A Day in the Life of a Labor & Delivery Nurse - LDR Side
By popular demand, I'm going to try to describe a shift at work as a Labor & Delivery nurse! Keyword: try, because there are just so many different possible scenarios, but here's my attempt at demystifying the world of L&D. In nursing school, I knew that I wanted to pursue L&D, and though I got to see vaginal deliveries and c-sections, the ins & outs were still such a mystery to me as a nursing student. Looking back now after hundreds of hours of OB clinical, practicum on the same unit, an externship, and then a 6 month internship... I have a grasp of what a real day looks like for a Labor and Delivery nurse.
Now, before I go on, I have to say that every L&D unit is so different. Some Labor and Delivery units are LDRP, meaning L&D staff also care for the woman in the postpartum period until she is discharged home. However, there are just LDR units, meaning we take care of the woman immediately postpartum (2-3 hours), but then transfer them to a separate postpartum unit where they stay until discharge.
In addition to this, our unit consists of several unique parts:
LDR side: "Normal" term labor, inductions, and vaginal deliveries.
Triage: Admissions from the office or home for car accidents, falls, non-stress tests, decreased fetal movement, walk-in patients, "laboring" patients (who aren't actually laboring), and basically anyone pregnant who needs to be assessed before either being sent home or to a delivery room.
Pre-Op: Scheduled c-sections get prepped here!
OR: Not just for c-sections, but also D&Cs, intrauterine fetal transfusions, hysterectomies, and tubal ligations.
Recovery/PACU: Where our surgical patients recover until being sent to postpartum or our high risk section.
High Risk: Our pregnant/delivered patients who are on magnesium sulfate, massive blood loss, extended recovery from emergent cases, pre-term labor, etc.
IUFD: Intrauterine fetal demise, patients waiting to deliver their nonviable fetuses, early terminations, specific cases of twins/triplets, postpartum stillborns, and some times No Info/VIP patients.
All this definitely intimidated me at first. I mean, as a new grad, you're already terrified, but having to navigate ALL that in just one unit!? Though intimidating, it is an amazing environment to keep up with skills and constantly be challenged. I hope that this helps demystify what L&D truly is. I hope to make this a whole series, where in each blogpost, we focus on 1 specific part of the unit.
In this specific post, we're only gonna be on the LDR side!
*Scenarios are fake and do not include any confidential patient information*
On the LDR side:
0700 - Get up to the unit and get report on your two patients.
You get report on a 39 week G1P0 patient, Mrs. Jones, who came in to rule out labor yesterday at 6PM. She was contracting every 5 minutes, was last checked in the office and was 0.5cm, 20% effaced, and at -2 station. She wasn't able to talk through her contractions upon admission, so the night nurse checked her and the patient was still the same exam. According to the night nurse, she placed a cervidil at 0000 and her contractions have slowed down throughout the night. The OB has ordered a pitocin infusion to start in the morning. Fetal heart tones (FHT) have been moderate variability with plenty of accelerations with no decelerations.
Your second patient, Mrs. Green, is being induced for postdates. She is 40 weeks and 5 days and a G3P2 and has been ruptured for 18 hours. She is still leaking meconium tinted fluid and has been afebrile. She is contracting every 2 minutes on 8 units of pitocin. Her most recent exam was 8/90/-1 and feels pressure in her rectum. She received an epidural 5 hours ago and is comfortable laying left lateral.The FHT strip shows early decels with moderate variability. She has requested female providers only.
0730 - Mrs. Green's husband calls out and says that she feels the urge to push.
You glance through the FHT strip and notice the heart tones slowly decreasing, and early variables turning into lates. You walk in to see her grimacing and laying flat on her back. You reposition her on her left lateral side, which resolves the decreased heart tones and then check her for dilation. She is complete (10cm) but still at -1 station. You call out for your tech and team leader to get the room set up for delivery and to notify the oncall midwife of the variables and the new exam. The provider states that she will be at the bedside shortly and to prepare for delivery.
0800 - The midwife arrives.
You reposition the patient into pushing position. Because the baby is in OP position, it is having trouble coming through the birth canal, and the patient seems to be an inefficient pusher. After pushing for 30 minutes, the midwife orders the patient to labor down and try again in 1 hour, allowing the baby to come down further. You position the patient on her right lateral side and leave the room. You ask the midwife for antibiotic orders for prolonged rupture, but she denies the need as the patient has been afebrile.
0830 - You check up on your other patient.
Mrs. Jones is still comfortable and denies having any pain or pressure with her contractions. She is contracting every 5-7 minutes, which allows her cervidil to stay in until it's due to come out at noon. You educate her about pain management, including deep breathing/relaxation techniques, IV fentanyl, and epidural. She desires an unmedicated delivery but will let you know if she desires medication.
