Navigating a Labor Experience: As A Student

By: Amy Smith, Student Nurse at MGH Institute of Health Professions, Boston

I could feel the excitement in the room as I entered. The couple was receptive to my questions and suggestions; and the woman was more than happy to involve me in her care.  I tried to build rapport even though I was nervous in my role as a nursing student. This was the first time I had assisted a woman in labor and, after her membranes were artificially ruptured, her contractions started to come about two minutes apart.  At one point, I had my hand on her back and her husband smiled at me across the room and signaled for to me to remove my hand!  It was a great moment in which the support person and I connected!  I remained quiet during her contractions and I asked her if she wanted me to breathe with her but she said she had it under control. I kept thinking back to my own labors and what I felt I wanted from support people so I asked her if she would like lower back counter pressure but she refused.  The family had not done a childbirth preparation course so I assumed that their interest or skills with working through labor was limited.  I thought that they would need my help more yet her prenatal yoga practice seemed to have given her the tools she needed to get through her labor. The tools I offered her personally were meditative.  I told her to focus on her favorite place, to discuss her needs and frustrations with us in between contractions and reassured her that I was there for her to breathe with her and regulate her breathing as needed.

Reflecting on the Nursing Care Women and Babies Deserve virtues I used during this experience, I believe they were humility and engagement. Humility in that I had to understand I did not know what was best for this family. I assumed they would want and need what I needed during childbirth or skills I learned from the comfort measures video I used to prepare for this clinical experience. The woman decided what she needed and I was there to support her. In respecting their wishes I could engage with the family. Before I left them for the day they commented, “We felt like we had our own doula”.  It was easy and a pleasure to engage with this couple and follow their commands and offer suggestions. I told them I had never wanted to stay at clinical so much as I did with them. I will always remember this family.

 

Additional Resources

AWHONN’s Nursing Care and Women Babies Deserve Poster –  AWHONN’s statement on ethical nursing practice, Nursing Care Women and Babies Deserve, is rooted in the American Nurses Association’s Code of Ethics for Nurses, and provides nurses with core elements of ethical nursing practice for our specialty and corresponding examples of the virtues of ethical practice in action.

Read a commentary about Nursing Care Women and Babies Deserve in AWHONN’s journal Nursing for Women’s Health. Consider submitting your own story of how you or your colleagues practice nursing care that women and babies deserve at https://www.awhonn.org/?NursingCare


nursepicamyAmy is an ABSN student at MGH Institute of Health Professions, Boston.  She was a stay at home mother for 12 years,  a community coordinator for a non profit kids running program and a volunteer at Dana Farber Cancer Institute in Boston before deciding to enter the nursing field.  With extensive volunteer experience from a camp for blind & visually impaired adults and children, to co-president of an elementary school PTO, she enjoys working with diverse groups of all ages.  Amy aims to work in labor and delivery after graduation in August 2017 but is also interested in global health and epidemiology.  She has intentions to keep making a difference in the lives of those she may never meet again.

Ladies on a Mission

Guatemala

by, Lori Boggan, RN

When we enter the medical profession, we make a lifetime commitment to the service of others.  As nurses, we serve our patients, our community, our friends, and our family.  No other profession has such a deep connection to and is so trusted by society.  We are the ones at the bedside day and night.  We are the ones that our patients trust with their privacy, their secrets, and their lives.

Volunteer nursing is no foreign concept for American nurses.  In fact, the earliest “nurses” were nuns, or family members of those active in the Civil War.  They were in the trenches before any formal nursing education or organization existed.

For most, nursing is a calling.  Nurses are innate caregivers.  What is it about a nurse that is willing to use her own money, travel to an unfamiliar place sometimes lacking basic accommodations, and work long hours without pay?  It is the drive to care for those in need.

The following interview is with one of AWHONN’s own that goes above and beyond.  Nancy Stephani Zicker, a labor and delivery nurse from Central Florida has journeyed to Guatemala yearly since 2014 to help less fortunate women in need of gynecological surgery.  She journeys with her friend and obstetrician, Dr. Cecille Tapia-Santiago, of Volusia ObGyn Daytona Beach.  In addition to gynecological surgeries each year, Dr. Tapia sees patients in the mission’s clinic and educates Guatemalan midwives.  I interviewed both ladies in hope to inspire others to join mission work.

