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Do you have an OB in the hospital 24/7?

Posted

Specializes in L&D. Has 3 years experience.

I used to work L&D at a large teaching hospital in NYC. We had residents and at least one OB attending physically in the hospital 24/7.

If an OB was on call at home for their group and a labor patient came in they usually came in right away.

But honestly it was so busy that "on call" usually meant "at the hospital"

If an OB had a patient getting an epidural or they wanted to induce with cervidil or pit they had to physically be in the hospital or ask another attending to cover their patient.

I recently started working PRN at a smaller hospital in the South and it is SO different.

They hardly ever have residents and OBs are hardly ever in the hospital, especially on nights.

There is no protocol that there has to be an OB in house when patients are getting epidurals or being induced. It's crazy to me!! And feels so unsafe.

Nurses manage the whole labor. Can even put in an order for pit based on a verbal order from an OB. Doctors check in via phone on their patients progress and usually arrive when multips are fully or after primips have been pushing for awhile.

What really blows my mind is if they had a REAL emergency on night shift (abruption, prolapsed cord or FHR in the 60's and not recovering....) there would be no one to do a stat c-section. The closest OB could be 15-20 away. That is too much time!!

I've decided to leave this job for a variety of reasons (this being one of them) so I'm not looking for advice on how to adjust.

I'm just curious if this is how L&D is in most of the country.

It feels to me like a disaster waiting to happen and I want OUT ASAP.

APL&D

Has 8 years experience.

I am sure there are still backwards hospitals out there in the country, but I think it is going towards having an in-house OB 24/7. I used to work in a small community hospital a couple of years ago, and last year they started requiring an OB present in-house 24/7. Not only do they have to be present, but they had to see all triage patients within 1 hour of arrival to the hospital. I think it is a law in some states and a standard of care. Sorry you feel so discouraged. Next time you interview for a job, make sure to ask questions like these. Good luck.

adpiRN

Specializes in L&D. Has 3 years experience.

What drives me crazy is that the nurse manager and other nurses don't see this as a problem.

I guess if it's all you know....

They act like there's something wrong with me that this stresses me out. Like I'm less of a nurse. The nurse manager even called me "sheltered".

Not sure I want to ever work L&D again but if I do I will definitely ask these questions.

Live and learn....

Calinurse4

Specializes in Perinatal. Has 3 years experience.

That would be so scary! We have at least one resident and one attending 24 hours a day, usually several of each. It's all I've known but I would be terrified of not being able to act fast when things go bad.

adpiRN

Specializes in L&D. Has 3 years experience.

Oh AND they actually had a stat for an abruption last week. Luckily on day shift and the OB was there. The baby did not do well and was transferred to a level IV NICU. If that had been night shift and we'd had to wait 20-30 min for an OB he likely would have died.

And even that didn't rattle the nurses and make them second guess the policy.

adpiRN

Specializes in L&D. Has 3 years experience.

Still interested in getting more input on this! Curious if any other hopsitals out there function like this one. And how the nurses feel about it and where these hopsitals are located.

LibraSunCNM, MSN

Specializes in OB. Has 10 years experience.

I'm a midwife in NYC, no hospitals that I've worked in function like this! Ours is a pretty small public hospital, with no private practices. Everyone is an employee of the hospital. We have one OB on at all times (they do 24 hour shifts generally), and 2 midwives (we do 12s). No residency program. 24/7 anesthesia and peds coverage. It's not a perfect system but it works pretty well.

A new midwife I work with was a longtime L&D nurse at a hospital about an hour north. What she describes is pretty similar to what you describe---RNs do EVERYTHING, and call the docs when the patient is close to delivery. She is going to be a damn good midwife because of her experience, but it definitely doesn't sound like my cup of tea! And honestly, it's not even fair! If the nurse is doing that much independently, he/she is doing a lot of the work that the OB is billing insurance for.

Yes I started nursing 34 yrs ago and it was like this. Small hospitals had no dr,the nurses did everything. I worked nights newborn nursery, small community hosp. I lasted 1 year. Very unsafe. I was the only nurse with 2 aides in nursery on nights.

