A Rude Awakening

If you happen to be friends with, live with or spend enough time around nurses, you’ll likely be privy to a discussion about our work.  A common need amongst nurses is to vent after a long or stressful shift, and often times, that vent falls on the ears of the family and friends who are nearby.

However, while airing the mishaps of our most recent disaster may do us a world of good, most of us don’t realize how much information–be it technical medical terminology or slang–our family members and friends pick up in passing conversation–that is, until it’s used against us…

It's A Shoulder! 1

It's A Shoulder! 2

It's A Shoulder! 3

It's A Shoulder! 4

It's A Shoulder! 5

It's A Shoulder! 6

Reference for the noobs/non-medical:
http://www.aafp.org/afp/2004/0401/p1707.html

Advertisements

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!

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

An Unimpressed RN

Dear sir,

I know you probably don’t remember me due to the combination of what was likely alcohol, drugs and God-only-knows-what-else in your system, but I was the L&D nurse with your girlfriend last night when she delivered her 9th child.  If you do have anything resembling a fleeting memory of me, it probably looks something like this:

Unimpressed

On second thought, I think the above image would be giving your brain function at the time a bit too much credit.  Perhaps the image below would ring a bell.

Unimpressed Under the Influence

But I’m getting ahead of myself.

It had been a pretty decent shift to that point. We were pushing, the doctor was on the way, and baby was tolerating the chaos very nicely.

Dear Sir 1

 

It was all a piece of L&D cake.  That is, it was until you walked in.

Dear Sir 2

 

Verbose as you’d ever be, you made your entrance into the delivery room just ahead of the doctor.  Your girlfriend, apparently used to this, was about as impressed as I was.

Dear Sir 3

 

However, it seemed that even her sharp remarks and desperate attempts to prevent you from making a fool of yourself were doomed to fail.

Dear Sir 4

 

Indeed.  Where would we be without you.

At any rate, the baby delivered easily as one would expect for baby #9 and was happy and snug with mom for a good 30 minutes while we got her cleaned up.  You wandered around the room, raving like the lunatic you are about how blissfully (sloppily) happy you were, bumping into the surgical techs, babbling about your “gangsta” status, and making a general fool of yourself.

When your girlfriend eventually asked me to get baby’s weight, measurements and footprints, I happily obliged.

Dear Sir 5

 

Happily, that is, until I realized that with baby away from mom, you felt compelled to join us.

Dear Sir 6

Dear Sir 7

 

You spent about five minutes taking countless selfies with your newborn daughter that included suggestive facial expressions, gang signs, sexually explicit hand gestures and more babble about how “fly”, “gangsta” and “fo’ real” you are.

As I found myself actively resisting the growing urge to reach across the bassinet and give you the sucker punch you deserve, you realized what I was up to as I finished up the footprinting process.  And that’s when you asked the crowning question of the night:

Dear Sir 8

 

To your negligible credit, you did have the presence of mind to inform me as I finished up footprinting the baby that you probably shouldn’t hold her….at least, not yet.  Bravo for your introspection.

As I see it, the score goes about like this: you, sir, have a girlfriend, a new baby, and about 10 other children (and that is no exaggeration) that don’t need you drunk, high and acting a fool.  They need a father and they will only ever have one.

Good luck to you, sir, and moreover, to your girlfriend and children.  They’re going to need it.

Signed,

An Unimpressed RN

PS: Proper storage of your first photos with your daughter is important.  I suggest:
1. A blazing campfire
2. An industrial-strength shredder
3. The bottom of a very deep ocean/lake

Trust me.  One day when she’s old enough to understand, she’ll thank you for destroying the evidence.

Newton’s Laws of L&D Physics: A Nurse At Rest…

It isn’t that L&D nurses are lazy.  Hardly, in fact.  It’s just that we get so little down time that when we do find ourselves with a second to relax, it can be difficult to pick up momentum and start moving again.

