[Treasure30]

Originally Posted by pbrtrails

I am a new nurse to the L&D department. I went to this floor 3/07. I graduated from school 5/06. I could not imagine having 2 patients in labor. Most of the time you cannot keep track of the baby, or the mother on the monitor. When you get the mom up to the bathroom, our policy is to never leave the mother alone by herself. How in the world do you handle 2 laboring moms at the same time, especially if they both want an epidural at the same time, and then there is all of this charting every 15 minutes. Yikes. I have been pulling some shifts in our emergency department, not nearly as much paperwork, and the patients down there get turned out either on the floor or they go home. My department co-workers remind me all the time that standards are 1:2 ratio in labor. I just do not know how long I will be staying on this floor. I just do not feel that I personally could provide safe and accurate care to a patient without guilt every night when I go home. Our charge nurse takes a team, we do not have a nurse that floats. This is a tiny hospital, we do not have physicians in house, they are available by phone. Our ED physician does not come to our department unless there is a CODE BLUE OR PINK. I often ask myself, "what in the world have you gotten yoursef into this time?" We do not have central monitoring either.

Sound like ... Anyway I started in a larger hospital as a new grad. I guess if I would have started in a hospital similar to where you are practicing, I may have the same concerns. I think I delivered my first baby on my own, without a doctor or other staff, I had been a RN approximately 15 months.
I remember working in the L&D as a nurse extern and almost delivering by myself, as I went to take VS, & the pt said, "I feel like I have to push". I looked under the sheet, & she was crowning. The baby was coming, so all I did was put on some sterile gloves & remember the stages ... rotation, extention, flexion, etc & how the doctors would tell them to breath at certain points of the delivery. OH BY THE WAY, THERE WAS NO RN ON THIS SIDE OF THE UNIT AT THIS TIME.
The LPN walked in & told me later, I handle the whole situation like the Doctor.
When I started, we didn't have central monitoring. Don't have no suggestion.
Treasure

[jhhrn68]

We have LDR rooms, a seperate post-partum unit and a nursery. Our charge nurse does not take an assignment and can float back to L&D if needed. During the day, the staffing is higher and there are usually 2 float nurses. In L&D, we might have 2 pts. in labor or one labor pt. and one outpatient. The nursery nurse has the nursery. Mother/baby couplets just do not work well with our physical set-up. I have had as many as 11 postpartum and surgical pts. at one time. But lately, our staffing has been excellent because of new hires. And, since I work casual labor, I haven't been getting any hours lately.

[L0v3MyM1nd]

I am a new nurse in OB and I feel exactly as you do. I work at a tiny hospital also. I feel our problems are we do not have enough staffing, our high-risk pt demographics are growing and our department isn't equipped to handle the sudden growth in this area. Some good changes are being made; but not at the rate of the growth of our community. I feel horrible when I hear some local expectant mothers refuse to give birth in our facility, or that they had a terrible experience there. We can have 1:8 couplets and 1:3 L&Ds at times. When things get crazy we call in floats and the house supervisor along with any OB staff available to work. A 12 hour shift turns into a 14 -16 hour shift with paperwork, and being new it is extremely overwhelming. Night shift is worse.
Thank you for your post! It's nice to know that some else feels the way I do.

[alicewhitt]

I just took a staff job in a small hospital after working there as an agency nurse for a few months.
After coming from a large magnet teaching hospital on the west coast, it seemed rather slow.
However, last weekend there was one labor nurse besides myself scheduled and we had six labor patients by the morning. No unit clerk. No pre-made charts. If the nurse from evenings had not stayed to help until our laboring twin near term repeat c-section mom was in recovery we would have been dead in the water. We had a brady, I got that mom in knee chest, had to run to another room for an 02 mask, and on the way realized that we had not set our one operating room back up again.
The OB docs are so spoiled by the nurses...
I so take back every unkind thing I ever said about working with residents. At least they do not touch your Pitocin pump and do 'active management' every time you are out of the room. A 12 hour shift turned into 14, and I was so blithering by the time I gave report it sounded like I didn't do anything all night. My second worst staffing nightmare in 18 years of OB.
So thanks for the guidelines reminder that I am not crazy, just stressed.
Thank the Most High for central monitoring. It could always be worse. What a weird way to find comfort.

