TexasCourgette

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Pie in the sky dream: birthing tubs. But maybe there isn't THAT much equipment allotment left? Wireless Tele with water-safe monitors (even without birthing tubs, you can monitor your patients while they're in a shower if you have the telemetry box sealed outside the water area--such as in a plastic bag on an IV pole) have made for some AWESOME labors on my unit. I'd ask for those. Birthing balls are wonderful--so are rocking chairs. Steady devices are great for moving post-epidural patients. One other thing I wish we had on our unit: good heating pads. Without heating pads that get warm enough for use in labor, I've jerry-rigged infant heal warmers, towel-chux pad creations, and washcloths--heating pads (single-use, or re-usable with single-use covers) would save a lot of time.

At my facility, our educator would make jello and put it in ziplocs for drills is visually estimating bloodloss-- we also had drills in which we would weigh pads that had been soaked (water/food coloring), and had to find and use the reference sheets that are on our PPH carts. We were lucky enough to have a Noelle for the last drills (we had to wheel her to the OR because she had a PPH and then set up all the D&C equipment), but in previous drills we did not. Our educator would drill us through visual blood loss estimates (using the props described above), and would give us scenarios (varying VS, fundal checks, in some scenarios the MD was really responsive, in others not, so you could practice collaborating with other RNs), and then walk us back to the OR so we could set up for D&Cs. The hardest thing to replicate at my facility is pulling drugs (we had to have a special "practice profile" set up in our pyxis so we could practice pulling anticipatory drugs), labs (same, we always incorporate anticipatory lab supplies), and blood. The "getting blood from the blood bank" part of the drill is the only part that always ends up being written-only, and it's also the part we all feel rusty-est on in a real emergency.

At my facility we chart q30 for labor without pit, and q15 for pitocin, and q5 when pushing (regardless of pit or not). We also have an intermittent monitoring protocol for patients who are unmedicated (no pit, or fentanyl, or epidural, or anything), where they're monitored 20 minutes/hour, and then you end up charting FHTs only on that 20 minute strip. For antepartums, it depends on their monitoring orders--if they're being closely watched, then chart FHTs/CTX q hour, if they're on NSTs, then just the NSTs.

Good for you! Know that preceptors don't generally give out that kind of praise very often. She's not crazy, and you're not crazy--you're good at what you do. Does it become less scary? Yes. Absolutely. Like, none of us would be able to survive L&D if we all hung on to the anxieties we had at the beginning. Things just become more familiar. But all the way not-scary? No. "Just another day at the office" is always going to carry some stress with it, because that's someone's sweet baby you're watching, and someone's sweet belly you're inducing. When I took my fetal monitoring course, it was really helpful--I'm very type-A, and having someone else back up and verify what I knew made me feel more confident when talking about strips (instead of asking if something was a late, I would talk myself through how deep it went, how long it took to get there, and how it fit into the variability of the strip--and that gives you your clinical picture). I became much less afraid of variables, and more able to defend interventions in the face of subtle late decels. Now that I have more experience, I know that it's the subtle changes--less variability, a high baseline, little lates--that are more telling than the big ones (like impressive-looking variables--now I see those and just think "that'll be a cool nuchal" instead of "PANIC"). My other major resource, when I was feeling the way you are now, was my co-workers. It really worked for me to joke about something ("ha ha ha, I know I'm paranoid"), and ask for help ("Do you have a moment? Could you look at XYZ section of the strip with me?"). If you know your preceptor is impressed with you, start with her. I promise, people would rather you be a "strip nazi" than not care. Also of comfort: babies don't live and die at the same time, so a sweet thing with good variability is not going to suddenly stop being oxygenated. And know that your reactions to recognized problems will get smoother, and calmer, and faster--I remember having a bit of a freak out when I was on my own and a baby of mine was in distress for the first time. Now, it feels just like a "mode" to switch into, where you stay very alert, and turn off the pit, on the O2, increase fluids, and turn the patient. It's like a math equation, and there's some comfort in the predictability. Welcome to OB! Time is going to be the biggest factor in your confidence level. You'll do awesome (just as you did in medsurg)!