And though we may gripe about the slow shifts where it’s hard to stay focused (much less awake!), we secretly kind of need these shifts every now and then…

Laws of Motion 1

Laws of Motion 2

Laws of Motion 3

Laws of Motion 4

Laws of Motion 5

Laws of Motion 6

Tips From an L&D Triage Nurse: How To Get Admitted…and How Not To!

Before I became an L&D nurse, I wouldn’t have known what qualified one patient for admission over another.  Since I began working L&D, I’ve come to realize that most of our patients don’t, either, but we also have a very different population–those patients who think they do.

I’ll bet you’ve heard all kinds of things from your friends, your mom, your neighbor, your coworkers, your cousins, the cashier at the grocery store, the talkative old lady in aisle 12 (let’s face it: pregnant ladies are prime targets for unwarranted advice!).  But what are we L&D triage nurses really looking for when you come into the hospital?  What’s the difference between a patient who will stick around until delivery and one who won’t?  And why did we send your great-aunt’s cousin’s neighbor’s best friend home when she was dilated to 3 and dying of contractions?

Sometimes it’s more of an art than a science, but I’ll try to break it down for you nice and neat, show you a few tricks that people have tried to beat the system, and divulge how we L&D nurses tease out the truth from the tall tale.

1.  Dilation Does Not Equal Admission.

While cervical dilation provides nurses and physicians with an idea of where a woman is in the labor process, dilating before labor actually starts isn’t uncommon, even in first-time moms.  Now, it’s more likely that your multipara (a woman who has had 2 or more babies) is going to dilate earlier and more than your first-time mom, but that isn’t always the case, nor is it unsafe to head home when dilated to 4 or 5 or even 6 centimeters, though the higher you go, the less likely it is that you’re not in active labor.  Trust me (and anyone who’s ever given birth before), babies don’t usually just fall out, especially if it’s your first.

I’ve discharged patients who were dilated to 4 or 5–a few of them even being first-timers!–who were definitely not in labor.  Often, I’m met with shock and disgust.  “How dare you discharge me!  Do you realize how far dilated I am?  I could go at any time!”

Yes, that’s entirely true.  At the same time, however, so could the other lady I’m preparing to send home who’s only dilated to a 1 and 30% effaced, and there’s no guarantee that she won’t deliver before you do!

So think about it: when you do come in huffing and puffing and ready to push a baby out, do you want to be admitted to a room, or would you rather deliver in a cramped triage room because we’ve admitted every lady who was dilated to 3cm or more?

Point being, if we kept every woman who was dilated to a certain degree but not in labor, our L&D unit would be full to bursting all the time.

2. Contractions Do Not Equal Admission.

I know, I know.  Those contractions are painful, and you really do look uncomfortable. I don’t think you’re faking that.  But your contractions are 4 to 8 minutes apart, incredibly irregular, and they’re just not that strong.

Both of the qualifiers above–regularity and strength–are two things that L&D nurses look for in assessing patients for admission.  With regards to regularity, we can determine that by placing the patient on the toco–a monitor that indicates the length and pacing of contractions.  As far as strength, that is assessed by placing a hand on your belly and feeling it during a contraction.  (Just in case you didn’t know, the external monitor that times your contraction doesn’t actually tell me how strong they are.  Only properly placed internal monitors can do that!).

But contractions on their own don’t necessarily indicate the need for admission.  Instead, in conjunction with cervical dilation, L&D nurses often check to see if those contractions, irregular and mild or not, are changing mom’s cervix.  So when the L&D nurse tells you to get up and walk for an hour and come back for another cervical check, what she’s really trying to see is if a) your contractions will go away with walking (meaning they’re likely Braxton-Hicks, or false labor) and b) if your contractions are causing cervical change over decent stretch of time.

If at some point you get the brilliant idea to try to fake a contraction by manually depressing the toco–don’t.  We L&D nurses spend our entire shifts reading those strips.  We’re pretty good judges of what’s real and what’s not.  Also, when we enter the room to talk to/assess you and your contractions suddenly stop for 10 minutes, we’ll know.