How long have you been going on missions?

Nancy:  I have been going on yearly medical mission trips every March since 2014.

Cecille:  I have been doing 1-3 mission trips a year since 2000.


Where has your mission work taken you?

Both: Guatemala


Why Guatemala?  Is there any particular need there with regard to women and infant’s health?

Cecille:  Absolutely. When we go there we provide contraceptive care, well woman care, and manage surgical conditions (uterine fibroids, large ovarian cysts, and pelvic prolapse being the most common).


Describe a typical day in the life of a volunteer nurse.

Nancy:  Each year that I have gone, I have been assigned to work as a circulating nurse (and sometimes scrub in to tech or assist) in the OR. There are clinic nurses, OR nurses, PACU nurses and ward (floor) nurses.

FullSizeRender-100We go in to a completely bare room and make it a functioning OR.

As an OR nurse, we first have to unpack and sort all of our supplies, as well as set up the operating rooms. We arrive on a Saturday late afternoon and get right to work. Sometimes we set up in community centers and sometimes we set up in an actual hospital. This usually takes Saturday evening and all day Sunday to accomplish.

Monday morning, the surgeries begin. Depending on the number of cases scheduled, we usually are in the OR from 8am-5pm. Once all surgeries are done at the end of the week, we have to break down the ORs to leave the space as we found it and inventory all supplies so we can order more for next year.  We all have had to improvise and be creative with available equipment and supplies. It’s quite the challenge, but the entire team comes together and we make it work.z


20140306_102410Cecille, describe your work educating midwives in Guatemala

It’s THE BEST PART. Midwives in Guatemala are mostly lay (no formal training at all). Guatemala has one of the highest infant mortality rates in the world. We do 1-2 day seminars and teach basic infant resuscitation as well as basic management of labor, delivery and postpartum complications. The midwives have to deal with a lot of prejudice from the physician community and often won’t get paid for their service if the patient has to be transferred to a hospital.  So anything they can do to show their critics that they are furthering their education and are doing right by a patient is helpful.

Is there any one particular patient story that you can share that stands out in your mind where you felt you really made a difference in that patient’s life? 

Cecille:  One of the midwives came back to a refresher course and told us that she gave CPR to a baby with apnea. Initially the family was resistant and thought the baby was dead. The midwife pulled out her certificate from the seminar and showed the family. She told the family to let her try and do CPR. She successfully performed mouth to mouth and chest compressions and the baby was fine!  We also had a young lady with an enormous pelvic mass that was compressing her entire abdomen and pelvis. She had been turned down by everyone and when we saw her, she was cachectic and probably a few weeks away from dying. We removed an enormous yet benign ovarian cyst. It was over 50cm in diameter and weighed 25 pounds.

How has mission work changed your practice?

Nancy:  It has made me a better nurse. Seeing and working with the patients I see on my mission trips has renewed my love of nursing and my compassion for people in general. The patients I see on these trips are so profoundly grateful for the care they receive.  It helps to renew one’s zest for nursing.

Cecille:  It hasn’t really changed how I practice at home, but you have to be a particular type of person to do well on these trips. In order to do this type of work you have to be patient, flexible, meticulous, and creative. You can’t go to these trips if you’re going to expect U.S. standards of equipment, timeliness and availability of things you have every day at home (for example blood, cautery, suction, light).  I have seen time and time again physicians, nurses and staff struggle because they have unrealistic expectations of what it’s like to operate in third world conditions. And by the same token seen plenty (like Nancy) that just sail, adapt and just sail.

How has mission work changed you as an individual?

Nancy:  Personally it has made me realize that as humans we all want the same things- we want our children healthy, we want access to quality healthcare, we want to be able to be happy in our daily lives, and we want a peaceful existence.