[Magik]

Originally Posted by keasc20

I actually work in a hospital that follows these guidelines!!!! Can you believe it?

ME TOO!!!!

[Magik]

I agree with the below statement, though having guidlines is a comfort and knowing that you are at a facility that response to the words, "But the AWHONN guidelines say...." is nice.

You are very right in that a couplet with feeding issues can really eat up hours of a shift (no pun intended). These sorts of things need to be passed along to the charge nurse so that these patients are placed with less heavy patients when assigned.

Originally Posted by SmilingBluEyes

Of course, the guidelines do not take well into account individual nurses' skills, attributes nor, even acuity very well. That is a problem when you staff "by numbers". Where I am we do fairly well at being a team. The numbers don't tell all. We don't assign all the "fresh" or "difficult" patients to one nurse----we spread the wealth, so everyone is treated fairly, most importantly, the patients. And I am sorry, but 6 couplets is way too many if they are to get any real quality of care. Just ONE couplet having big breastfeeding issues can take hours of my time.

[Laboranddeliverydiva]

[IndigoCarmine]

Intrapartum:
1:2 pts in labor
1:1 pts in 2nd stage
1:1 pts w/ med or ob complications
1:2 Pit induction or aug of labor
1:1 Coverage for initiating epidurals
1:1 circulation for c/s

They seem to pretty much stick to this at my new travel position, but on shifts where there are few spare hands (which is most shifts) it can wreak havoc on nurses, pts and MDs alike when it comes to breaks. I've seen pts pass through four nurses hands in an hour.

RN 1: "I have a pt pushing so I need you to cover my labor pt".

RN 2: "Whoops, now my original pt needs an epidural, so take the one I'm covering for so-and-so. She needs her pit started".

RN 3 [Having spent 15 minutes looking for but not finding a working pump]: "hey, I'm covering for RN 2 [also not realizing that actually the pt belongs to RN 1] and Chargie is sending me to dinner break. Can you take this pt. and start her pit?"

RN 4: Ummm, sure, but my pt just got her epidural and I need to stay bedside for 15 minutes.

RN 3: "Don't worry. She's a post-dates induction. No rush on that pit".

Later, in the lounge, the MD violently confronts nurse number 2 as to why the hell her pts pit is STILL not started.

Anyhoo...

I can't agree with 1:2 for pit. Where I work now we chart q15 for all pit pts, even if they are 1 cm. No, I'm not kidding. Once you get two pit pts howling in pain without epidurals or family support you can get really screwed really fast.

[webbiedebbie]

Which is why I don't work L& D anymore. Worked one hosp where you stopped the Pit on second pt when first pt started pushing. Didn't make sense to me.

[djfam]

I work in a separate postpartum unit at a unionized hospital in California. We have couplet care; our max is 4 couplets, and most of the time assignments are made within ratios. Our moms have the choice of sending their newborn to the nursery during night shift which is staffed with one nurse assessing and caring for 8 or less newborns.

Lately though, if a nurse has two or more newborns going to nursery then she is assigned another couplet. Management is saying that as long as we aren't over 8 patients total, i.e. 4 mom/4 babies, 5 moms/3 babies, 6 moms/2 babies, etc... then we are still within ratio. I am hoping to get some input on this because it just seems a little funny to me when the state ratio law for just postpartum moms (no babies) is 1:6. I asked about that and was told by management that we are a couplet unit, not just postpartum and are allowed 8 patients total, doesn't matter the mom/baby mix.

Any thoughts on this? Keep in mind, the nursery newborn(s) might be breastfeeding on demand in which case the primary nurse is still responsible for taking baby back and forth, and helping with breastfeeding. Sometimes moms change their minds and/or want baby back half-way thru the night as well, not to mention the hour after the nursery is closed and the primary nurse has full responsibility of all 5 or possibly more couplets, until the next shift comes on.