3.  Pain Does Not Equal Admission.

I hear this one a lot, too.  Ladies in various stages of pregnancy come in complaining of pain, and while some women feel their labor entirely in their backs or butts, chances are, if you’re feeling only constant pelvic pressure and/or back pain, you’re not in labor (at least, I really hope you’re not!).

Many of our OB docs won’t give more than a Tylenol or ibuprofen for pain in the pregnant population due to the risk to the fetus.  We have some patients who come to triage in an attempt to refill narcotics and/or get narcotics prescribed to them.  If you have issues in your pregnancy that do require narcotic drug management, do not expect your triage OB to provide/modify/manage these for you as this should be addressed by your primary OB and/or pain management team.

If you’re tired of being pregnant and you think that exaggerating/creating nonexistent pain will get you admitted and induced, think again, especially if you’re preterm.  Most hospitals these days won’t even consider an elective induction unless you’re 39 weeks along or more, and it is rare that the triage OB will opt to schedule an elective induction for a patient that isn’t his or her own, especially on the spot.  Hospitals are busy places, and trying to get your triage staff to finagle you into an impromptu induction is a really, really poor bet.

If we were to keep every pregnant woman who came in complaining of pain, we wouldn’t have any room for actual laboring patients.

4.  Water and Waders: Real or Fake

One thing that will get you admitted quicker than you can say, “Let’s have a baby!” is ruptured membranes (ie, your water is broken).

If you’re really preterm (see: earlier than 34 weeks), you will have just signed yourself up for an extended stay at the L&D Inn.  Because of the infection risk and risk of other emergencies like cord prolapse with preterm premature rupture of membranes (PPROM), you will be admitted and remain in the hospital until you deliver, which is usually around 34 weeks.

If you’re 34 weeks or later, chances are we will give you some antibiotics and either let you labor or induce labor if you’re not already in it.

Now, if you’re itching for an admission/induction and you’re thinking you can fake rupture of membranes (ROM), think again.

Let’s go over a few things that do not comprise ROM:

  1. Cervical discharge (normal in pregnancy, but can also indicate a vaginal infection)
  2. Urine
  3. Apple juice/water/Mountain Dew

I’ve had patients who have honestly mistaken both of the first two items above for their water breaking, and sometimes, it really can be hard to tell what exactly is coming out of there, especially if you’re late in pregnancy and you haven’t really seen it in a few months!

However, I’ve also had patients who have intentionally urinated on themselves to make it look like their water has broken.  I’ve had patients who have told me that it had to be their water breaking because “urine just isn’t that clear!”  I’ve had patients who have used other substances (see item #3) to make it look like their water is broken.

Let me be the first to warn you: if you’re silly enough to try to fool us with pee or any other liquid in an effort to get induced/admitted/delivered, we will figure out the truth.  Don’t be the talk of the break room.  Quit while you’re ahead.

The first thing we do when you come in through triage is test your vaginal canal with a little strip of paper called nitrazine.  This tells us the pH (acidity) of your vagina.  Normally, vaginal canals are acidic.  However, amniotic fluid is basic.  Our test strip will turn blue if your water is broken.  Of note, urine will also change nitrazine paper blue..

So after we do the nitrazine test, we’ll do another test called AmniSure.  This test checks to see if there are actual proteins from amniotic fluid present in your vagina, and this test is considered diagnostic.  If it is negative, your water isn’t broken.  If it is positive, welcome to the Inn.

If you really do believe your water is broken, it is important that you come in.  If your water is broken and you neglect it, you could end up losing your baby and in serious jeopardy yourself if you should get an infection.

5.  Looking for a Lost Mucous Plug…

While losing your mucous plug typically means you’re beginning to dilate, this by no means indicates that you’re in labor and certainly isn’t a reason to visit your L&D triage unit.

If you do come in telling us that you lost your mucous plug and you aren’t having contractions and/or some other medical issue, we will put you on the monitor for the obligatory 20 minutes, make sure your baby is OK, possibly check your cervix, and (barring some other medical issue) send you home.

