OB Nurses, Help!

pierand · Oct 23, 2014

I could have written your post 6 years ago when I started in OB after only 5 months in nursing. It's a tough field, but very rewarding. I know you said that management is not on your side, but could you ask to have another preceptor? The basics are what will save your butt time and again, while the other stuff, like planning, will come with experience. As far as your co-workers laughing at you, try not to take it too personally. They were all in your shoes once. I have also realized that unfortunately, we nurses tend to "eat our young", instead of fostering and teaching. Maybe it's due to jealousy or insecurity, but take heart that it happens everywhere, not just there. If this is where your passion lies, hang in there, become a little more assertive, and talk to your co-workers. Ask all of them if you can check their patients and compare notes. Everything you are learning just takes time and practice, practice, practice. Good luck!!

taz5869, RNC-OB · Oct 24, 2014

Dear Bronze,

I have been an OB nurse for a couple of years now and there is a huge learning curve - especially for new grads. It's really a tough transition for new grads when you're really just getting the basics down and I can't imagine starting right in the thick of it on a high-risk maternity floor! (I work with lower-risk patients). I'm sorry to hear that you feel so unsupported at work, though.... that makes it particularly tough.

Here are a few things I recommend:

1. Utilize a good "nursing brain" for shift reports with all of the essential data.... there are several good ones here which I used as a template when I customized my own. As a new grad it will help you feel less scattered when you have to give report.

2. When you need to communicate with your docs, try to make sure you have all of the info. that might be pertinent to the pt. situation. Unfortunately, knowing what you need to know/report per pt. situation often comes with experience and knowledge about potential complications or disease processes. Part of it is going to be learned through experience, but try to anticipate what they might need to know: VS, significant assessment findings, pertinent maternal hx., meds given, lab results, I&O, interventions, etc.

3. Keep reading/studying/practicing when you're at home! The more you learn the more you will be prepared to deal with various situations. Practice "measuring" all kinds of round objects with your fingers... a bottle top, tupperware lid, etc. and then check your guesses to see how you did. I know it's hard when you have just graduated and have student loans and stuff, but invest in your field: go to conferences, watch videos or take online CE modules, make sure you understand the physiological concepts re: EFM, utilize free resources from places like https://www.cmqcc.org (preeclampsia & OB hemorrhage toolkits & more), Preterm labor assessment toolkit | March of Dimes (preterm labor assessment toolkit), and become an AWHONN member if you're not already one.

4. New grads are very task oriented because EVERYTHING is new to us. We have to think about every little thing - like remembering to position pt. on her side and turning on the record button on the fetal monitor whereas these things are just intuitive for experienced nurses. Get as organized as you can.... make notes regarding all of the tasks and things which you need to do and create a "checklist" to use as a template to help you keep your thoughts organized... I think it helped them become "habit" for me a lot faster. But.... be flexible!!!! Understand that you're not going to be able to always do it all at once or in order!!! You have to use nursing judgment a lot when you're prioritizing. (i.e. if your G1P0 34w pt. just arrived, has no contractions, has BP 172/108, is c/o vision changes, N/V and epigastric pain, what pertinent assessment data will the doctor need and what are your priorities? You'll need to hone in on preeclampsia assessment items and let the rest of the stuff wait until the pt. is stabilized. Is a SVE important? Do you really need to know when the pt. last had a bowel movement? What is your focus?)

Here's an example of the list I made for myself when I was new and wanted to remember everything that I needed to do for a basic admit... it's crazy detailed because I needed it to be (so I didn't forget a ton of stupid little things):

Initial:

Run test and push record button on monitor

Have pt. provide urine sample if they haven't already / gown if desired

Check equipment (O2, suction, etc. - tox. kit for preeclampsia, etc.)

Get pt. some water to drink & linens for SO if needed.

Put bath blanket on chux if pt. has ROM or is expected to do so during night

Initiate orders if pt. is here for induction. Confirm GBS status and order abx if positive and in active labor or ROM.

Position pt. on side and monitor FHR and UC's for 20 mins.

Note: For an induction, do the above items, then warm pack arm for IV, get quick VS and Head/Toe assessment, start IV, perform SVE (verify vertex), calculate Bishop's score, note frequency of UC's and verify that the correct method is being used (cervidil/misoprostol/pitocin) per protocol. Start medication and then finish full admission assessment, tasks, & documentation. Induction should be started within 30 mins. to 1 hour of pt. arrival.

VS, pain

Maternal Head to Toe Assessment

Current/Past issues: bleeding, discharge, fluid leakage, UC's (frequency & time they began), epigastric pain, H/A, N/V, dizziness, vision changes (blurry, spots), swelling, SOB, frequency/burning when urinating, UTI's, STI's, how much water pt. has been drinking (dehydrated?). Alcohol/tobacco/drug use, medications, allergies, last time ate/drank. Problems with this pregnancy or previous pregnancies, significant medical hx, etc. (HTN, Diabetes, preeclampsia, previous difficult delivery, etc,) If diabetic, find out last blood sugar. (Many of these questions are in the PDP).

GBS Status - order meds if needed

SVE & Nitrazine for suspected ROM, if needed. DO NOT PERFORM SVE IF PT IS BLEEDING

Discuss plan of care (Birth plan, Pain meds, epidural, natural labor, labor process, support, who pt. wants in room for delivery, etc.)

Documentation: Antepartum triage, cervical exam, presentation, membranes, PIH screening, Urine dip stick, Vital Signs, Systems Assessment.

Check urine for protein/glucose. Send clean catch to lab if indicated and put in order.

