Aspiring midwife, frustrated with L&D

[withwomen]

Hi everyone, 

I'm looking for advice on my situation and welcome any input! 

First off let me say I have been working off and on in the "birth world" since 2001 starting with being a doula, childbirth educator, etc., but never worked consistently during that time, so although my experiences range over a long period of time, they are not that extensive. I focused on raising my kids and have always had the goal of becoming a midwife once they were grown. I'm in my early 40's and after four years of nursing school and obtaining my BSN my plan was to work as an L&D nurse and then apply to Frontier to become a CNM so after a year on a medical surgical unit, I was hired on to a busy L&D unit at a level 3 facility in my city. I'm currently three months off of orientation and feel really frustrated with some of the really outdated practices my hospital continues to do at every birth. 

Some examples:

None of the nurses I work with "allow" their patient's to walk the halls, even if they are not on pit or cytotec. During my orientation I was told it was dangerous to not continuously monitor the baby during labor - even if we had a positive NST and mom was healthy and not under augmentation, etc.

We always break the bed and patient's are required to deliver in the lithotomy position every time. 

The use of valsalva pushing "hold your breath and count to ten" at every single birth. I use open glottis pushing with my patients, and as soon as the provider is in the room, they order the patient to push and hold their breath.

Most of the nurses I work with bring a bottle of formula into the room after birth and do not encourage breastfeeding. 

I have only seen two patients out of the sixty that I have delivered have a due date over 40.0 weeks, most of our patients are induced at 39 weeks, sometimes earlier.

I could go on and on. The issue is that during nursing school, I joined AWHONN, did all of my extra honors work on evidence based practice related to maternity nursing and read up on ACOG and ACNM guidelines for maternity care. So, I find these outdated practices to be frustrating and because I am new, I feel pressure to fit in and go with the flow.

The thing is I feel like a fish out of water to be honest. There are so many times where I think everything is going well with my patient (they are dilating, they are managing contractions, baby and mom are doing fantastic) to have a coworker ask me why I didn't up the pit or why I'm not calling the provider to break water. I feel like I work in a factory. 

Another issue is that I LOVE when I have a patient who wants a natural delivery. I am her champion and will use my doula skills to provide a TON of support, but then find my charting to get really far behind during births like this. The amount of paperwork and busywork detracts from real nursing care (this is true of all specialties, but really evident in L&D).

I just don't see birth as being pathological. Don't get me wrong, obstetrics is fantastic and when the proverbial s*** hits the fan, I am grateful we have the science and technology we do, I just don't think every woman and every labor needs it routinely.

Many of the nurses I work with are very opinionated on labor and they loathe when a patient wants a natural delivery or if she wants to walk or - god forbid- delay cord clamping, etc. The attitudes and remarks I hear about women are shameful. I fully support all choices women make, and if they want their epidural, I'm on their team. I just don't know why my coworkers are so opinionated all the time and have such a fear of doing anything outside the box, or (gasp!) support a woman's choice as long as it is within the bounds of safety.

For those who have stuck with me this far, here is my real question:

Is being a CNM this frustrating? Won't I be working with nurses like this on a daily basis, relying on them to care for my patient's, helping them to breastfeed, etc.? Is this a one off situation, or is this American birth? If so, how have many of you come to terms with the lack of evidence based care and heavy medical management? 

As a CNM, how much time do you spend with your patients during labor? Is it possible to have a hands on approach as a CNM, or does the sheer number of hours force you to use the call room and let the nursing staff manage most labors? 

Is it unrealistic for me to want to provide hands on care with my patients (meaning labor support, breastfeeding support, etc.) and still work in a hospital?

I'm so discouraged and am having a difficult time going to work lately. To work so hard toward a dream and then be here is really tough for me, but I want to face reality and if this is just how it is, please let me know before I spend the next three years in midwifery school only to feel this way on the other side. 

 

 

[analystmama]

I hear what you’re saying and I don’t like the way birth is so highly medicalized either. You will find your way to navigate the physician orders, hospital protocols, legal ramifications of charting, and other nurse duties while also being true to your patient’s birth wishes and your own philosophy of birth. Give it some time as you’re fresh off orientation.
Please try to be kind to your coworkers. As nurses we are really working under the constraints of your MD orders and hospital protocols. Sometimes a higher acuity level facility has a more medicalized culture than a smaller community facility. I think this is why some coworkers will ask if you’ve increased the pit. If you’re supposed to increase the pit every 15 minutes you do that while also watching protocols in regard to monitoring baby and mom. This is where your nursing judgment comes in and your opportunity to shine as an aspiring midwife while being an L&D nurse.  Some patients just need a whiff of pit (or none) and some do just need more especially in these facilities where everyone in an induction. They’re just trying to help you. 
Also an AROM (ugh interventions, I know) is not always a bad thing. A multip will literally sometimes be complete but hold on to that baby at -3 station until her water breaks and if they don’t have an epidural sometimes it’s a kindness to rupture so she can deliver if she is out of her mind due to pain. 
Patients don’t always want a natural birth. I work in triage also and most inductions are happening because moms are ready to have their babies even if it’s less than 39 weeks and roll in knowing pretty much any complaint they state will allow them to stay and have their baby. Oh, your “mucus plug” came out after sex- induction at 39 weeks ? Remember that this is a public forum and not just for nurses FYI.

Finally, don’t be discouraged. After some time your OBs will allow some leeway on your pushing styles and before you know it you’ll push with mama how she wants in whatever position she wants. Your doc will sit outside until it’s catching time because they’ve gotten to know you and you can leave with a smile on your face knowing mama had the (mostly) kind of delivery she wanted. 

[LibraSunCNM, BSN, MSN, CNM]

You're not wrong to be discouraged.  Some institutions are just bad, like yours sounds like.  There is nothing wrong with intervention in birth when medically necessary, but you're right---it sounds like you work at a factory, where interventions are routine and non-evidence based.  I didn't work in L&D prior to midwifery because of this.  I just thought I'd get too discouraged, and there were no institutions in my area that *weren't* like that.  

Try to keep your head down and push onwards.  Keep your focus on how differently you will practice when you're a midwife.  You can help change the culture where you work, or if that's not possible, you'll move on to a better one.  Don't pay attention to your coworkers butting into how you're managing your patients and try not to succumb to their pressure to be unnecessarily interventive. 

To answer your questions about working as a midwife in a hospital---yes, there are many practices where you can spend a lot of hands-on time with your patients.  And there are many practices where that's not the norm.  You'll find your way and find the right fit for you, eventually.

[withwomen]

Thank you very much for both of your replies. 

Analystmama, I completely see where you are coming from and I appreciate your response. ? 

LibraSun thank you for your reply. I took both of your replies and applied the wisdom therein this week at work and can see that it may be possible for me to stay in this environment and make a *very small* influence, at least on the moms who want it and the providers who are tolerant enough to give them a chance ? 

 

[Surfandnurse]

Hope things are going better @withwomen ?? Hard work pays off.... work culture of a birth factory is probably pretty difficult, especially when your new and your dreams are to be a kind, gentle midwife. It takes time, to gain the trust of your peeps on the unit. For sure smaller hospitals aren’t so crazy, but over all birth in America is chemically induced/augmented... something about a natural birth in the hospital (unless the pt is adamant) doesn’t go well because of the protocols in place for high risk patients.... all the things go across the board for all patients and I don’t agree with it either and I also hope once my children are of age I will go back to get my CNM. Gain the trust of your fellow employees and you will have autonomy! But I will say continue to be an advocate for your patient ??