Continued: (Also is it okay if you answer privately) Very rarely will our obgyn be in the room for a NVD. But to be clarify you don’t have to be dual registered to work in obstetrics. You can study just midwifery and be able to deliver babies. So in short what exactly is your process to be able to deliver babies :P sorry for the long winded question :P So is there no such thing as a labor and delivery nurse in Australia? That’s so interesting, I didn’t know that! Here in the U.S., the labor and delivery nurses don’t deliver the babies - the provider does, whether it’s the OB-GYN or the midwife. For a normal vaginal delivery, it could be a midwife or doc depending on who’s on. To be a nurse, you need either a 2-year or 4-year degree in nursing and then you can specialize to be an L&D nurse. It varies depending on the hospital, but my L&D orientation was about 16 weeks. There are a few different pathways to becoming a midwife in the US:Lay Midwife/Direct Entry Midwives are those that become a midwife through an apprenticeship with an experienced midwife. They don’t go to an actual school, their education comes from experience as a midwife’s apprentice. They can’t prescribe meds and they typically only practice in the homes of their patients.Certified Professional Midwives are people who are not nurses but went to a professional midwifery school, typically about 3 years in length. They can’t prescribe medications, and they can practice in both homes and birth centers. Certified Nurse-Midwives are those that have become registered nurses first and then pursued a 2-3 year Master’s degree specifically in Midwifery. Certified Midwives are similar, except they have an undergraduate degree in something other than nursing. They are credentialed through a different board than the Certified Professional Midwives and, in a lot of states, are considered independent providers and don’t need to work under a doctor. They can diagnose and prescribe medications and work in hospitals, birth centers, and homes. To distinguish between the role of the OB nurse and the provider, let me tell you about my day yesterday:We had a mom come into triage, she believes her water broke. I take her to the triage room, hook her up to the monitors, do her admission intake and assessment. Then I go out to the desk, chart fetal heart tones and contractions then talk to the doc - “We have a 29 year old G1P0 who’s here for a rule-out rupture. Started feeling leaking clear fluid around 2 this afternoon and is feeling contractions every 5-10 minutes apart, rating them 6/10 pain. She has a history of HSV and opioid abuse, currently on methodone.” The doc goes in to do a speculum and cervical exam, check to see if she’s ruptured and if she has any open lesions - the doc says she’s ruptured, has no open lesions, is dilated to a 3. So she admits her and says to start her on Pitocin since her water has been broken for a while. I take her to her labor room, put the monitors back on, sign consents, talk with her about what she plans to do for pain and what her non-pharmalogical and pharmalogical options are. I start her IV and get the Pit going. I chart fetal heart tones and contractions every 15 minutes for my mom’s that are on Pitocin and the order said to increase by 2 mu/min every 30 minutes. She starts getting really uncomfortable and asks for an epidural - I start her fluid bolus and call the OB CRNA. I stay with her offering labor support during her contractions - repositioning, walking, counter-pressure, fanning, visualization - until the CRNA gets there and I stay during her epidural placement. Afterward, I make her comfy and tell her to rest while she can. We go over her postpartum folder which includes infant safety (safe sleep, car seat safety, breastfeeding information). Then I let her sleep while I go out and call NICU, who has to be present at delivery since mom is on methodone. Then I call her methodone clinic to get her morning script sent over, and get the delivery table set up. I notice baby looks super flat which is normal with mom’s on methodone - I reposition mom and give her some juice and an extra bolus in hopes to perk baby up. I don’t notice much difference so I ask the doc if I can do a bolus of D5 since I need an order for it. She agrees, so I put the order in and get that going. The D5 works and I get some nice accels. Mom is super comfy and resting. I straight cath her after 2 hours of her epidural and then reposition her because I noticed some variables. Variables go away. I talk with mom about calling out when she feels pressure or any urge to push. When mom has had her Pit at 20 for an hour, I call the doc to come and check her to make sure she’s progressing. She’s dilated 8-9 at this point, which is good. I put her side-lying with a peanut ball between her legs and call the OB CRNA for an epidural bolus per the patient’s request because she’s really uncomfortable again. She starts feeling pressure and pushy - I perform a cervical check and tell her she’s unchanged since her last check. So I sit her up in high-fowler’s and told her we’ll continue to labor down. At this point my shift ended - if it hadn’t, I would have kept repositioning her to help move baby down. If she started to feel an uncontrollable urge to push, I could check her to see if she’s complete. If she is, I can perform a trial push to see how effectively she pushes. (I don’t typically do this with multips, their babies come a lot quicker.) If she’s pushing effectively then I’ll call the doctor (or midwife) and update her, the doctor (or midwife) will either come and push with her or tell me to keep pushing with her until she gets closer. If she’s not complete, we’ll keep laboring down and moving positions to aid in moving baby down. During delivery, we have two nurses: mom nurse and baby nurse. I call in my baby nurse, or my “second” as we call them, into delivery during pushing when I think we’re getting close. Their role is to focus on baby - place skin-to-skin, stimulate if need be, take baby over to the warmer with the NICU team if they were called for delivery, get initial vital signs, take cord blood/segment/gasses to lab if needed, clean up my delivery table and re-stock. The mom nurse stays with mom - starts the postpartum pitocin, gets the doc or midwife needles or sponges if a repair is needed, get the methergine or hemabate if a hemorrhage occurs, clean mom up and get her comfy. Once the delivery is over, I do the recovery. Fundal checks and vital signs every 15 minutes on mom, vital signs every 30 minutes on baby and we do this for 2 hours. During this time we help our moms eat, void, shower and do peri care with highly decorated ice pads adorned with postpartum ointment and witch hazel pads. After an hour of skin-to-skin, we do our head-to-toe assessment on baby and administer the vitamin K and erythromycin if the parents desire. We also provide breastfeeding support to our moms, we like to get baby to eat within the first hour. Once we’ve checked off everything on our recovery list, we move mom and baby to postpartum where the postpartum nurses take over for the next 24-48 hours. If my mom had required a c-section, I would have gone back to the OR with her. Our labor nurses are duly trained as scrub nurses and their role is first assist during c-sections. I, as her labor nurse, catch the baby and take baby over to the warmer to do a quick assessment and then give baby to the support person who came back with mom. The scrub nurse stays with mom and helps the doc. Since the scrub and baby nurse are sterile during this time, we also have another labor nurse in the back acting as “circulator” who is not sterile and acts as our runner if we need anything, she documents the surgery, pages NICU if they are needed, etc. So in our hospital, the midwife or OB determines the plan of care, the nurses carry it out, and then the midwife or OB do the actual baby catching at the end of it all. Their level of labor support depends entirely on the provider. Some doctors will only show up when the patient is ready to push or if the nurse notices an issue and calls them to see the patient or take a look at a strip. Most of the midwives are a little more hands-on and provide more labor support, but again it differs depending on the provider how hands-on they are and it’s typically the labor nurse providing most of the support throughout labor. If the mom is delivering at a birth center or at home, then the role of labor nurse and midwife are a lot more blended and it’s the midwife playing both roles because there typically isn’t a labor nurse present to do it. I hope this clarifies it for you! A long-winded answer to compete with your long-winded question!