Orient pt. to the room, white board, remote, call light, rounding schedule

If time permits, add pregnancies into pregnancy summary

Associate monitor with FetalLink when band comes up

Call provider if needed with update and any questions/concerns.

Cerner:

Orders (Initiate). (Ensure that the proper blood orders are in computer per PPH protocol)

Antepartum Triage, PIH screen, POC Testing (Urine dipstick)

VS, Systems Assessment

Perinatal PDP - Be sure to do social hx and ask pt. if they have help available at home after delivery. Also verify that pt. is okay with receiving blood products if needed in an emergency.

Fall Risk

Skin Risk

Valuables/Medications

Immunizations

Care Plan

Pregnancy Summary

Document phone call with physician, pt. education

Tasks:

Get Blood Band and allergy band, if needed

Start IV (18 gauge preferred)

Draw Labs from IV start (611, date and time go on lab labels.)

Document IV start, lab collection and IV fluids in Cerner

Start Abx if indicated for GBS prophylaxis

Put hat in toilet to track I/O

Notify Anesthesia if pt. is going to want an epidural

Pull out foley catheter for after epidural placement (No foley for Dr. X's patients!)

Fill out Pink Sheet

Information to go over & Paperwork to Sign:

Conditions of Registration (sign, initial)

Visitation and Security Policy (sign)

Hepatitis B Vaccine, baby (sign)

Make sure they are okay with baby admit meds (Vitamin K & Erythromycin)

Document in computer

Infant Tracking Log

Blue Folder with birth certificate info.

Paternity Affidavit

Pt. Education:

Fetal moniitoring: continuous vs. intermittent, telemetry, characteristics: baseline rate, baseline variability, accelerations, decelerations, and possible interventions: lady partsl exam (why), reposition (why), start/increase fluids, medication off, pulse ox on finger or toe, O2 mask

Plan of care with interventions (SVE's, AROM, VS schedule, GBS prophylaxis, FSE, IUPC, UDS, DAU/DAM, etc.)

What to expect: Labor process, support, positions, medications, delivery info. & staff, breastfeeding & breast massage, golden hour, fundal massage and assessments after delivery, preeclampsia, etc.... whatever is applicable that the pt. is receptive to discussing.)

Obviously, a lot of this doesn't make sense to you because it was specific to my facility and my computer system. But it shows you the kinds of tasks that I needed to remind myself of because it is easy to miss something. Again, you can't just go down your checklists item by item... sometimes you need to jump around, but having outlines for the various aspects of care: triage, admissions, epidural procedures, preparing for delivery, etc. really helped me to think through things in my mind to organize my care so I didn't forget as much.

Another thing I did was had a basic "report" format for the doctor... I didn't always have time to plan/prepare all of the time and some things weren't always applicable, but here is my initial triage call format:

Initial Provider Report:

Hi, this is ____, RN at (your hospital name). We have Dr. _____'s patient _____ here. She is a G __ P ___ with an EDC of ______. (Verbalize pt. hx, allergies, complications, assessment s/sx variations from normal, if needed)

Dilitation: Effaced: Station: Firm / Med / Soft Post / Mid / Ant Vertex / Other:

Membranes: Intact / SROM @ / Bulging Clear / Mec / Blood / Odor

Ctx Onset: Frequency Duration Pain Mild / Mod / Strong

FHR Baseline Rate: FHR Variability:

Periodic / Episodic / Accels / Decels: Early / Late / Variable GBS: Pos / Neg

Abnormal VS, interventions. If GDM: FSBS (Finger stick blood sugar) status

Again, we often have to move fast and can't take the time to sit and write every little thing out, but this will help you think about those things that you need to communicate.

Anyway, that's my 2 cents for now... I've gotta run, but I hope some of this helps!!!

Best of luck!!!

iPink, BSN, RN · Oct 25, 2014

Completely new grad stuff you are feeling. I didn't start in OB, but on a stepdown ICU. I dreaded going into work and I often left work late to finish up charting. I almost wanted to quit nursing and I had only been there for 2 months. But I hung in there and eventually I got more efficient in my skills and my confidence level increased. It did help that I had support from my preceptor, coworkers, and management. My unit was new grad friendly and it makes a difference in one succeeding.

Hang in there for a year and if you still don't like it, try transferring to a different unit in women's health (if your hospital has it separated). I'm now in postpartum and plan to stay in that specialty for a long time. I love it and grateful for my hard experience from my previous unit. Good luck!

Sent from iPink's phone via allnurses app

SeattleRS24 · Oct 25, 2014

Taz5869, thank you SO much for all of your kind words and helpful information! I will definitely put your tips to use. By learning/practicing with your tools, I can at least have a bit more "structure" within my shifts. It's nice to hear from all of you that the learning curve is this high, and that my feelings are normal. I cannot thank you enough!!

SeattleRS24 · Oct 25, 2014

Thank you very much pierand for your kind words and encouragement! I definitely agree with you that I need to be more assertive. I appreciate your response!

SeattleRS24 · Oct 25, 2014

iPink RN - thank you very much! My coworkers really are very nice and supportive for the most part. I hope that they help me through it like your unit did for you.

Katie71275 · Oct 27, 2014

I'm so sorry you are feeling so overwhelmed! It is definitely new grad stuff that you are feeling. I graduated May 2013 and started nursing in L&D shortly after. Even after a year and relocating to a new hospital, I still had a lot to learn. I was also blowing tons of IVs as well. That will come with practice! Also I don't know if you are on FB or not, but there are L&D groups on there that is a wealth of information also.