I worked at a hospital like you describe for 16 years. Drs did have to come in for epidurals. We were to call for a multip once she was 6 or a primip once she was fully. As a nurse, I learned a lot from doing a lot. It was a huge responsibility. In some ways, I miss it. Always something exciting. I think there is a happy medium. My daughter still works at that facility and they often have a CNM in house. The CNM's are a lot better about taking calls and looking at bad strips during the nite. Back in the day, we did not do our own C/S. I became their educator and we did do a practice drill and have a plan for starting a C/S under local. We also went in the ambulance on transports to higher level hospitals which were 20-60 miles away. Your whole team has to work together well to be safe. The team isn't just OB, but can include your supervisors, ED personnel, and other units. It is important to drill and to talk about the what if's... on those slow nights. When you have an adverse event, you need to carefully dissect it and plan what you will do "next time." If you really only feel comfortable with 24/7 providers, it isn't the place for you. There are things you can do to make it safer, but no matter what you will always have to be more independent than in a teaching facility. You do need to have protocols to which physicians are required to adhere. You need a gutsy manager and cooperative risk management and quality departments.

shortstuff31117

Specializes in OB.

Yes where I work is like this. Small community hospital, doing around 50-60 births a month. Mainly 1 group of OBs. It varies as to when they come in, or when they might actually stay in house. They don't come in for epidurals. This hasn't been an issue in the time I've worked there (8years). Not to say there haven't been emergencies, but somehow they seem to happen when the OB is there, or at change of shift when there is extra staff around.

Maybe it's "backwards" but it is what it is. I don't see it changing, at least not around here. I'm in WA by the way...

RNmom7

Specializes in Acute Rehab, OB, MedSurg. Has 5 years experience.

I am from the Midwest and the facility I work at is just as you have described. It is scary, but also has made me a stronger nurse, IMHO. As previously mentioned, when a crisis occurs all hospital staff have to be a part of the team. I'm not sure however, if this is backwards. Rural community hospitals do not have the luxury of endless resources as do larger facilities. Our facility provides a service to women that can't afford to travel for prenatal care or birthing services, as many of our patients do not own reliable transportation. We also have patients who choose to deliver with us due to the holistic approach our midwives offer.

MotherToPeanut

Specializes in LDRP; antepartum. Has 4 years experience.

I work in one of these hospitals. Our entire facility, not just the OB department, has 25 beds. We do about 180 deliveries per year. (No, that was not a typo.) We have three OB physicians to cover this hospital 24/7. This hospital could not afford to have an OB in-house 24/7. When we are fully staffed, we have 12 nurses to cover our department with two nurses per shift. Is it scary? Yes. As someone else already mentioned, this is the reality of living in a rural area. No, we are not backwards. This isn't all we know. Some of us previously worked at other hospitals, myself included. I took the job at this hospital to be closer to home. To get my foot in the door for OB nursing, I took a job that was 60 miles away and slept in an on-call room between shifts. That hospital did about 350 deliveries per year. They also had three OB docs and did not have an OB in-house 24/7. When a position opened up at a hospital closer to home (still 35 miles from home), I seized the opportunity. Yes, they do things differently here. Yes, sometimes it feels unsafe. We only recently convinced management (who do not really understand the realities of OB) that we NEED to have two nurses scheduled for every shift. For years prior to my arrival, it was a fairly common occurrence for a nurse to be here alone. Now, that's scary!

We do the best we can with the resources we have available. Communication and trust between the nursing staff the the OB docs is critical. The second one of the nurses feels something isn't right, they're calling the doc. The OB's usually don't come in for epidurals unless anesthesia has a concern. For multips, the docs usually come in when they're around 5-6cm depending on their progression and previous labors. For primips, they usually come in when they're 8-9cm. In this environment, everything is a case-by-case basis.

Working in a hospital like this isn't for everyone. We have to be a jack-of-all-trades. We have to know antepartum, L&D, postpartum, nursery, and GYN surgery. We try to be as prepared as we can. We are the only hospital in this county. Some neighboring counties have no hospital at all so some of our patients drive 30+ minutes to get here because we're the closest. These patients deserve the best care we can offer. It would be nice to have an OB in-house 24/7. It would be nice to have anesthesia in-house 24/7. When you work in a facility that routinely has stretches of several days without an OB patient, with only 3 OB's to share the responsibility of coverage, it just isn't feasible to have someone here 24/7.