Mucus Plug 1Mucus Plug 2Mucus Plug 3Mucus Plug 4Mucus Plug 5Mucus Plug 6Mucus Plug 7

**********************************************

Long story short, admitting in L&D is much more complicated than “Oh, you’re contracting? Let me get you a bed!”  So when you go in, expect a thorough assessment.  Be patient and honest with us.  But most of all, be patient and honest with yourself.  Doing so will likely ensure a healthy baby and a better outcome for both of you.  That’s our goal when we’re evaluating patients for admission.  Hopefully, that’s your goal, too.

The Catch

**Names in the following story have been changed to protect the privacy of patients and coworkers**

I’m proud to say that I recently found myself in my first precipitous birth–that is, it happened so fast that I had to catch the baby myself.

In some ways, doing a “precip”, as it is commonly called, is a rite of passage for night shift L&D nurses.  With many doctors in my hospital opting to head home and trust us to call them in time to deliver versus camping out in the call rooms just down the hall, this sets us up for precips, especially when you have a grand multip (a lady who has delivered 7 or more babies) come huffing and puffing into triage screaming, “The baby’s coming now!”  If you want to see an entire floor of L&D nurses run, be a fly on the wall when that scenario repeats itself.

My experience wasn’t quite as dramatic, but it was a surprise nonetheless.  It was Alana’s second baby–those dastardly, sneaky second babies!–and she had been admitted at 1800 for an elective induction.  The previous shift had started her Pitocin just before I arrived, and by the time I took over, she was well on her way into labor.

Things progressed nicely, and soon, Alana was getting her epidural as contractions kicked out every 2-3 minutes.  Dr. Donaldson, Alana’s OB, had stopped by after her epidural was placed and broke her water, telling me to give her a call when Alana was complete and it was time to push.  Alana had had a long labor with her first baby and on our cervical exams, this baby’s head was still high, so we figured it would probably be a little while until Alana would deliver.  As I checked Alana’s cervix through the night, it was clear that she was making steady progress, going from a 2 to a 7 from the time she was admitted to the time of my last check just before midnight.

It was right as the hour hand was edging past the 12 when I asked my charge nurse, Erin, if I could head down for some dinner. “I don’t think my patient is going to last long enough for me to eat a normal meal from the cafeteria,” I had told her.  Two AM was when the cafeteria opened its full selection of the overnight meal, and being that it was a little over halfway through a 12-hour shift, most of us night shifters held out for 0200 with surprising tenacity.

Erin nodded. “Sure, we’ll keep an eye on things while you’re gone!” She said.

As planned, I headed to the cafeteria, scarfed down some lunch and headed back to my floor.  One of my coworkers had looked in on Alana while I was eating, and Alana was starting to feel lots of pressure with contractions–a good sign that things were moving along well.

I headed straight in to see Alana after lunch and noticed during a contraction that she certainly was having increased pain.  Suspecting that she might be making a quick move for delivery, I headed to the supply room for a straight cath kit (used to catheterize moms with epidurals who cannot empty their own bladders due to the anesthesia) and returned to Alana’s side.

A common trick of the smart L&D nurse is to check a patient’s dilation immediately after straight cathing her.  She is in the right position for a check (lying down nearly flat on the bed, legs apart and knees out) and if you keep the sterile glove on your dominant hand sterile during the cath procedure, you already have the glove and gel necessary to perform a cervical exam.

That had been my plan as I gelled up the catheter, slipped it into Alana’s urethra, and glanced at the clock.  It was just before 0115.  Making a note of the time for charting purposes, I glanced down at my cath tray to make sure I had enough gel for a cervical exam and looked back to Alana.

Alana’s perineum was bulging under my fingers, the distinct and growing form of a fetal head peering out between her labia.  I was so surprised, I had to look twice.  Sure enough, that was a head crowning.

“OK, I’m feeling a lot of pressure all of a sudden.” Alana said, her breathing suddenly labored.

