OB4ME

Our director staffs our couplet care/ante/gyn unit based solely on unit census. We can, per the guidelines, take 5 gyns, or 4 couplets, 6-8 individual moms or individual babies, or 4-6 antepartum patients. She claims that these are excellent guidelines to go by...After all, many med surg nurses take 8 patients each (And, how many patients do we have when we have 4 couplets? 4 moms and 4 babies = 8 patients!) But, are all of each med-surg nurses' patients fresh post ops, or newly diagnosed, needing TONS of teaching and support? Usually not. And, is the turn-over so high in med-surg? We often start with 4 couplets, send them ALL home, admit a pre-op ectopic pregnancy and send her to surgery (or admit an antepartum pt for observation, give her major IV therapy for dehydration, and send her home by the end of the day), and admit a whole other full load of patients. Day in, day out...It's exhausting. One difficulty we are finding is that our staff nurses (including the charge nurse) are routinely starting the shift "maxed out" at our 4 couplets, and then they are wanting us to rush through our discharges so that we can take more patients who are sitting, delivered, in L&D. Our suggestion to at least start the unit staffed well enough to have some built in flexibility the first part of the shift, before discharges go home and then flex down if the census went down was quickly shot down. So, they continue to cancel a nurse when it would mean that we are staffed for 3 couplets each, and then refuse to call her in, telling us to hurry and get our discharges out instead. The other difficulty is with our gyn guidelines. Sure, 5 gyns who are up walking, self care, stable pts would be fine. But, the gyns we are getting are almost all fresh post ops with IVs, antibiotics, PCAs, confused, vomiting from anesthesia, with a myriad of chronic health problems (usually COPD or chronic heart or BP problems) that are often exacerbated by the surgery. To have one RN take 5 of those would be impossible, not to mention unsafe. By the time they become "simple" enough for one RN to take 5, they're going home (usually on post op day 2) It's really hard to follow those staffing guidelines when you may have a mix of gyns and antes and couplets and moms or babies. And, it's especially difficult to provide good patient care to the patients when you are being rushed by the managers to get them out in order to take more admits. The director keeps comparing us to a med-surg floor, trying to make us look wonderfully staffed...but the fact is, we're in a different ballpark. We have lots of first time moms who need TONS of teaching...The goal should not simply be to get them to sign a paper saying that we reviewed everything and point them towards the door. And, our gyns are not stable gyns that would fit the 1:5 ratio. (Oh, and then I love it when the nurses have something like 3 couplets and 1 gyn, and they want them to take another gyn because the 1 gyn they have is "like half a couplet") As charge nurse, I am really caught between a rock and a hard place trying to come up with ideas which make financial sense (so that our director will listen), while keeping things safe and keeping staff morale up. Because one thing is for sure, if this doesn't get resolved in an appropriate manner, we're looking at losing half our staff RNs...and where would our budget go if we had to go back to relying on registry and travel staff? Certainly, there are benefits and drawbacks to staffing per census only and to staffing per acuity only (Then it can get abused, and you get the nurse who absolutely refuses to take a 5th couplet, in a real crunch, just because she's maxed at her 4 couplets, even though her 4 couplets are all "easy" care-wise, and she's spent the whole shift at the desk reading a book...lol!). However, since our director is directing while far removed from the floor, and doesn't really see what our nurses are running their tails off doing...I think that we need to start actively tracking what our nurses are so busy doing, in a way that she can see. Maybe our tracking will show that we simply need another aide to help ambulate pts and deliver care supplies, etc...Maybe we need an LPN to help with meds...Maybe we need to totally re-do our staffing guidelines. We may see that by tracking it on paper?

My husband and I are planning to move to CA, probably the San Diego area, possibly LA area (nicer areas, though). I've been looking into hospital job opportunities in CA, and can get some ideas of which facilities to look into. However, especially with all of the news about the nursing staffing issues in CA, I'd much rather hear from nurses who are actually working in the trenches. I'd be looking to work either in L&D, antepartum, or postpartum/gyn, and have experience in all those areas. I've worked in all sizes of facilities, from large teaching medical centers to small community hospitals, so I would feel comfortable at any size facility. I'm looking more for the best "environment" (management supportive of staff, respect of RNs by MDs, etc.)...and, of course, good pay and benefits are nice. :-) Can any of you recommend any CA facilities, esp in the San Diego or LA area? What do you like about your facility, and why? How are the staffing ratios? What kind of unit are you working on? How big is your facility? Do any of you advise against working in certain CA facilities? Why? If you are uncomfortable with posting this info on a public forum, feel free to send me a private note, or email me at [email protected]. Thanks!