Cecille:  It refreshes my choice and faith in my profession. Medicine has changed so much. The physician/patient relationship many times is not what it used to be. We live in a defensive medicine environment that often plays in to how we practice here. Over there, patients and families trust and believe that, just like at home, I do my very best to provide the very best care my skill set allows, and that I will never go above that skill set and take unnecessary risks. That trust factor makes any responsibility tolerable.

Guatemala

What advice would you give a nurse contemplating mission work?

Nancy:  It’s important to choose the right organization to join, one that interests you. Each one has a different application process and requirements, as well as when and where they go on their trips. They all differ with their missions and what they offer. I have gone on 3 trips so far, and have applied for my 4th with the same group. It’s called Cascade Medical Team, whose parent organization is Helps International. I have friends that have used various other organizations. It’s important to choose one that fits your interests and your budget, as well as the dates you’re available to go. Also, for me on my first trip, it really helped that I went with someone I knew and who had experience with volunteering for medical mission trips. Not only was she able to give me a heads up on what to expect, but it is just amazing to be able to share the experience with someone you know- someone who understands why you would want to, or should want to, volunteer for such a trip
.

How can a nurse prepare for his/her first mission?

Nancy:  Be open-minded. Prepare to go out of your comfort zone and learn new things, both in the nursing/medical field and also culturally.

FullSizeRender-101Where to next?

Nancy:  To date, I have only been to Guatemala. At this point in time, I only volunteer for one mission trip each year and I have found that I really enjoy helping the people there and so have concentrated my trips to Guatemala.

Thanks for sharing, Nancy and Cecille!  And thank you for your service!  For more information on their work with Cascade Medical Team, visit www.cascademedicalteam.org.

Lori Boggan, RN
Lori is a NICU Staff Nurse at Sahlgrenska University Hospital in Gothenburg, Sweden. After becoming a nurse, Lori traveled across the country to work a three-month travel contract in San Francisco, California. Nearly five years later her journey continued to Gothenburg, Sweden, where she now lives and works. She also write her own blog Neonurse at https://neonursetravels.com/ or on Instagram.

Specialty Training for Novice Nurses

by, Heretha Hankins, MSN-Ed, RNC

Twenty-five years ago when I was a young, new nurse there was a lot of talk about the nursing shortage. Every nursing magazine speculated on how patient care would suffer if we didn’t train more nurses. Several years ago I looked around and saw tangible evidence of this looming shortage for the first time in my career. At first limitless overtime was available and then came incentive pay and bonuses as an effort to cover the shortage. Finally, nursing broke the unwritten golden rule. We started accepting new grads into specialty areas.

When I started nursing school I knew I wanted to work in L&D but my instructors explained that I must first work “general nursing” (med-surg) before I could even consider a specialty like OB. Today there is such a low pool of applicants for multiple open positions we are seeing a growing trend of graduate nurses entering specialty areas. After six months they are expected to possess critical thinking skills; one year later they train another new graduate. As we see an increase in the hiring of graduate nurses into critical practice areas such as OB, ICU and ER there needs to be a change to the training approach. The “each one teach one” approach is no longer effective.

OK, so here is where I want to really talk to nurse leaders. How do you know when a nurse is successfully trained? Can you measure the progress? Is the retention rate of your unit impacted by turn over from the nurses with less than two years experience? When I asked myself these questions I was inspired to design and implement the Perinatal Nurse Training Program (PI.N.T).

Developing the Program

The PINT Program is a 16 week program which includes 72 hours of didactic information in the classroom setting with a curriculum and reading assignments. Peer-reviewed books are required purchases (build a practice on research not hearsay). We also incorporate AWHONN’s basic and intermediate fetal monitoring courses into the training to assure the information received is consistent with national standards. Yes, it sounds and looks like going back to school.  Didactic hours are spaced throughout the 16 weeks building on concepts as the nurse builds in practice.

Use of a focus plan and checkpoints makes progress measurable. The checklists are tasked-based because a new learner has concrete thought processes. Consistent feedback in 1:1 sessions helps to promote progress or strategize about practice opportunities. In the last four weeks there are two to three novice nurses assigned to one preceptor. This gives the novice an opportunity to strengthen a solo practice while keeping that preceptor safety net nearby. After the 16 weeks, periodic monitoring is used to assure practice assimilation, answer questions and offer support. By the one year anniversary of practice the novice must pass the National Certification Corporation (NCC) exam for fetal monitoring to be considered successful.

