Where are the docs??

I posted below about my unit closing. I have an interview at a local hospital next week. I am used to having OB providers/ anes. in house and on the floor 24/7. I have done OB for 7 yrs at the same **^%$#@ hospital and it is my only OB experience. How much more autonomy/ responsibility do you have when OB's are not in house? How does triage work? etc...

I have never even delivered a baby in 7 years because the attendings are there so I am a little nervous losing the safety net. I am confident in my skills, but there was always a doc/resident or cnm.

Also, what do you do when you have a decel/abruption/preterm delivery that just walked thru the door.....? i mean in regards to getting a doc in there asap.

I am sure ER doc or house officer comes, right?

ANY input would be great.

[ERNurse752, RN]

I'm not in OB, but I really doubt any ER doc would leave the ER to go deliver a baby. They have enough going on in the ER to worry about, plus the liability would be insane.

I'm not sure what type of hospital you're going to, b/c it could possibly be different in a rural setting.

We have family practice residents who can do vag deliveries at my hospital. As far as fetal distress/preterm/abruption...I'm pretty sure our OBs just get called in and they come as fast as they can. And yes, that sucks, and if I were in OB, I would really not like that!

[USA987, MSN, RN, NP]

I work in a community hospital doing 2400 deliveries per year. Docs don't have to be on premises except for epidural initiation. We do have a voluntary doc in the box program from 7p-7a and it has worked well...most nights are covered. That being said, even with a doc in house, they sometimes miss deliveries. I've been there a little over a year and we have had only one case in which the ER doc came and delivered the baby. I once had a doc tell me that a baby that comes so quickly usually "is just fine, because we don't have time to screw them up!! :chuckle "

I agree with your concern over extremely emergent situations. Luckily most of our ob groups have at least one MD that lives close by...and I have seen on more than one occasion where another OB happened to be in the house and they will come and perform the emergency section.

Good luck with your interviews.

[JaneyW]

I work in a smaller community hospital. We do 150-175 births a month--occasionally a 200+ month. We normally staff 2-3 RNs with a charge in L&D. We have no in house docs and that is pretty much the norm for most hospitals around us other than teaching hospitals. I have done 4 deliveries myself in the past 2 years. I work NOCs and it just can't be helped at times. We have a couple of docs that live close and we just pray that nothing horrible shows up at 2am!

We don't have a NICU so the women that are supposed to come to us for delivery are generally low risk. We do get situations where we have to transport moms or newborns. We have done emergency c/s under local. Not preferred but it can happen. Our anesth are sometimes 30+ minutes away. We triage our own patients and let the MDs know if they need to come in. It takes some experience, but you might be suprised how smoothly it does go.

I have never worked any other way, so I can't tell you if you will adjust well. I just know that it is OK. We had an ER doc come up one night for a delivery but he ended up just getting in the way and we had to tell him what to do anyway. I am hoping to go to a larger teaching hospital in a few years when I want to work more and I have been nervous that I will get frustrated because I will lose some autonomy.

[BETSRN]

I posted below about my unit closing. I have an interview at a local hospital next week. I am used to having OB providers/ anes. in house and on the floor 24/7. I have done OB for 7 yrs at the same **^%$#@ hospital and it is my only OB experience. How much more autonomy/ responsibility do you have when OB's are not in house? How does triage work? etc...

I have never even delivered a baby in 7 years because the attendings are there so I am a little nervous losing the safety net. I am confident in my skills, but there was always a doc/resident or cnm.

Also, what do you do when you have a decel/abruption/preterm delivery that just walked thru the door.....? i mean in regards to getting a doc in there asap.

I am sure ER doc or house officer comes, right?

ANY input would be great.

Personally, I LOVE not having the docs there all the time. It gives us a chance to be nurses! We have so much more autonomy and it is wonderful not having them breathing down your back. As far as triage goes, we triage all the time, rule out labor and send them home or admit them: whatever needs to be done. If we need the doc or CNM, then we call them in. As far as an ER doc coming...... NO WAY, NEVER! NOHOW!!That's the last doc you want at a delivery! They don't want to be there, either! We deliver babies on occasion, but it's a rarity.As far as something really bad......we do whatwe can, get the pt ready for a section and call the closest doc (all of ours are pretty close). WE all pull together and work as a team. We do fine.