There is absolutely a "shock value" that comes with L&D, especially if it's your first obstetric experience. I absolutely love women's health, and knew that going into L&D, and there was still an adjustment period--seeing my first birth was amazing (women are SO STRONG. I'm in awe), but I think it was around delivery 20-30 that I didn't have some degree of "OMG" when that head popped out. I still look away when episiotomies are cut--the sound bothers me, the physicians I work with sometimes do them when they aren't necessary, and I don't like it. That's not gonna change. For my first month, I would look away when they made the first cesarean cut (skin incision)--after that cut I was fine, but it did make me feel dizzy, my first time in an OR. It gets better. You get more used to it--and L&D is a very charged thing. Most people are affected by birth at some point in their adult lives (and obviously, everyone was "affected" by it as an infant), and there are lots of cultural rituals or beliefs around it. I know it sounds a little touchy-feely, but take a long, honest look at yourself and try to figure out what, exactly makes you so uncomfortable, and why. For me, I know one of the reasons I don't like seeing episiotomies is because I'm angry when they're inflicted without reason, and one of the reasons maternal mortality bothers me more than infant mortality is because I'm more directly afraid of it--thinking about these things made them seem more normal, and less emotional. You may have different reasons for being viscerally uncomfortable, but figuring out what they are will probably be helpful. And hey--if it's not your thing, it's not your thing. Get through these days, de-compress with a friend who also isn't that into OB, and soon enough, this clinical will be over and you'll never have to look back. :)

We just started offering birth classes at our hospital, and are increasing the number of tours we give per month. Our unit is in the middle of remodel, and we're gaining an LDR from that. In the last year we've added a "birth plan" to our tour packets (a list of statements people can circle/cross out/write in/edit and bring with them to the hospital, or just use to think about available options), and we're including statements in our classes and tours encouraging women to make their birth preferences/plans known, whether or not they're in writing. Our lactation department is growing, but not fast enough for our patient population--now we screen all babies for "high risk" lactation problems. If they're delivered by cesarean, premature, have any abnormalities, or if the mom is a first-time mother under 18, they're automatically seen during their stay, and if not, then lactation sees them by request and lactation support is offered by RNs. Our outpatient lactation program is also growing. Not directly related to patient care, but this year, in an attempt to bring our women's services department together as more of a "team", we're registered for the local March of Dimes event this year. The fundraising is fun, even if not everyone participates, and a I think the more unified staff behavior is making for happier nurses, and that affects patients, even if it's indirect.

We had lots of "drills" with our educator--she'd make jello and spread it on pads and have us guess amounts to demonstrate how hemorrhages are often underestimated, run mock codes, mock neonatal resuscitations, and role-playing common patient scenarios (poor coping, poor education, hostile family, etc). I was incredibly lucky when I started out, and landed a spot in a nursing residency--one of the things that really stuck out to me in the classes was how well emergencies were covered. It's rare for sure, but the first time I had to deliver a 26 week infant, take care of a hemorrhage, or saw HELLP lab values, I was really grateful that these rare-ish events were covered in my orientation, even if it was only in passing. It helped me to know what kind of help to ask more experienced nurses for. In terms of skills, my educator made sure the new grads got lots of IVs, SVEs, foley placements, and Leopolds practice, and really emphasized "flawless mastery of the basics". These, and the drills, were far and away the most helpful.

I had a 3.5 GPA, and GRE score of 158 verbal (I think?) and 155 for the math portion (I think? This was back in August, and all I remember was trying to make sure I had over 150 in both portions). I applied to the CNM/FNP dual program. So far I've been accepted into the CNM portion, but haven't heard back from the FNP department (it's possible to get into one, both, or neither with a dual application).

