  We had stepped out of the room and were hanging around the desk getting the chart ready to transfer and we kept hearing a lot of shouting from triage, and both of us, anticipating a fast delivery, got a little antsy.

About ten minutes later, my coworker, Karen, comes marching down the hall with her patient, a first-time mom whose water has broken and who appears to be in some rather intense labor.

A lesson I had learned early-on in L&D was this: especially in women experiencing childbirth for the first time, a pain rating can be a real wild card.  For some women, early childbirth is the most painful thing they have experienced in their lives, so when you get a first time mom who is having mild contractions but is nauseated and breathing through them as if she’s about to imminently deliver a baby elephant, you have to ask yourself two questions: is she just naïve to pain, or is something else going on here?  In the case of these patients (Karen’s included), one of three things was happening.

Option #1: Your patient has a low pain tolerance.

Often times, this is exactly what’s happening when you get a first-time mom who is presenting with pain that seems disproportionate to her labor stage.  In fact, that is so often the case that L&D nurses can get into the nasty habit of assuming that it’s true all the time.

Pain Scale 1

Pain Scale 2

Pain Scale 3

Pain Scale 4

Pain Scale 5

Karen was very fast to assume that her patient was simply not tolerating early labor all that well.  And in her defense, I was guilty of doing the same thing as were many of my coworkers, especially when it comes to a first-timer who was dilated to 1, wanted to go natural and was already rating her pain a 10/10.  That can be the makings of a very long, painful shift–for everyone.

However, the events of the next 30 minutes would teach me a lesson I’ll remember the rest of my life.

Complete 1

Complete 2

Complete 3

Complete 4

Option #2: Your patient is progressing faster than your objective assessment is telling you.

Yep, ol’ Karen had made a newbie’s mistake.  You see, the alternative to Karen’s patient having a low pain tolerance is this: Karen’s patient is presenting with a disproportionate amount of pain to her contraction strength/dilation/labor stage because her labor is moving faster than what we can physically assess.

Especially in a primip (first-time mom), you can see how this scenario could take a nurse by surprise.  I’d wager that 99% of the time, Karen would probably have been right in assuming her patient was, for lack of a better term, just a little bit of a wimp.  Dilated to 1, having mild contractions and presenting with that kind of pain?  Chances are, she’s probably not going to deliver imminently, despite what it may look like.

However, some women–even with their first babies–move so fast through labor and deliver so quickly that there is little to no opportunity for the nurse to reassess her patient’s pain before the baby is very nearly looking her in the eye.  I had no doubt that the contractions Karen initially palpated were mild.  But what about the one two minutes after that?  Five minutes?  Ten?  Chances are, if Karen had reassessed her patient just a tad bit earlier, she would have noticed a change in the quality of her contractions.  Especially in unmedicated first-time moms, reporting high levels of pain even in early labor isn’t necessarily unusual, and Karen likely had no reason to reassess her patient until the patient was presenting with a more urgent symptoms: the urge to poop, the urge to push, or a panic-inducing level of pain.

However, though that is the likely scenario, that may not have been the case at all.  Some women’s cervixes seem to dilate with contractions that, by all accounts, shouldn’t cause cervical change, and it isn’t until she’s complete and screaming for her nurse that you realize she’s delivering off contractions that are every 5-6 minutes apart and moderate in strength at best.  It’s mind-boggling and rare, but it does happen.

Option #3: Your patient is not mentally prepared for labor.

To pause and backtrack for a moment, please note that psychological distress, whether that be fear, feeling out of control, a pre-diagnosed condition like anxiety, a history of sexual abuse, and other emotional factors can also affect the physical level of pain reported by the patient.  I’ve found that not only can these factors present like pain on their own, but they can also intensify and aggravate pre-existing pain.

A triage patient who sticks with me to this day is a young first-time mom who was 39 weeks and came in for contractions.  When I went to the front desk to bring her back to triage, I found her sitting with legs spread in the assessment chair, sobbing and vomiting into a trashcan with several family members hovering nearby.

As you might imagine, remembering my experience on orientation, I hustled this patient back to the triage room and immediately began to gather data.

To my surprise, as I began to interact with the patient and explained what I was doing and looking for as I assessed her, her pain dissipated before my eyes.  In the end, I concluded she was having extremely mild Braxton-Hicks (false labor) contractions and she was sent home.

As she was discharged, I reviewed what had happened.  The strength of those Braxton-Hicks contractions between the time she arrived and the time I sent her home hadn’t changed.  Her dilation hadn’t changed.  Her baby hadn’t changed position.  And she was still 39 weeks pregnant.  But when she came into triage, she had been crying and puking into a trashcan, and now she was disappearing out the double-doors, waving to me with a smile on her face.  What was the difference?

