Whitney Bush, charge nurse of labor and delivery at Bon Secours St. Mary's Hospital in Richmond, takes special notice of major snowstorms that have folks snuggling for warmth. "You can pretty much guarantee that nine months down the road from that snowstorm we are going to be busy," she says.

"We're also busy at the end of September and in October because of the holidays each year."

Bush loves working in labor and delivery. "We have a lot of autonomy," she explains. "The physicians trust our nursing staff a great deal because they can't stay with the moms 24 hours a day, seven days a week. We are the eyes for these doctors."

Dr. Emily Drake, assistant professor at University of Virginia School of Nursing, became familiar with labor and delivery during her student nurse rotations. "I knew that this was my thing," she says. "I knew these were my people."

Bush and Drake agree that labor and delivery often is a happy, healthy place. But, there are times when the mood becomes somber. "The truth is, it can be either very, very happy or very, very sad," observes Drake.

Some of Dr. Mary Gibson's most rewarding experiences have come from providing care to mothers with either genetic abortions or fetal demises. "Women during these times are so in need of knowledgeable support and a caring presence," observes the assistant professor at University of Virginia School of Nursing, "that I feel a real commitment to them and want to see them through the experience."

By the nature of their business, labor and delivery units tend to be a combination ER, OR, ICU and med/surg unit. "It's a very different type of unit," Bush explains. "It's hard to predict what's going to happen." Because of that, nurses in the unit have to be a jack-of-all-trades. "We have a little bit of everything," Drake says. "We have surgery, anesthesia, genetics, infectious disease, psychiatric disease, pediatrics and geriatrics (the grandparents). We have cardiac and hematologic problems, diabetes and even death."

Even the most low-risk delivery can become an emergency situation within minutes, Drake adds. "People walk by the newborn nursery and look inside and see us rocking babies and they think, 'What a nice job.' Sure, it's fun to rock the babies, but you also have to be ready to resuscitate those babies if needed. We're on alert, assessing them all the time."

Most new moms coming into the unit are excited about the experience. "You also have the moms who aren't excited because it was an unexpected pregnancy," Bush says. "We try and help them make the best of it and make the delivery as easy as we can. We also have support services for moms who need help putting their babies up for adoption."

Sometimes, moms just need their space. "That's when we don't need to be in their face constantly," Bush says. "You [learn] when you are working with them how much you need to be in there with them."

Coaching a woman through delivery is hard work, Drake adds. "It's push, push, push! I walk away from every delivery exhausted, almost as if I had delivered the baby, too."

While moms are the focus in labor and delivery, nurses also have to deal with new dads. "You really have to calm their nerves," Bush says. "They may be scared to do anything. We try to get them involved. We always encourage them to cut the umbilical cord, except when the delivery is a C-section."

Dads who are skittish often get job assignments from Drake. "I have them get ice chips or watch the monitors," she says. "We'll also ask them to hold [one of their wife's legs] during delivery, all of that helps."

Some dads are so involved in the pregnancy and delivery that they share in their wife's pain. "It's like they are having the baby, too," Drake says. "The French have a word for this – couvades."

In her work, Jeannette Brown, charge nurse of the antepartum unit at St. Mary's in Richmond, helps moms who are having problems with their pregnancy and are required to stay in the hospital. "It's a different type of OB nursing. You really build a connection with these patients, especially the ones that stay for a long time," she says, noting that one patient stayed in the unit for 83 days. "You get to know these patients and their families."

Being in the unit is stressful for soon-to-be moms. "A lot of people feel like they have lost control because of the bed rest," Brown says. "We try to make it less stressful for them by making their room their home while they are here."

Nurses in the unit – St. Mary's has the only freestanding antepartum unit in the Richmond area – learn about fetal monitoring as well as how to comfort patients. "They have to learn to keep the patients and their families calm," Brown says. "We laugh and we cry with the moms. It's a very special unit."

Nursing care centers on the patient and the baby. "We let them guide when they want things done," Brown explains. "We don't wake them up [early] unless we have to do some testing or an ultrasound. If they are in the hospital around the holidays, we make it feel like it really is their home. We encourage them to decorate the room."

Patients in the unit can have outside businesses come in to do haircuts, manicures, pedicures and massages. The unit also has wireless access and DVD/VCR players in each room. "These are the little things they miss out on because they are in the hospital," Brown says. "We also have lots of baby showers in the unit."

Whether it's working in the antepartum unit or in labor and delivery, nurses in the units often have to deal with family dynamics. "You can't make any assumptions about the families," Drake says. "You really have to dive in there and get to know them very intimately, very quickly."

Birth can be very stressful for any family. It can bring out the best and the worst in people. "If you think 'As the World Turns' is a soap opera, real life in labor and delivery has that beat," Drake says.

