somedayCNM

As a L&D nurse I start IVs all day long. After my hospital downsized the IV therapy team we are the ones who get called for difficult starts on the med-surg floors. Here's some tips: -Pick the smallest cath you can get away with. You only need a large gauge cath (18 or 20) for surgery, blood transfusions, or large IV boluses. Otherwise, the smaller, the better. Easier to land, lasts longer, and less damaging to the vein. -Use veins you can feel. If you can see it, but don't feel it, don't use it unless you have nothing else. -Try to put it in where two veins converge. Fewer valves in those spots. -Your angle of approach needs to be shallower than you think. That's my best advice. Good luck!

My first job was at a nursing home and I hated it, but it paid the bills. It was two weeks before my wedding and I needed a job, so I printed out 10 resumes and went to the 10 nearest nursing homes. They practically hired me on the spot (not many BSNs walking through their door, I suppose). Did I mention this was a the start of the recession and no one was hiring? Anyway, I worked there four months, then got hired on to a medical-oncology unit. Two years later I got my dream job in L+D, an area that is very preferential to experienced nurses. It's been a hard road, but this is a career worth fighting for. For now, do what you have to to survive and if your fiancé "doesn't approve" dump his ass. Don't partner yourself with someone who doesn't support you 100%.

In 2010 I took a full-time job in my hospital's oncology/medical unit, but I always knew L&D is where I wanted to be. I kept my eyes open for a position and a supplemental one opened up in 2011, but taking it meant I would lose my benefits including my family's health insurance. The manager of L&D let me keep my old position on the onco unit part-time and orient to L&D for 16 hrs a week (the typical orientation would have been full-time for three months). This was not an ideal way to start L&D. My orientation took seven months and I had 12 different preceptors. It's a major critical thinking shift between med-surg and L&D and it would have been better for me to make a clean break from my old job. Not long after that L&D had a full-time position opened up and I took it. I've been full-time nights here for more than three years now. Love it, but it was hard work to get to where I am. I'm very grateful to have gotten the chance to get my foot in the door when I did.

We use a combination of WatchChild by Hill-Rom and Meditech. A few months ago we made a switch to a more comprehensive form of the Hill-Rom software so we can now do most of our admits and charting in that system (previously we had the strip and papers and meditech to deal with). We still use meditech for a few things, mostly to communicate with lab and pharmacy. Some like it, some hate it. I think the admission pages are clunky and too detailed, but I love that I can do the labor and recovery records in the computer instead of on paper. Over all it's much faster than charting in meditech, but anything would be faster than that dinosaur.

Congrats! Your story is nearly almost the same as mine. I really wanted to go straight in to L&D from school, but had to settle for a medical-oncology position. I've been in L&D full time for a couple months now. Prior to getting the job in L&D read pretty much anything I could get my hands on related to birth. And I mean everything from pregnancy haiku to textbooks. The book I found most helpful on the job was "The Midwife's Labour and Birth Handbook" (2nd Ed) by Vicky Chapman and Cathy Charles. It's a small book layed out in an easy to read outline format with illustrations and chapter summaries. It covers close to everything in L&D nursing. It is written by British midwives within the context of how they run their system in the UK, but I think it is extremely applicable here in the US as well. It's a great book. Buy it today. Read it with a highlighter and bookmarks. Then read it again. Having knowledge on your side will help a lot. That being said, I learned quickly that reading books will take you only so far. At some point you have to get in there, be bold, and get hands on experience. Be confident in what you know. What you don't know, admit, then seek out the answers. When you make mistakes learn from them, them move on. Good luck! You're going to have a great time!

I always do, but only because I maintain an uptight and anxiety ridden attention to detail (not recommended). I expect 0 reflexes. However, the other day I had a patient who had had perfect BP's her whole pregnancy, but was in labor with an epidural in place for several hours and having BP's 160/90. When I checked her DTR's at her knees I got 2+ bilaterally. No other s/s of PIH, and after delivery her BP's started going down. Stress of delivery?? Who's knows. Never thought of checking DTRs at the elbows, though. Thanks for the tip!

Also an aspiring CNM over here. I did an independent study in nursing school specifically on midwifery. This allowed me to shadow a midwife, mostly in the office, and get an idea of what she does and ask her lots of questions on how to get there. (If I could do it over, I would ask to shadow her through an entire night on-call. I never got to see her do a delivery.) Also, get NRP certification, go to some childbirth ed workshops, lactation workshops, etc. Gather as much knowledge and experience as you can. If you know someone working in one of these L+D units, start there. People do get in straight out of nursing school, but a lot of people have to do something else first. If you go to med-surg first, don't give up, don't get discouraged. It took me two years to even just get my foot in the door of a L+D unit, but I got to bring some good experience and knowledge with me. Good luck!