I had taken the time to build trust with her, teach her about the things that worried her, provided her with reassurance and education so she felt better prepared for the labor that was to come, and eased the worry from her mind.  And that rapport and confidence in one’s nurse can be some of the most potent pain relief of all.

Option #4: Your patient is being induced.

I know, I know. I added an option.  Now, this clearly doesn’t apply to Karen’s patient in the scenario above, but it does apply to many, many patients who will have babies in the US.  I hate to be the first to tell you this, but especially if you’re a first-time mom, induction can be painful.

First, before we even induce you, we have to check your cervix.  That involves a vaginal exam that can be rather unpleasant, especially if your cervix isn’t really ready for labor and is high in the vaginal vault and posterior (off to the back of baby’s presenting part–hopefully, the head!).  Cervical exams in this stage can feel like we’re reaching for your tonsils, and this is just the first of many.

If your cervix isn’t soft and dilated to a certain degree, we will likely choose to give you medication that will make your cervix thin and dilate before we start an IV medication like Pitocin to start, strengthen and stimulate contractions.  The reason being, if your cervix isn’t soft and thinned to a certain degree, it probably won’t open, even if we do get your contractions nice and strong and regular.

These medications are usually given vaginally, so that means another vaginal exam AND the added bonus of receiving a medication that can make you raw and sensitive in the area from which that you’re soon to push a baby.  Note that you can get multiple doses all of these drugs, and you will get more and more sensitive with each dose.  You will also get rechecked with each dose, so chalk up another vaginal exam with every drug.

If your cervix is stubborn and doesn’t want to change with medication, there is a method that is commonly used to manually (physically) dilate a cervix.  Some physicians will attempt to manually dilate digitally (with their fingers), but many will attempt to place a little balloon in the cervix, inflate the balloon, and therefore manually dilate the cervix.  If you thought the drugs were painful, I’d suggest before they use the foley balloon on you that you request to be discharge, pack your bags, and go home assuming you and baby are medically cleared.  (**Little known fact: as long as your water isn’t broken and you and baby are deemed safe after 1-2 hours of observation, this is perfectly acceptable!**)

When your cervix is favorable, unless you are already contracting steadily on your own, Pitocin is next on the list.  This is an IV drug that will make your contractions stronger, closer together, and more regular.  Those super-charged contractions are going to push baby down on what is likely a very sore private area, and most women who undergo inductions typically elect to receive epidurals so that they don’t end up experiencing the full scope of pain involved in induction.

So, with all that said, if your patient is presenting with higher levels of pain than what you’d expect, ask yourself the question: was she induced/is she being induced?  And if so, what with?

To Conclude…

Pain is a vital part of assessing patients in labor, but there is an added component of assessing a laboring patient for pain that the current pain scale model does not adequately encompass.  As a result, the nurse must compensate for this lack when talking with a laboring patient about pain.

To get an accurate pain assessment, make sure your patient feels as supported and informed in her care as possible.  Do your best to encourage and educate her if you sense her tolerance for pain is limited.  Be aware of treatments and medications that may cause the patient’s pain rating to be higher (or lower!) than expected.And of course, don’t dismiss a patient’s reports of increasing amounts of pain as blowing smoke unless you’re ready to catch!

The Happiest Job On Earth

Somewhere between the shampoo and conditioning experience of my haircut a few days back, I mentioned to Anna, my hairdresser, that I am an L&D nurse.

“Ohhhh, you’re so lucky! I’ll bet you have the happiest job on earth!” She cooed.

“Well, kinda…” I trailed off, realizing that I was in a salon full of nice-looking ladies who probably didn’t want to hear about the ugly side of my work.

“Well, I’m sure it has its downsides, but you spend your whole shift holding babies, right?”

“Actually, Anna, babies are only on my floor two hours before I send them to postpartum.” I said, not even bothering to foray into the real meat and potatoes of just why L&D nursing isn’t what practically everyone who isn’t an L&D nurse seems to think it is.

I left my haircut exceedingly happy with my new look, but a bit rubbed by Anna’s faulty yet common opinion of my profession.  And then I realized–Cervix With a Smile!  What better place to write an expose on the real ins and outs of L&D nursing?

This post is admittedly geared toward nurses who are interested in L&D, but really, it applies to anyone, especially if you think my shift is entirely comprised of baby powder and cute little outfits with a Johnson & Johnson “Nurses Heal” ambiance and slow string music.  As an aside, if you know a postpartum, pediatric, PICU or NICU nurse, many of the below points also apply to their work.