Prior to PINT unit based orientation was largely completed with using preceptor pairing. Small amounts of didactic were used but were generally attached to vendor presentations for products used in the practice. Many things such as fetal monitoring and high risk pregnancy care were covered by use of self-learning modules. It is also worth noting, prior to my arrival the educator position was vacant for approximately five years.

Road Blocks

The greatest obstacle identified was seen in the change with preceptor assignments. Traditionally a novice was assigned to one preceptor for all of orientation. In the PINT program the preceptor assignment is fluid but generally stable for two weeks. My philosophy for this approach is based in inherent human error and autonomous practice. No one is perfect and sometimes what works well for one may not work for another. Seeing multiple different practices allows the novice to build his/her own autonomous practice.

Measuring Success

My measurement of success for this program is in the pass rate of the exam and the increase retention of new hires on the unit. With a total of 71 novices trained to date we boast a 98% pass rate by one year of practice on the NCC exam, a two year retention rate of 75% and a one year of near 90%. Program evaluation surveys provide feedback from the participants regarding what they gained and what could be improved. The participants noted the program worked well for them and they appreciated the structure. I am most proud to know that this leads to increased patient safety and healthy moms and babies. As I recall that was what motivated me to want this practice when I was a new graduate nurse.

Advice For Nurses Wanting to Start A Specialty Training:

  • Provide didactic training on the routine patient type starting with normal before sending the novice to the unit or training on complex procedures.
  • Make time for didactic classroom throughout the process so time if given to build on concepts.
  • Start the process with cohorts so that each participant can connect with someone in the group.
  • Encourage journaling because it helps develop critical thinking.

HerethaHeretha Hankins MSN-Ed, RNC is a Professional Development Specialist at Holy Cross Hospital in Silver Spring, MD, affiliate of Trinity Health System. She is the creator/facilitator of the Perinatal Nurse Training (PiNT) Program which she has presented to the Central Virginia Nursing Staff Development Organization, Maryland Patient Safety Perinatal Collaborative and Trinity Health Perinatal Summit. With 20+ years of nursing experience she also freelances as a Nurse Education Consultant. Her professional passion is to train the best nurses to provide the best patient care. She is always willing to discuss this at HerethaHHankins@gmail.com or any other forum.

Confidence Building for Nurses

by, Lori Boggan, RN

I would like to call myself a bit of an expert on the subject of confidence.  Working as a travel nurse for many years, mine has been tested over and over again.  The one thing I have learned is that confidence comes and goes and that is perfectly ok.  Some days are better than others.  Travel nursing has forced me to learn new routines, try every new kind of IV catheter, learn each new unit’s policies, and adapt.  In the last five years, I have managed to find myself in another country and added the super challenging task of learning a new language to the list.  It has tested my confidence and given me the opportunity to reflect.  Here are just a few tips.

Develop Routines

There are certain tasks we as nurses do repetitively in our day to day work.  We take reports, check our monitors, calculate our drips, triple check our medications.  No matter how much time it takes initially, make these a part of your day to day routine.  It will be as subconscious as breathing eventually and once mastered, it leaves space for the most important task of critical thinking.  Why is my patient’s urine output low?  Why has my patient suddenly had multiple episodes of desaturation and apnea?

If At First You Don’t Succeed, Try, Try Again

So you didn’t get that IV or blood draw on the first stick?  Ask any honest nurse and they will tell you that it has happened to the best of them.  Having a bad access day does NOT mean you are a bad, incompetent, less worthy nurse.  It means today is not your day and that is ok.  Tomorrow is another day.

Ask

Asking a question is a sign of strength, not weakness.  No matter how small the question or how many times you ask, keep asking until you understand.  When starting in a new unit, whether you are a brand new nurse or a seasoned one, it is your duty to ask questions.  The ones to worry about are the ones that do not ask questions.