I'm looking to create a form for tracking pt acuity, in order to determine appropriate staffing. I've heard that some units have a form with something like a point system, where, for example, a pt on fall precautions or on certain drugs requiring increased RN attention are valued as more than a patient who is doing relatively well and able to do most self care. We'd like this form to be something that our charge RN would use each shift to track the actual acuity of the patients currently on the floor, to better determine when the staff RNs can take admissions vs are maxed out. We would also track these forms over a longer period of time to determine whether we have the right staffing mix. (Are our nurses getting overwhelmed and unable to take admissions, because they don't have enough CNA help? Or do we actually need another RN?) Our unit is a new couplet care (postpartum)/gyn floor, currently experiencing some growing pains. Does anyone have anything that works well for them, that I could take a look at, to help me design our acuity tracking sheet?

Interesting thread here... Not wanting to repeat many of the comments that have been said repeatedly here, I do have something to add... In our area, welfare/medicaid is now refusing to pay for newborn circumcisions. Many of our local insurance companies are following suit. Few of our parents want to pay the $300 procedure fee out of pocket. This is having a dramatic effect on our circ rate, to the point that I'd say non-circumcised is now the norm, not vice-versa. Is anyone else out there experiencing this?

One dose of ampicillin as adequate tx for +GBS? That doesn't sound right. Our unit is switching to PCN q4hrs as routine tx (Clinda for PCN allergic pts), as most GBS is supposedly resistant to Ampicillin. Are most of you still using Amp? We also strive to get 2 doses in, with the 2nd one being at least an hour prior to delivery. If not, the babies are in house for 48 hours (no early discharges), and they have CBC and blood cultures drawn.

One dose of ampicillin as adequate tx for +GBS? That doesn't sound right. Our unit is switching to PCN q4hrs as routine tx (Clinda for PCN allergic pts), as most GBS is supposedly resistant to Ampicillin. Are most of you still using Amp? We also strive to get 2 doses in, with the 2nd one being at least an hour prior to delivery. If not, the babies are in house for 48 hours (no early discharges), and they have CBC and blood cultures drawn.

Yeah, that amazes me to see docs scheduling inductions for "maternal discomfort" as the diagnosis! And, these patients seem to have no clue about the risks involved...they just want a quick fix to their aching pregnant body...

OMG! I think I saw that one too! The one where the midwife is checking her in the tub, and "thinks" the cord might be prolapsed, and tells the pt that she needs to get out so that she can recheck her...instead of dragging her out of the tub like we would. Then, she confirms prolapsed cord, and tells the pt that they'll have to go to the hospital...The pt stands there and bawls crocodile tears "OH! But I wanted to deliver at home!" like she has NO CLUE that her baby's life is in danger! And then they spend time discussing how to get to the hospital around all that construction...and then she WALKS the pt into the hospital, rather than calling ahead for a gurney and people who know what the heck they are doing... And, of course, she was a crash c/s because "the baby's heartbeat was low" DUH! I remember being amazed at her allowing that film to be shown...makes things real easy if the family sues her!

Our unit bought a tele unit, so our moms can ambulate and even soak in the jacuzzi with continuous EFM...even if ruptured or on Pit! I love it! Am now trying to get them to order more than one!

I know that most OB RNs (including myself) have NO interest in working med-surg, but med-surg skills do come in handy when you have anyone with health issues come in for OB care. If taking care of med-surg patients on your unit seems more and more common due to your facility's bed situation...Would you consider taking a med-surg skills refresher class, such as those offered to nurses returning to the workplace? It doesn't mean that you will have to float all over the place (don't tell your boss you took it, if you are worried about being floated!), but at least you will feel more confident when you do have to take a med-surg patient (even OB!), and your patients will receive better, safer care. It will also make you more marketable, if you enhance your OB skills with med-surg and even critical care classes/experience. Helpful in the current day of large sign on bonuses and such recruiting methods! :-) I am often found to be the "odd duck" sitting in on various med-surg and critical care classes. Often, the other nurses will imply that we just hold babies all day...what do we need to know this for? I invite them to come do my job for a day... LOL!