I’ll bet you are! My mind exclaimed. “I’m not too surprised to hear that.  It looks like the baby is coming right now.” I said, pulling out the straight cath, throwing away the kit, ripping off my dirty gloves and grabbing a new set of sterile gloves as I pulled the emergency cord out of the wall.

“Right now?” Alana exclaimed.

I was hurriedly pulling on sterile gloves as the baby’s head pushed further and further out of Alana’s vagina.  “Yep, right now!” I replied. “It’s OK, Alana.  Baby’s almost out on her own.  Take nice, deep breaths for me and hang on while I get the cavalry in here.” I said, placing a hand on the baby’s head and supporting Alana’s perineum as I watched the baby wiggle her emerging noggin between contractions, working to help her mom push her out.

The door burst open. “You OK, Sophie?” Shelly, one of my favorite coworkers, asked as she entered the room.  As her eyes fell on the bed, they widened into saucers. “What do you need?” She blurted.

“A delivery cart, a tech and a charge nurse!” I said, keeping gentle pressure on the baby’s head as another contraction pushed the baby against Alana’s perineum.

“Oh, man, there’s so much pressure!” Alana grimaced.

“Breathe through it, Alana.  You’re almost there!” I coached.

“You got it!” Shelly said, ducking out of the room just as Erin, two other nurses and Jerry, the surgical tech, burst into the room.

“I’ve got a precip!” I called, now holding half of the baby’s face in my hand as Alana’s contractions involuntarily squeezed the head out.

“Oh, well!” Erin said, slapping on sterile gloves and zipping over to Alana’s side.  Shelly came running through the door with a delivery cart a few seconds later and I heard a sterile gown rustle just as Alana’s body kicked off another contraction.

“Here comes another one!” Alana shrieked.

Erin reached over Alana’s leg and slipped one hand around the baby’s neck, checking for a  cord.  “Push, Alana, push that baby out!  We’re here now–you can do it!”  Erin commanded, her voice full of reassurance and encouragement.

Alana needed no further invitation.  I moved my right hand to hold the baby’s head and held up Alana’s perineum with my left hand, guiding the slippery, wiggly little body gently out of her mother as Alana delivered her baby girl with minimal voluntary effort.  Even as the rest of the baby delivered, I noticed to my surprise that the newborn already had her eyes open.  A scream of indignation arose from the bloody, sticky little bundle in my hands and two dark brown eyes gazed up at me.  I don’t think I was able to hide my sigh of relief as I looked over the kicking, pink little baby and realized she had come out perfectly.

“Great job, Alana!  You did it!” Erin was congratulating the beaming new mom.

I was watching the baby, whose squinting eyes searched the room with a level of alertness I had never seen in a newborn.  Shortly after she was born, those eyes met mine and paused, her forehead creasing as if to say, “You’re not the doctor!”

Another nurse placed a delivery blanket on Alana’s belly.

Yeah, well, you’re not supposed to be here yet, you stinker! I replied mentally, placing the baby on Alana’s abdomen and drying her off with the delivery blanket as those beautiful cries filled the room.

“Nice job, Soph.”  Erin said quietly, joining me at the end of the bed. “Was that your first precip?”

“Sure was.” I replied, my heart still racing with the thrill of the moment.

“Way to keep your cool, girl!” She gave me a pat on the back and headed to the warmer for more blankets.

Jerry clamped and cut the cord, stepping into my place to check Alana for tears as Erin and I tended to mom and baby.  About fifteen minutes later, Dr. Donaldson arrived and confirmed that Alana had no tears–we were good to clean her up.  For about the tenth time, I told the story of how the baby was nearly born during a straight cath attempt.  Dr. Donaldson, a (thankfully) very laid-back physician, smiled and congratulated me, heading back home for some sleep.

L&D is by its very nature an unpredictable work environment–you never know what will happen from second to second.  And although that can often encompass a number of traumatic and terrifying experiences, I learned that night that not all surprises are bad.  Some of them are pink, kicking and crying with big brown eyes.

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.