I'm a fairly new grad, feeling somewhat overwhelmed by my position. I'm seeking some guidance/encouragement/honesty/anecdotal advice from other labor and delivery nurses out there who have experiences beyond my small corner of the obstetric world.
Some background on my facility: I work at a fairly large teaching hospital - we typically do ~10,000 deliveries/year. Our facility has a level 4 NICU as well as a dedicated high risk antepartum unit, making our hospital a magnet for higher risk deliveries in our geographical area. We are not an LDRP, only an LDR. Our antepartum unit has 45 beds (it typically runs around half capacity), labor and delivery has 30 beds (typically runs at full or near-full capacity), triage has 9 beds, and there are 6 women's ORs (one OR is usually designated to GYN surgeries, while the others run c-sections)
I started working at my facility as a new grad, about a year ago. I act sort of as a float pool nurse between the high risk antepartum unit, the labor unit, and the women's OR, but due to patient census and staffing needs, I spend most of my shifts on the labor unit. My orientation included 12 weeks on the antepartum unit, 11 weeks on the labor unit, and 1 week in the women's OR (from what I've heard from others, this was a pretty great orientation, but I might have liked some more training in the OR)
Our staffing ratios are 1:1 in the OR, 1:2 on labor, and usually 1:4 on high risk antepartum (many ask why the ratio is higher on antepartum, and the main reason for this is that we ONLY do intermittent fetal heart rate monitoring in antepartum (in increments of 2 hour periods) NOT continuous monitoring, whereas all patients on the labor and delivery unit are on CONTINUOUS fetal heart rate monitoring. As such, all antepartum magnesium patients are cared for on labor and delivery). We have aides on our antepartum unit, but we don't have aides on our labor unit.
Nurses on labor and delivery perform all basic tasks for their patients such as: foley catheter insertions, IV starts, checking vitals, blood glucose checks, blood draws etc. We are almost always 1:2 on labor, though occasionally we'll have slower days. At my facility, PACU is staffed by another team of nurses entirely, and only highly experienced nurses staff the OB emergency department/triage.
Being at a facility of this size definitely has some obvious perks. It's well organized, by necessity. The 30 Labor beds are split into 3 wings, and each wing has a "mini charge nurse." These mini charge nurses are meant to attend any deliveries that occur in their wing, in line with the recommendation that all deliveries be attended by two nurses - one for mom, and one for baby. When they don't have a delivery to attend, these mini charge nurses can serve as a decent resource nurse. We also always have plenty of NICU staff nearby, in the event we need immediate assistance. Additionally, we ALWAYS have one resource nurse (sometimes 2, or even 3 on a slow/overstaffed day) with no patient assignment to help around the unit where needed. That's particularly helpful during emergent admissions. The charge nurse NEVER takes part in direct patient care, but they do attend assisted vaginal deliveries (forceps/vacuums) to facilitate communication with the OR team.
Situations where our staffing ratio is 1:1:
- For epidural placement and for a 15 minute recovery period thereafter
- For about 1 hour after delivery time (at the one hour mark, you are expected to reassume responsibility of your other patient)
- (Almost always) for spontaneous fetal demise/termination situations (very rarely we have to be 2:1)
- Pushing, regardless of parity
To give an idea about the patient population our labor unit serves, below are some patient assignments I've experienced recently:
Patient A - an induction for gestational diabetes, on pitocin, with insulin and Q1 blood sugar checks.
Patient B - another induction, for IUGR. Induction done with cervical ripening, then a foley bulb, followed by pitocin and an amnioinfusion.
Another: Patient A - a preterm labor patient on magnesium with elevated blood pressures, and
Patient B - an induction, on pitocin, with extremely elevated pressures requiring frequent IV hypertensive medications
Another: patient A- a TOLAC in active labor, and
Patient B - an active labor patient on pitocin without risk factors
Or: Patient A - recently delivered couplet, both mom and baby requiring Q30 minute blood sugars and
Patient B - an active labor patient on pitocin
About 90% of our patients receive pitocin during labor, and probably 1 in 3 of our vaginal deliveries are inductions for some sort of high risk factors.
To be clear, I have never had more than 2 patients on the labor and delivery unit at one time (or a couplet in the recovery period, and a mom in labor) and I am very thankful for this. However, I sometimes feel like the two patients I DO have stretch me very thin, especially as a new grad with little experience.
I was looking over ACOG staffing recommendations recently and realized many of our practices are in direct opposition to these recommendations. Among the recommendations for 1:1 staffing were:
- complicated labors, such as moms with diabetes or other risk factors
- 2 full hours of recovery after delivery
- Patients receiving pitocin, due to the diligence required with fetal heart rate monitoring
- Preterm labor patients on magnesium
In your experience, do places exist where these staffing recommendations are taken seriously? Am I reasonable for feeling slightly overwhelmed? I love the work that I do, but I frequently operate in fear that I will be stretched too thin. I often feel like I can confidently handle one higher risk patient, but two becomes very challenging for me. I'm wondering if I should advocate for/seek different ratios given patient circumstances, or if that's an unrealistic expectation? In many ways, I feel spoiled at my facility with resources. But in others, I feel overwhelmed by the acuity.