So here we go, folks.  Take a walk in my plastic wipe-able clogs and see what L&D looks like from my side of the bed.

Why L&D Nursing isn’t what you think it is:

  1. I’m a professional.
    When you walk into your friend/family member’s room and see that brand new little baby, you see a new part of your life.  You see your friend or family member’s new son or daughter, a new part of your social circle, a new little person that you will come to know and love.
    I’m a nurse.  You know what I see when I look at that same baby?  A patient.  That baby, just like his or her mother, is my patient, and while I will certainly talk to the kiddo while I’m taking her temperature and making her cry with her first shot, I’m not forming emotional attachments to the baby like you and the baby’s parents are.  While some may see it as cold, I view that infant through the objective eyes of a professional.
    Case in point, when I visited a close relative in the hospital and met her baby for the first time, I had to remind myself that I was not her nurse–and it wasn’t my job to watch the monitors (although I admittedly did, purely out of habit!).
    My perspective on my tiny patients isn’t to diminish the significance of their lives; rather, it is for his or her protection.  Because if something bad starts to happen to that baby, what would you rather have me do–freak out like your best friend or react like a professional nurse?
  2. I have a lot of things to do that don’t involve holding the baby. No really, I mean a lot.
    During the course of my shift, I am charting on mom’s contractions and baby’s heart rate and ensuring that those are happy patterns every 15 minutes.  If something goes wrong with either, I am at the bedside to intervene.  That may include changing the rate of medications on the IV pump, giving more fluids, giving oxygen, or sometimes even repositioning mom to make baby happy–even if that takes five coworkers to do because mom is 300lb and has an epidural.
    Speaking of which, if mom has an epidural and all is going well, I’m checking on her level of consciousness, respiratory pattern, anesthesia level, pain rating and a host of other things every 30 minutes.  I’m getting her temperature and emptying her bladder every 2 hours.
    And all that stuff is what I have to do before baby is born.
    After baby arrives, I’ve got vitals, pain and fundal checks (those fun, fun tummy presses for those of you who have delivered in a hospital) on mom every 15 minutes for the first hour, every 30 minutes for the second hour, vitals on baby every 30 minutes for 2 hours, two meds for baby, one med for mom, and a whole ton of charting that has to be done before I can move mom and baby to postpartum.  And that doesn’t even begin to cover teaching mom to breastfeed or doing a recovery from a C-section!
  3. Once baby is here, my work is almost done.
    As an L&D nurse, I only keep mom and baby on my floor for another 2 hours after birth.  This certainly doesn’t even begin to encompass an entire shift of baby holding.  But even if you were to talk to a NICU nurse or a postpartum nurse, they’ll tell you they certainly don’t spend their shifts holding babies.
    Postpartum nurses have 4-6 couplets (moms and babies) to tend to.  That’s 8-12 patients that are fully dependent on them!  Between med passes and breastfeeding assistance and parent education and charting, you probably won’t catch any of them spending their shift baby rocking in the nursery (which is minimally used anymore at most hospitals anyway).  While there certainly are nurses who take a few minutes here and there to rock their smallest patients to sleep if mom is already out, this is a rarity, especially in the 21st century.
    NICU nurses are highly specialized, rendering care to the most fragile little humans on the planet.  Just like myself and postpartum nurses, they especially view their infant charges as patients and keep their carefully trained eyes open for the first hint of trouble.  Many of their patients are so small that they are actually being shielded from external stimuli such as touch to simulate the warm, dark environment of the womb.  And while some of those babies certainly are big enough to hold, the fact that many NICUs have volunteers who come in specifically to hold their babies should tell you that a NICU nurse’s day is filled with much, much more than baby holding.
  4. Labor is hard…on everyone!  Ladies, I’ll take your high fives in the comments.
    Even with an epidural and a great nurse and doc and a wonderful partner and supportive family, labor is tough.  And that’s under the best of circumstances.  How about we look at a more common scenario.
    Let’s say you come in at 5 centimeters with killer contractions.  The anesthesiologist is back in a C-section, your breathing techniques aren’t working anymore, I have to strap a bunch of monitors to your abdomen amidst your contractions and need you to stay seated so I can monitor the baby, but the only thing that helps your pain is walking–but then I can’t see baby’s heartbeat.  Your mother is freaking out at me because I can’t sugar-plum-fairy your pain away, your other relative is taking pictures of you as you cry on the birth ball, and the OB is trying to get ahold of me to let me know that she/he wants you delivered by 1700.  Somehow, an anesthesiologist magically appears, but it’s your unlucky day because the epidural isn’t everything you dreamed of and more, and you can still feel some amount of pain through your epidural (which is normal, but God forbid anyone suggest to a woman these days that labor will still have its painful moments!).  Meanwhile, your baby’s heartbeat is starting to dip in ways that I don’t like, I have a room full of your crazy family, and you’re so caught up in your contractions and your screaming family members that you can barely hear my coaching, which might actually make your labor tolerable until the anesthesiologist comes back to give you a nice extra epidural dose right after this next C-section, assuming you are still pregnant.