Never Stop Learning

That is why there is such an emphasis on continuing education hours when renewing your license.  Continuing education is critical.  There is always something new to learn or some change in research that may change your practice.  Be open to change.

Speak Up

If something does not seem right, follow your instincts and say something.  Chances are you are right.  Always err on the side of caution.  You will learn to trust your own intuition.  Perhaps speaking up can create a change in policy on your unit.

Leave the Bad Days Behind

So you were not super nurse today?  Today was not your day?  That’s ok.  You are only human.  There is no super nurse.  Anyone who pretends otherwise is kidding themselves. We all have had that day where you wake up late, spill your tea in the car on the way to work, walk into a frantic situation in the unit, and then are assigned said frantic situation.  You just want to turn right around and go back to bed.  Take a deep breath.  You will get through it.

While the list can go on and on, I think the most important thing of all is to remember that confidence comes with time and practice.  Each new environment and new job will test your confidence.  And remember, try not to compare yourself to anyone else.  Be the best nurse you can be.

LoriProfileLori Boggan, RN
Lori is a NICU Staff Nurse at Sahlgrenska University Hospital in Gothenburg, Sweden. After becoming a nurse, Lori traveled across the country to work a three-month travel contract in San Francisco, California. Nearly five years later her journey continued to Gothenburg, Sweden, where she now lives and works. She also write her own blog Neonurse at https://neonursetravels.com/

Five Easy Steps to Save Lives and Promote Healthy Families

by, Donna Weeks

It’s staggering to think that 54 to 93 percent of maternal deaths related to postpartum hemorrhage (PPH) could be avoided.

So what can we do on our units to reduce the number of women with complications, or even death, from an obstetrical hemorrhage?

I have taken part in many discussions about high tech simulation and drills, and we are always asking ourselves:

  • How can we have effective drills without a simulation lab and simulation models?
  • Can low tech simulation play a beneficial role in decreasing obstetrical hemorrhage?

I recently took part in a pilot program that the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)  trialed on postpartum hemorrhage risk assessments, evidence-based oxytocin orders, and hemorrhage drills and debriefing based upon a variety of settings.

Here are a few ideas that I have implemented without utilizing a simulation lab. These easy suggestions may help every obstetrical unit  raise awareness of obstetrical hemorrhage and contribute to decreased maternal morbidity and mortality.

First, have a mock code on your unit using your own crash cart.  You may be surprised to find out how many nurses are uncomfortable with finding key items in your crash cart.  Use a pillow to simulate a gravid uterus and have one nurse demonstrate left uterine displacement while other nurses deliver compressions and ventilations.  Additional nurses may find supplies, IVs, and medications in the code cart.

Second, devise a scavenger hunt and ask your staff to find the closest location of items needed during an obstetrical hemorrhage.  In many units the OB techs check the hemorrhage cart and the nurses may be less familiar with the items on the cart.  They may be leaving the room to get supplies and medications that are already on the cart.  In a true emergency this will use up valuable time.

Third, consider efficiencies. Do you have your medications locked in a Pyxis or Omnicell?  Do nurses have to remove the uterotonics one at a time? Due to the awareness raised by our hospital’s participation in AWHONNs postpartum hemorrhage project,  the day after our medication administration system was installed our pharmacy was notified that we needed a postpartum hemorrhage kit.  Now with one selection we retrieve ergonovine maleate (methergine), misoprostol (cytotec), carboprost (hemabate) and oxytocin (pitocin).

Fourth, how do you drill? What about drills in an empty patient room?  Have a drill in a patient room with nothing more than a mannequin.  Change the scenarios and include the less common situations.  With a type and screen being completed on most admitted labor and delivery patients it is not common to be ordering uncrossedmatched blood.  I use a scenario that includes a woman presenting to L&D with an obvious hemorrhage. This scenario presents the opportunity to review how and when to retrieve uncrossmatched blood.  What is your procedure?  Is there special paperwork or forms?  During one drill we strongly stressed the time element including how quickly we could generate a medical record number and how much time would be lost if an OB tech was sent for the blood. In our institution uncrossmatched blood may only be released to a physician or nurse.  Take the scenario further and include your massive transfusion protocol.  Review when and how to initiate the protocol.