I can't answer this as a midwife (yet--just got accepted to start in Vandy's CNM/FNP program in Fall 2014), but I've been an L&D nurse for 2 years, and have seen several demises. Most of the demises I've seen have not been intrapartum--a woman comes into the office for her prenatal appointment, or into the office/hospital for decreased fetal movement, and there are no fetal hearttones. The few times I've seen midwifery transfers for fetal problems, the baby's been ok (and the close calls we've had have been a result of some weird clinical judgement by unlicensed midwives--for intrapartum incidents that threaten the fetus, I really think risk management and appropriate OB backup is paramount). One of the hardest things about demises is not necessarily knowing what caused them. Like I said, most of the demises I've seen have been sometime in earlyish pregnancy (14-26 weeks), and several (but not all) of those babies are born with something grossly wrong--facial or torso deformities, noticeable edema incongruent with intrauterine decomposition, etc. Those are harder, because they're more disturbing to look at, but offer up some answers as to why the pregnancy wasn't viable (there was something wrong with the baby). Term demises are very hard (and less likely to be born with an unknown anomaly), but much rarer. In all cases (intrapartum events or in-pregnancy loss), I think how the death is talked about is incredibly important--I always avoid using the term "miscarriage" when talking to the mom (it's not like if she'd somehow "carried the baby better", it would have lived), and while the idea of loss is often really helpful to discuss, I try to avoid "losing the baby" (like "We lost the baby" or "you lost the baby", because even in intrapartum events, everyone comes to the table with the best of intentions, and, one hopes, the best possible clinical judgement). The most helpful phrase (which I don't think I've ever been able to deliver without crying) has been "I'm so sorry this happened to your family." There have been times when I've seen bad outcomes occur as a result of interventions in labor at the hands of OBs (vacuum injury once, but usually maternal morbidity)--as a midwife, I think it may be more likely that a bad outcome occur as a result of not intervening in labor (I say this because I think that's the bias in the respective professions, and because of what I've seen at work--like a far-too-late transfer). Those are always hard. There is no way around that--even if it's just a birth injury, rather than a death, or a relatively common-but-benign-but-weird-occurance (a broken clavicle on a not-shoulder dystocia), it's hard to look at the people you're taking care of and tell them that something's not perfect with their baby, and that you messed up and that is (or might be) the cause. I also think that uncomfortable truth--that because we are human and make mistakes, and since we work in an industry where we work with people, there can be a very human cost for those mistakes--reinforces the need for a good clinical network. As a midwife, you want really excellent clinical judgement skills, and really excellent coworkers attending births with you or acting as backup--do you both think the woman's OK at home? Does she need that intervention? If you had to explain the case to someone else, what might they advise? 2 heads are better than one...and that also applies to the grieving process. It's good to grieve and talk shop with your co-workers--we all find demises hard in similar ways. This has gotten so long, but a last thing: don't let fetal (or maternal--those are the worst for me) deaths keep you out of birth work. It's for sure one of the hardest things about this crazy, beautiful, super-awesome field, but in a lot of cases (such as when a pregnancy is lost early, when something is wrong with the baby), it's part of life, and your job is to handle that delivery and short-lived life with the same respect you'd use to deliver a term, healthy infant, and to help the mom on her pregnancy journey--wherever it may go. If midwifery is in your veins, this is too important! Go be an advocate for a ton of women, know that in order to do that well you have to have a good network, and know that sometimes that won't be enough to save a baby who's not going to make it (because of anomalies or illness)--I think that's the biggest hurdle to make peace with.

I think it mainly comes from how uncomfortable it is for the OB/midwife/nurses to hear someone making that kind of noise (and truthfully, I see this most with OBs, at least at my hospital). It's not a societal norm we have, and so people are asked to stop and coached to do the quiet, closed-glottis thing. Even in cases where open-glottis pushing takes longer (and I do think it tends to), I think it's how uncomfortable it makes the care providers, rather than the time, that drives a lot of (over) coached pushing. Personally, I think if you, as a care-provider, have a problem with how someone looks in natural labor, then it's *your* problem, and the onus is not on the patient to conform to something you like better. If there's a mom who is screaming during a push, or not pushing effectively, I'll often tell them to try "grunting against the pressure", or making the same low-pitch sounds I encourage them to use during labor. In my experience, it works well, particularly with moms who are going sans-epidural, or have some feeling. If a mom is just totally numb (can't feel her contractions, has never had a baby, needs lots of coaching for pushing), I'll labor her down if I can (per OB), and include open-glottis in my coaching. Sometimes the OB will come in for delivery and tell them to be quieter (in so many words), but by that point, the baby's almost out. Open-glottis pushing isn't something that's caught on much in my hospital, but I use it in my practice, and so do 2 of my co-workers.

I once had a dad ask me, immediately following delivery, if we could "put a tracking chip" in his son (for child safety, in case he got lost?). His rationale was that "in the military, they do it all the time, so I know that technology's out there". I told him, with a straight face, that microchip placement was not a service the hospital currently offered.

I'm 9 weeks into my first job, on an L&D unit, and oh my goodness, is there a lot to learn! One of the best pieces of advice I've gotten (after "read everything" and "know as much as you can") is to not be too concerned with being the BEST nurse yet--just shoot for flawless mastery of the basics, when starting out. Knowing how to read a strip, and how to react to what's on it, will take you far--knowing every pushing trick there is will take you far too, but it's less critical when you're just starting out. I know it's not a great "tip", but on nights when I feel overwhelmed, it helps remind me to keep my eye on the prize.

At my hospital, we actually draw labs when we start their IV/saline lock (the IV/lock is recommended to everyone, even if they're having a drug-free birth, in the event of an unforeseen emergency) and test for these same things the day of delivery. If it's a fast labor or stat/emerg situation, we send the lab stat, so we know what we're potentially dealing with. I don't know if it's the same at any hospital, but just wanted to point out--at at least some facilities, there ARE safeguards in place to provide staff with the knowledge of disease development that the prenatal record may not reflect--and bath or not, every nurse I know uses gloves to touch baby, generally for the protection of the baby more than the nurse.

I know in Canada, they require you to be licensed in whatever country you're coming from, and then take a roughly 9-month "bridge" course before registering as a Canadian midwife.