I work at a hospital that does have 24/7 laborist coverage, but this is fairly new (within the last 2 years). We did about 4300 deliveries last year which was the most in the state. The laborist is not a substitute for the patient's OB. We still communicate with their OB for updates, orders, etc and they are not usually in house. We do have anesthesia and our OR staff in house 24/7. We have never had to have a doc in house for epidural placement and usually the patient's OB or the one on call for them doesn't show up until complete and/or pushing. The laborist is there for STAT sections, precipitous deliveries, unassigned patients, and transports that we have accepted from outlying hospital. They also occasionally cover for other OBs when they have a VBAC patient so they don't have to stay at the hospital the whole time they are in active labor.

beachmom

Has 6 years experience.

No, we don't have a 24/7 OB. Luckily all our OB's live 5-10 minutes away, and they can park right next to LDRP. The clinics are across the street - 2 minutes away. Our peds live farther away, 10-20 minutes. All of us are expected to be skilled with NRP. The next nearest LDRP is 2 hours away, so we do our best. Some of are CRNAs (anesthesia) live 15 minutes away, and that's scary. We have a "stat C/S box" in case the Dr. needs to get a baby out with a local. We all hope and pray we don't have to use it. It was used once in the past, and it was quite traumatic for the pt and the nurses.

We have about 600 births/year. Not enough to pay for a 24/7 Dr. or CRNA. Although there is a 24 hour hospitalist if we have a medical problem. Doctors don't have to be in house for epidurals or inductions. Never heard of that. They have to see the pt. at teh start of an induction, and they all answer their phones quickly. Doctors and anesthesia both have to be in house or at the office (2 min away) if we do a VBAC. We have sleep rooms if they need it.

NurseNora, BSN, RN

Specializes in L&D. Has 52 years experience.

I spent 30 years working in big city, high risk, teaching hospitals where the nurse had to fight her way thru the med students, interns, residents, and attending a to get to her patient. When I moved to a rural hospital with no OB in house, I was really scared. It took a while, but I developed new reflexes. The nurse has to be on her toes and pick up problems early. She has to develop a good relationship with the providers, a real sense of mutual trust. It's a different world. I'm glad I've experienced both.

stephncal544

Has 2 years experience.

We do not have an OB in house, We do not have Anesthesia in house. And starting soon we will not have Neonatalogists in house. We have 1-6 deliveries per day. The docs do not show up for triages unless very serious, nor for pitocin or epidurals....Soon I will not be in the house. :)

I currently work in a hospital in NH on the L&D floor. We use midwives here mostly. Often there is not an OB on the floor. They are able to access our EFM from home and they all are required to be within 30 mins away (most are much closer than that). They frequently monitor the strips at home, but they are rarely on the unit itself let alone in the hospital after clinic hours. Having been trained in bigger hospitals in MA this scared me to no end initially (we also do not have neonatologist and the pedi's play by the same rules as the OBs). As I've grown as a nurse however, I find it at times empowering. I feel as though I've learned so much more from the midwives and from having to be more independent. We don't have a NICU either. Obviously we do not take high risk pts but as we all know that's well and good to say but doesn't always happen. My assessment skills are stronger than they would have ever been staying in a bigger teaching hospital. I understanding that it can be scary though. As it is, we recently had a placental abruption that resulted in an emergency c/section at 28 weeks. Scariest day of my life, but in the end DART drove a breathing, crying very much viable 28 week newborn after we resuscitated her and stabilized her for over 2 hours. I guess this is just a long-winded answer to your question. There is at least one other hospital that operates like this, and yes it can be very scary at times. If you have a good team of nurses and providers and communication remains good it can be empowering. I too have about 3 years of experience in the field and feel as though I am much stronger having worked in a smaller hospital like this. Teaching hospitals are awesome and you will see things you don't typically see so if you are more comfortable with that then I think it would be a better choice for you. If you can work through the initial nerves and be confident in your skills and your team than a smaller place can be a good thing too. It has more to do with the individual dynamics of the unit, I think.

I work in a pretty big facility (~2500 births per year) and it was only around when I was hired that we had an OB in-house 24/7 for the first time. Prior to that, trauma surgeons in the ER were on standby for anything emergent that walked through triage or went super south super fast on the unit. We did (and do) have in-house anesthesia.