Lastly, practice quantification of blood loss until it becomes routine.  Use scales, work sheets, and a variety of scenarios to keep staff informed and interested.  These can be presented by a charge nurse on any shift without preplanning.  It is just one more way to keep obstetrical hemorrhage on the forefront of everyone’s mind.  The more awareness we raise the better chance we have of early recognition and intervention. The goal is to have a healthy mother and healthy family.

DonnaDonna is a Perinatal Clinical Specialist at JFK Medical Center in NJ.  She has always loved OB nursing and also enjoys teaching.  She is currently an adjunct instructor at Kaplan University and Walden University.  She was the Hospital Lead for AWHONN’s PPH Project.

 

 


Citations

Berg, C. J., Harper, M. A., Atkinson, S. M., Bell, E. A., Brown, H. L., Hage, M. L., . . . Callaghan, W. M. (2005). Preventability of pregnancy-related deaths: Results of a statewide review. Obstetrics & Gynecology, 106, 1228–1234.doi:10.1097/01.AOG.0000187894.71913.e8

California Department of Public Health. (2011). The California pregnancy-associated mortality review. Report from 2002 and 2003 maternal death reviews. Sacramento, CA: Author. Retrieved from http://www.cdph.ca.gov/data/statistics/Documents/MO-CA-PAMR-MaternalDeathReview-2002-03.pdf

Della Torre, M., Kilpatrick, S. J., Hibbard, J. U., Simonson, L., Scott, S., Koch, A., . . . Geller, S. E. (2011). Assessing preventability for obstetric hemorrhage. American Journal of Perinatology, 28(10), 753-760.doi:10.1055/s-0031-1280856

Resources

Get free postpartum hemorrhage resources from AWHONN.

Learn more about AWHONN’s Postpartum Hemorrhage Project

For more in-depth info and to learn more about how to reduce clinician errors associated with obstetric hemorrhage mortality and morbidity, join AWHONN’s newest implementation community on Postpartum Hemorrhage.

The Real-World Impact of the AWHONN Convention

by, Michelle Amstutz, RN
Saint Joseph Mercy Hospital, Ann Arbor MI

I would like to share what an impact attending nationals has been for me over the last few years.

A few years ago I went to hear Michelle Collins present on Nitrous. She talked about bringing nitrous to Vanderbilt University Hospital. I was so inspired by her talk that I reached out to her to find out how I could do the same thing. Continue reading

See You In Grapevine!

Victoriaby, Bree Fallon, BSN, RNC-OB, C-EFM

When I was told my administration would be sending three of us to the AWHONN Convention, my heart skipped a beat. Actually, I squealed like a child and jumped up and down. It was a dream come true! I couldn’t help but compare Convention to a labor and delivery nurse’s Disneyland. It’s funny to me now remembering that day, as I would have had no way of possibly knowing what a tremendous impact the trip to Convention would have, both on my own nursing career as well as my unit. Continue reading

Top 10 Posts of 2015

When we launched AWHONN Connections in May of this year, we could not have imagined the response that we would have received from our members, nurses, parents and members of the media.

In less than a year our blog has received over 232,000 visits, from 167 countries and had 4 blogs republished on the Huffington Post! As the year comes to a close we want to say a HUGE Thank You to our readers and our bloggers.

Here’s Our 2015 Top Ten Round Up! Continue reading

Growing as a Leader

Cathy Ivory, PhD, RNC-OB
2014 AWHONN President

At some point in their life, every person is called upon to lead.

As perinatal nurses, the call to lead may come from many directions. Perhaps you have a friend or loved one who needs to make an important decision about a pregnancy or birth experience and looks to you for advice. You base that advice on current evidence and your experience as a nurse; if we are honest, we acknowledge that our own birth experiences (if we have them) influence the advice given to others. Those who ask our advice look to us as leaders in nursing, even if we consider ourselves (to use a phrase I really dislike) “just a nurse”. At the bedside, we lead by advocating for our patients and families, by mentoring new nurses, and by participating in unit improvement activities. Continue reading