    Take any aspect of that scenario.  I see at least one of those situations on every shift, usually more.  There are some shifts that I’d kill to spend a night rocking babies.
    The last few points mostly focused on the circumstances of my job that make my work what it is.  But what about the circumstances that my patients bring in with them?
  5. Not all moms are healthy.
    In fact, a rising number come into pregnancy with serious preexisting conditions.  Obesity, diabetes, heart disease–you name it.  Women with all kinds of health problems get pregnant, and pregnancy is often no walk in the park for those who do begin the race healthy.  Add an already unhealthy mom and you’ve got a stage primed for preeclampsia, gestational diabetes, HELLP syndrome, and a myriad of other conditions and complications that go along with disease processes that not only affect mom but baby, too.
  6. Not all moms stay healthy.
    The truly unfortunate cases are those women who enter pregnancy from a healthy vantage point only to be blindsided by something unforeseen.  They had no risk factors, no predisposing issues, but they got hit with whoppers anyway.
  7. Not all moms care enough to keep themselves healthy.
    These are the cases that infuriate most healthcare workers.  They’re the moms who get pregnant and just don’t want to kick that smoking habit.  Or using crack or heroin.  Or drinking.  Or cutting or overeating or under-eating.
    Or, they’re diagnosed with a serious illness either before or during pregnancy, and they won’t take their medication, follow up with their doctors, or do much of anything to ensure not only their own safety, but the well-being of their unborn child.  It’s heartbreaking and frustrating and ultimately, I as a nurse can do nothing about it other than educate and try to help mom see a better way to live her life.Between the women in any of the categories above, some will stay with us for months prior to delivery.  Some will deliver early.  Some will have emergency C-sections.  Some will become NICU moms.  Some will deliver normally and everything will be fine.  A small number will get seriously sick, and a few will even die.  Some will lose their babies either before or shortly after birth.  Either way, their ailments will not only affect their lives, but the lives of their babies, their families, and all those around them.
  8. Not all babies are wanted.  It isn’t necessarily the norm, but L&D nurses see the full range of the human spectrum.  We see the parents who are ecstatic and have read every book on the planet about parenting.  They’re ready.  They’re beaming.  It’s glorious.
    And then, there are those moms who don’t want anything to do with their baby after he or she is born.  Mom sits in bed withdrawn, numb to the little life in the bassinet beside her.
    I’m not talking about mothers who have postpartum depression or some other condition that prevents them from bonding with their infant.  I’m talking about fully healthy and entirely capable women who just don’t care.
    Neglect is often evident long before mom leaves the hospital.  And the kicker?  There’s not a darn thing any of us can do about it.
  9. Not every parent will treat their baby right.
    In a similar vein as the category above, there are those moms who scream and cuss at their unborn babies and newborns, who have begun the process of ruining them with profanity and abuse and anger.  There are the angry fathers, the disappointed parents, the ones who wanted a girl and not a boy or a boy and not a girl.  They’re the ones who you say a silent prayer as they slip down the hallway–an innocent life disappearing into violent, unloving arms.  They’re the ones you pray don’t end up in the NICU, PICU, or worse.
  10. Sometimes children have children.  I know, I said it.  In an age where Teenage Mom is all the rage, I’ll tell you that from my standpoint, often times, those are sad stories, no matter what the good ol’ TV or the teenage mom’s mom or her sweet little old auntie will tell you.  I know that not every child born to an adolescent will end up in the admittedly fatalistic picture I’m painting, but I also know there are a good many who will, and when you’ve seen your third 16-year-old who has miscarried twice in a year and is now on her third pregnancy because “I just wanna have a baby”, then perhaps you’ll understand my disdain for the culturally rampant lie that would have you believe that teenagers in the USA are ready to be parents.
    These aren’t daytime soaps.  They’re stories about innocence and opportunities lost.  They’re stories about children raising children who will never have the benefit of being raised by an adult, and as a result, will likely struggle to become adults themselves someday.  They’re stories about balancing high school and parenthood, about a child clinging to the tattered remains of a past adolescence as circumstances thrust them into a premature adulthood, often without any real role models to copy.  They’re stories about absent parents and the perpetuation of a cycle that sees children as possessions, not human beings to be treasured and disciplined and brought up.
    And it’s a sad reality that our culture has opted to sensationalize and normalize such behavior instead of exposing it for what it really is–a selfish, dangerous lie.