I know what you mean about being bounced around to different preceptors. I kept my scheduled position on a med-surg unit and reduced my hours to take a supplemental position in LD. 24hrs/wk on my home unit, 16hrs/wk orienting in LD. Initially my LD schedule was worked aboard med-surg schedule, resulting in orientation run by 5 different preceptors. Every day I would learn something new, but the next day a new preceptor would tell me I was doing it wrong and I would have learn how to do it her way. It's super frustrating, right! It's no way to learn a new job. Are you orienting on a full time schedule? Is there no way they can match you up with one preceptor for awhile? I know I would feel a lot better about my progress in LD if I could orient with just one person full-time for a few weeks. Is there anyway your manager can work out an arrangement like this with you? I think it might be your best option. If that doesn't work out, I would go to postpartum. You'll be able to establish skills in monitoring a postpartum patient for stability, assessing the newborn, breastfeeding, etc. All of those skills will be valuable to you when you make the transition back to LD. I think this would be a better option for you than med-surg. If you've learned how to put in foleys, administer medications, do a general assessment and document it than you've already learned all that med-surg would have to teach you. If not, postpartum would teach you all the same things while keeping the focus in the birth-world. Whatever you decide to do, remember confidence is key! Once you get it, tell yourself everyday "I've got this!" before you even walk in the door. You can do it! I hope my thoughts are helpful. Good luck!

I would also love to find research on intermittent straight cath vs foley. Someone at my childbirth educator's workshop mentioned research that straight cathing causes fewer UTIs and the older nurses in our group were in total disbelief.

It depends on how far along the mom is and how fast we expect her to dilate. If she's a prime, 3cm, and just got an epidural, she gets a foley. If she's a multip, approaching transition when she gets her epidural and we can guess that she only has an hour or two before she's complete, we'll straight cath her. BTW, eden, I love that you can walk your patients with epidurals. Gravity is a good friend that we lose once the patient gets an epidural.

THANK YOU! This is a revelation. I'm still orienting in labor and delivery and have been trying to figure out how to explain to my patients that certain procedures are unpleasant, but have to be done. Thanks for the tip!

I'm just starting out in L&D after two years in Med-surg and one of the books I read advises keeping your own birth book mostly to keep track of statistics and trends, but also as a memory keeper. This sounds very appealing to me, especially since I plan on becoming a CNM and will be keeping a birth log of sorts at some point in the future. My question to the forum is would you consider this a violation HIPAA even if I didn't keep names or other specific Patient Identifiable Info? I haven't started a book yet, but the information I want to record would be: initials and age of mother, G's & P's, time and type of birth, baby's sex, weight, length, apgars, pertinent interventions for mother and baby. What do you think?

OP: I get where you're coming from. I'm in the middle of orientation to Labor and Delivery after two years in Med-Surg and half the battle here seems to be how do I ask (in a polite and PC way) all these weird questions and what teaching goes along with them. I'm finding that everyone has different knowledge levels and require different levels of explanation, but with everything there are key points to cover. I think your question is a little broad to get much of a response from this forum, especially from those who seem to take the word "speech" literally. In my opinion, you can't go wrong with the risks, benefits, and alternatives, but take your cues from your patient's personality and knowledge level. Good luck!

Thank you both! Very helpful. I'll ask what kind of filters they use the next time I talk to the dialysis RNs.

I work nights on a medical unit, and we have several hemodialysis patients at any given tits; I'm charged with getting this patient set up for breakfast and ready to go to HD between 0600 and 0700. My unit has an ongoing debate/confusion about which meds to give before patients go to dialysis and which to hold because they'll dialyze off. All "daily" or "BID" meds have scheduled administration times at 0900. The dialysis nurses do not give meds or let patients eat during HD, so if I don't provide them before they go, they end up being late (as in the early afternoon or later). I always give Synthroid (scheduled for 0600) and Renagel, Phoslo, insulin, and any other meds that MUST go with breakfast, but what about the rest of the AM meds? I've heard, "Don't give the antibiotics," but today's pharmacist contradicted that idea. Can anyone give me some hints, classification by classification, and which meds I should hold until after dialysis? Thanks for your help!