When it comes to family situations, nurses have to be the patient's advocate. "You need to make the environment optimal toward the mother's physical and emotional well-being," Gibson says. "If that means asking a family member to go for a cup of coffee or to check on the kids at home (after having discussed it with mom), that is OK. Our focus is to provide the best birth experience for that mom that we can."
Brown, Bush, Gibson and Drake all agree that they wouldn't want to work in any other area of the hospital. "The rewards are too numerous to list," Gibson says. "What could be better than seeing a new baby take a first breath or handing [the baby] over to his mother for the first time or to see the father look at his child for the first time?"

Drake agrees, "I get to see a birth, to witness a miracle almost every day. That beats a desk job any day."

By Sandy Keefe, MSN, RN

Utilizing evidence-based nursing practices to promote normal physiological birth and exploring how nurses can promote these practices in a climate favoring routine medical interventions are hot topics lately. 

For instance, the Association of Women's Health, Obstetric, and Neonatal Nurses devoted the January 2008 issue of its peer-reviewed publication, the Journal of Obstetric, Gynecological and Neonatal Nursing (JOGNN), to normal birth.

As part of its coverage, JOGNN spotlighted six evidence-based care practices adopted from the World Health Organization, i.e., labor that starts on its own, freedom of movement and continuous support for the woman throughout labor, no routine interventions, spontaneous pushing in non-supine positions, and no separation of mother and baby.

But when implementing evidence-based practices promoting normal birth, nurses may face resistance from their patients.

Consumers' Expectations

"I've been an OB nurse for over 28 years, and have seen a lot of changes within our specialty during that time," said Robyn Magnuson, RN,C, assistant clinical manager of labor and delivery at Advocate Lutheran General Hospital, Park Ridge, IL. "We went through a period where natural was in, and women rejected anesthesia and technology.

"Today, we have very savvy consumers who come in knowing exactly what they want, and that often includes an epidural to make the experience as pleasant as possible. A lot of women come in with a birth plan, but they usually don't want a completely natural birth," Magnuson continued.

"'When can I have my epidural?' is one of the first questions we hear."

What Can Nurses Do?

Still, seasoned nurses can and do set the stage for normal births.

"We have a large number of passionate, caring nurses who ensure successful labor experiences, with a healthy mom and baby at the end," Magnuson said. "They enjoy their work, and all the high-touch nursing they provide buffers somewhat the high-tech components. They're caring individuals who come to work with a desire to help mothers achieve a normal birthing experience."

Skilled clinicians are able to ensure continuous support during labor without being intrusive.

"We're very aware birth is a family affair and a huge event in people's lives, so we make sure they have private time," Magnuson said. "As an OB nurse, you develop very close relationships with your patients very quickly, and can provide the level of support each one requires. One woman may want you to teach her partner and come in only when needed to check her status, while the woman next door may want more frequent visits."

Once the baby is born, nurses can help keep mother and baby together.

"We try hard not to separate the mom and baby, promoting skin-to-skin contact and breastfeeding right in the delivery room," Magnuson said. "Unless the baby is very cold or there's a problem, we'll allow them time to bond before moving them to the post-partum unit."

Facing Facts

Arlene Costello, MS, RN, CNAA, director of maternal child nursing at Good Samaritan Hospital Medical Center, West Islip, NY, believes women will make better choices if they know the facts.

"What the women of today value, is very different from what those of us who had their babies in the '60s, '70s, and '80s wanted," she said. "Today, women value having control over when their babies are born, and they have no fear of anesthesia.

"Once women are in the labor room, it really is too late for nurses to intervene because we don't have the right to interfere with the relationship between the woman and her physician at that point in time. When a woman comes in for an elective induction, which actually increases the incidence of C-sections, we have to support the woman and her decision."

Early Nursing Involvement

Costello recommended early nursing involvement to promote normal births.

"If the outcomes were the same, I would support the fact that women have the right to choose C-section over vaginal delivery when it's not medically indicated," she said.

"But the sad fact is that the literature shows that C-sections are associated with an increase in both maternal and neonatal mortality and morbidity. It's not a dramatic enough difference to grab the attention of pregnant women, but it's still a fact we need to face," Costello continued.

"We need to educate tomorrow's mothers about their options, and the associated risks and benefits, even before they're contemplating a pregnancy. We can't expect them to value what we valued, but we can expect them to make informed decisions in light of the statistics around morbidity and mortality."

Reference
Romano, A.M., et al. (2008, January 24). Promoting, protecting, and supporting normal birth: a look at the evidence. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 37(1), 94-105.

Sandy Keefe is a frequent contributor to ADVANCE.