Hi Karen, Please check out the post that I posted today (8/8) called "Computer Charting"...We've had some major glitches that you should look at. I'm also looking for some input on this system... Best wishes, Michelle

Some of our doctors order a bolus first...some order it to be stopped after that, some order a continuous rate. So, of course you'd have to document when rate changes occur. I like to use a pump for my amnios. So, I always chart that. Also, running an amnio is contraindicated if there are late decels...so make sure that it is indicated, and that such is charted as well.

Living in the southwest, we have a huge number of spanish speaking patients. Learning the basics has been quite helpful for me, too. I can now get through most of the important things on an admission and get through most procedures (iv starts, etc) and general labor and delivery. However, there is some risk involved in not getting a translator-or even in using a non-certified one. Suppose you use a family member and that family member misunderstands you, and conveys the wrong message to the patient? Or, your pt. misunderstands your broken spanish? If there were to be a bad outcome because of it, I'm sure their lawyer would love to hear that you didn't obtain a proper translator. Patients also do not always answer in truth when it comes to sensitive questions if translated by visitors. It does put us in a tough spot! In the hospital I was trained at, they were working on getting 24 hour in-house coverage for spanish translation. The translator was shared between L+D and the ER. That was pretty handy-but the translator wasn't always readily available. Obviously, if something big is going on in the ER, that takes precedence over just another delivery...But it did help to have an actual "Spanish Translator," that we weren't constantly having to look for someone who speaks spanish, who then has to take time from their own job to translate. At the last hospital I worked at, we have access to a "CyraCom" phone-which is a phone used specifically for translation. Anyways, it has 2 receivers. You plug it in to the phone jack in the patient's room, pick one receiver up, access the service (MANY different languages are available), and you are connected to a translater. They give you an ID number which you then write in your notes ("Admission H+P completed, as translated by cyracom rep#..."). Then, you give the second receiver to the patient. And you actually have an official translation session going! I like it, other than the extra time taken-figure it will take twice as long as it would for you to do for your english-speaking patients. Usually, when I admit a pt, I will cover EVERYTHING that I can think of in one translation-from admission paperwork to consents to plan of care (including possible use of pitocin, ivs, etc.) and pain management. The service really is handy. Maybe you can suggest it to your manager??? The do have a website: http://www.cyracom.net. I'm sure there are probably other companies out there as well.

Proper prenatal care should've included the now routine glucose screen (at around 26 weeks, I believe?). Your doc never did the 1 hour glucola? I'm curious to find out what the actual time period was of your "prolonged first stage" and "prolonged second stage" of labor? Jub-mind if I ask what your area of nursing specialty is?

Hello, dcuson! I think that's wonderful that you are entertaining the idea of going into L&D!!! We need more nurses that truly love this specialty! I worked with one of the best male nurses when I worked ante-postpartum. Though he sometimes got kicked out of the room ("No way you're going to go looking down there for any swelling!)-many patients were fine since he came across as very professional. I think that is the key. Some hospitals exclude male nurse from L&D, due to the anticipated discomfort felt by patients and/or their husbands. In the debate of whether or not it is fair to exclude them, I am in the middle-I don't think they should be excluded from the area, but I believe that the patient who is truly uncomfortable with having a male nurse in OB has the right to refuse. Many patients will be totally fine with a male as their nurse, as long as he comes across as professional. Many argue that most OB docs are male, so why should this even be an issue? Please keep in mind that most patients choose their OB, often referred to by a friend or family member. And they build a relationship through the course of the pregnancy, whereas a male nurse would just be "thrust" upon them. I think that as you pursue L&D as a career goal, just keep these things in mind! Enthusiasm can often get you in the door to the job of your dreams, and professionalism will keep you there! Good luck!