  11. Especially these days, many people see their children as accessories.
    On the same note as item #10, sometimes even adults are really just children having children.
    I guarantee you, you know someone like this.  They’re the mother who is being induced because she has to have her baby on this specific day so she can still make her hair appointment two days after.  Or she has to have a boy because that’s the color she painted the nursery.  These are the parents who love to talk about their kids like prize trophies, but the instant the children become real little people with needs of their own, the desires of the parents trump the needs of the kids, and suddenly mom’s throwing a tantrum because she doesn’t have time to feed the baby–she’ll be late for girls’ night out!
    Now, I’m certainly not saying that once you’re a parent, you forego any semblance of your own life.  I’m talking about parents who consistently and arrogantly put their own desires above the needs of their children, and when you see it as often as I do, it’s an ugly sight to behold.  It is a disease borne out of a very human urge to think only about me, me, me, and there are few traits more disgusting and misplaced than when found in parents.
  12. Some births don’t go as planned and some are downright traumatic.
    There are few things more heartbreaking to me than to have to tell a mom who is hell-bent on delivering her baby vaginally that it just isn’t going to happen–we must do a C-section.  Or seeing a mom, with no support from her partner, opting to get an epidural when all she wanted was to deliver without pharmacological pain intervention.  Or watching the on-call OB cut an episiotomy without warning or reason on a woman who didn’t want to be cut.  Or watching a traumatic birth take place, knowing that that woman’s sex life and bowel patterns will never be the same.
    Say what you want to about some women who come in with 12-page birth plans, but if it were your birth and your baby, you’d be just as heartbroken if things didn’t go the way you wanted.
    As a nurse, I am your advocate, and when you experience what you perceive as failure or trauma in the process of delivering, you can bet that I feel it as well.
  13. Not all babies are born alive.
    I know that’s a loaded statement, but it’s one that you should think about when you imagine me at work.  Some of my most important contributions to my profession and my patients are when I take care of those parents who have lost their children.
    L&D nurses, despite our usual role in delivering new life, are also present for when babies are born dead.  Moms still labor, contractions still hurt, and babies must be born, even when their lives are over before they begin.
    L&D nurses are present in that process from start to finish.  Often times, it’s the L&D nurse who will look for baby’s heartbeat when mom comes in, telling us she hasn’t felt baby move in a little while.  It’s an L&D nurse who calls the doc, orders the STAT ultrasound, and is there when the parents get the bad news.  L&D nurses admit those patients and are with them and their families throughout labor and all the way through delivery to recovery.  We are the ones who set the tone for the family, provide the keepsakes and photos they will treasure, and try to protect and respect the body and memory of a child that the no one will never get to know.
  14. Not all babies live.  If you thought #13 was as tough as it gets, think again.  L&D nurses are not only there with the parents who deliver stillborn or miscarried children, but also for those who deliver babies who are alive, but will almost certainly die.  Anything from birth defects to prematurity to unknown causes can be the culprit, but it’s only one more aspect of the heartbreaking and frighteningly common theme of loss in obstetrics.
    When that baby is born alive and gasping for air, who will the parents rely on to teach them, to reassure them, to make baby comfortable as he or she slips away or to try to save that life?  How will those precious moments with that little one be remembered?  It is possibly the most difficult aspects of the job.

The points listed above certainly do not comprise an exclusive or complete list of why L&D nursing is difficult; they’re just the most obvious ones to me; the ones that come immediately to mind.  I fully expect to return to this article and edit as needed, either to clarify or augment points listed.

And sure, I could write a whole different article on why I love my job and why it’s so rewarding, but honestly, those are reasons you can probably think of yourself.  They’re things you commonly associate with my work and perhaps things you’ve had the pleasure of experiencing firsthand.  What you need to take away from this is that it takes a certain kind of person to do my job and still walk away at the end of shift feeling fulfilled and happy.  And unless you can take all the wonderful, happy things that come with L&D nursing and accept that with the list above, you’re not cut out to do what I do.

So the bottom line is that L&D nursing is still nursing.  It still is an art and science that deals with human beings, and as long as that is the case, it will include pieces of all the heartache and pain contained in the span of a human lifetime.  Indeed, if pregnancy and childbirth have the potential to be some of the brightest and happiest events in a person’s life, they also have great potential to be the darkest and saddest.

In short, if you’re looking for the happiest job on earth, don’t look to L&D.  Heck, please don’t even look in nursing.

But I hear Disney’s still hiring.