[palesarah]

hmmm... I work in a community hospital, we just topped 800 deliveries last year. We have 2 OB/CNM practices with priveledges, plus the family doc at the prenatal clinic does a couple delivieries a month (the larger of the two practices treat the rest of the clinic patients in house as they have a working relationship with the clinic). The larger of the two practices has 4 docs, and 3 midwives currently. They always have 1 doc and 1 CNM on call every night, and they alternate who is first call and who is backup (if it gets too busy for one provider to handle, or to backup the midwife if they need to go to the OR). The smaller practice has 2 docs and 1 midwife, they just lost one but are getting another fresh from school (they have a revolving door CNM thing going on, In two years they have had 5 midwives, usually only one at a time) They always have a doc on call, when midwife is on call there's a doc to back her up if needed, but they don't arrange call in a way that would allow their patients to choose CNM or MD preference, as the larger practice does

(I think I'm getting off topic, sorry, I worked a twelve hour shift on only 3 hours of sleep and am a wee flighty now!) So, yes, we do occasionally have nurse deliveries, maybe 0-2 a month? It's a rare occasion to be sure, but when it does happen it seems like we get them all at once- you know how everything in OB comes in threes!

We triage the patients. The patients call the practitioner on call, they tell us so & so is coming in for ?labor, ?ROM etc. The smaller practice never has anyone in house unless they have an active labor patient or some complicated antenatal patients. The larger practice always has practitioners in house during the day, and a few will spend the night in their callroom regardless. One of them camps out in her call room with her kids - they're really cute!

Whether a practitioner is in house or not, we (the nurses) triage the patient, and consult with the doc or CNM by phone (unless they're in house and sometimes even then, if they're in their call room!) in deciding whether to admit or send home, etc. If we admit someone in active labor, most of the practitioners will come right in. Some will come in as soon as they call to say so & so is coming in. A few will wait, or come in and go to their call room, until it's nearing time to push. The midwives tend to come in sooner and spend more time in the room, it's a totally different role for me the nurse when I'm laboring a midwife patient vs an MD patient.

So it's rare that a practitioner not arrive (whether it be from home or from their call room) before the baby is born- but people do walk in crowning! In those cases, if no one is in house, we get the message for them to come in stat and work as a team to assess the patient. Usually those precips are pretty uncomplicated but if for any reason we feel that we need "a doctor, any doctor" in the room we'll call a "Dr Rush" (medical emergency, gets the code team up to us) or call down to the ED just to have a doc in the room and have the liability off our hands. Dr. Ed from the ED is pretty good about it- he hates coming up to our floor but he knows that we just need him in the corner "just in case". If it's going to be a nurse delivery and we suspect that we may need to resus the baby we can call respiratory to be on standby if the baby needs to be intubated (obviously someone else would also be calling in the peds and anyone else who should be there).

In an emergency, one of the docs for the larger practice lives 5 minnutes away and she has been very clear it letting it be known that if we need someone NOW, for either practice, we can call her. One of the peds also lives about 5 minutes away and can cover another ped in a jiffy (the peds aren't present at all deliveries, just sections, preterm, twins, and anything else that the OB feels they should come in for). It's the OR team and anesthesia that we have to wait for- up to 30 minutes. We can open up the OR and the OB can do it under local, if need be though. Thank god that's never happened on my time. My preceptor had one (in her 20 or so years as a nurse) and said she hopes she never sees one again

I'm sorry, I really strayed from the original topic. I'm off to get my smarty sleep...

[SmilingBluEyes]

We do fine w/o an OB doc in house 24/7. If an emergency arises, we can have all players in within 10 minutes, by that time, we have the IV's, foleys, shaves, consents, etc done....they are here. Precips don't upset me (unless they are very premature)-----they are the least of my worries---- it's the abruption, rupture, prolapsed cord, PIH'er who decides to seize on me, or any number of other true emergencies that get my adrenalin flowing and worry me. But when we communicate the emergent state to our docs, they are there in NO TIME FLAT. And we have good house supe's to help out, too, with whatever is needed, including stabilizing patients, or making things happen in the way of csection, newborn transfer, etc.