0900 - You catch up on charting.
Because patients on pitocin require close observation on FHT and contraction pattern, you chart FHT for every 15 minute interval and contractions for every 30 minute interval. The midwife for Mrs. Green returns and would like the patient to push again.
0930 - Mrs. Green delivers.
After only 3 pushes with contractions, a baby girl is born at 0931. The resuscitation team (NICU+Respiratory) is present at deliery because of the meconium. They assign 8/9 APGARs and the baby is cleared to be skin to skin with mom for the golden hour. She had no lacerations and needs no repairs, but quantitative blood loss at delivery is 720, even with IM methergine and IV Pitocin. The plan is to recover her and observe her postpartum blood loss closely. You discontinue her epidural, and insert a straight catheter to avoid bladder distention. You assess her Aldrete score intermittently and provide fundal massage Q15 minutes for the first hour, Q30 minutes for the second hour, and Q hour until her recovery is over.
1030 - You catch up on charting.
You weren't able to finish up FHT charting on Mrs. Green, so you do that on top of delivery charting and recovery charting. Mrs. Jones is still doing well and denies any pain. You catch up on charting on Mrs. Jones.
1100 - The OB for Mrs. Jones calls and asks about the patient's status.
You tell him that the patient is comfortable, the strip looks great, and that you have not checked her for dilation. He orders that the pitocin be started as soon as policy allows upon pulling of the cervidil. You return to Mrs. Green's room to take out her straight catheter. She is still feeling numb in her right leg and is not ready to get up to the restroom. You give her her dose of postpartum ibuprofen and a lunch tray.
1200 - Mrs. Jones calls out for her nurse.
She would like to know more about an enema and you educate her that it will simply empty her bowels and possibly allow space for baby to descend further into the pelvis. She would like that because she would like to avoid having a bowel movement during delivery. The provider okays an enema and a shower prior to starting pitocin. You remove her cervidil and check her. She is now 4cm dilated, 60% effaced, and at -2 station.
1230 - You call report to postpartum.
Mrs. Green's recovery is coming to an end and she is firm at the umbilicus with scant lochia, and her second and third QBL was only 50. The postpartum nurse says that the room is not ready for a patient yet and will call you when the room is ready.
1300 - You catch up on charting and prepare the pitocin for Mrs. Jones.
You educate the patient on the effects of pitocin on her contractions. Postpartum calls and says that the room is ready for Mrs. Green. You remove her epidural line, help her pivot into a wheelchair, and your tech transports her and her baby upstairs.
1330 - You catch up on charting.
Mrs. Jones starts contracting more frequently with pitocin, and rates her contraction pain at 5/10 and denies the need for medication. You titrate the pitocin every 30 minutes. Because her contraction pattern remains irregular and does not show signs of tachysystole, you are able to continue increasing the rate of pitocin.
1430 - You receive a new patient.
Mrs. Lee is a previous c-section, G2P1L2 patient who has a low transverse incision and has been approved by her OB to have a Trial of Labor After Cesarean (TOLAC)/Vaginal Birth After Cesarean (VBAC), who has been contracting every 5 minutes for the past 3 hours. She is anxious because she has never felt contractions before because her c-section was scheduled because she was pregnant with twins. Because of her anxiety that is rooted in feeling pain, she plans on getting an epidural as soon as possible. You attach the contraction monitor and and FHT ultrasound monitor.
1500 - You finish Mrs. Lee's admission.
Upon calling the provider for orders, the midwife would like to come check her and develop a plan from there, but would like basic labs drawn and an IV access started. She states that she will be at the bedside in about 30 minutes as she is currently assisting in a c-section.
1530 - Mrs. Jones calls out wanting pain medicine.
You educate Mrs. Jones about her 3 doses of IV fentanyl that she can receive before receiving an epidural. Because the FHT tracing still shows moderate variability with plenty of accels and no decels, she is a candidate for IV fentanyl. You educate her that it will take edge off of the contraction pain, but not take it away completely. However, this is a good option for Mrs. Jones if she would like to avoid an epidural. She states that she would like to try the IV fentanyl.
The midwife comes to check Mrs. Lee. She is 4/20/-2. She orders her to walk around the unit.
1545 - Mrs. Jones receives her first dose of IV fentanyl.
She is aware that she is only able to get 1 dose of IV fentanyl every hour and will let you know if she feels the need to get the epidural before her next dose of fentanyl. Her husband asks lots of questions about the epidural procedure and you educate both her husband on the process and what happens after the epidural.
1645 - Mrs. Jones would like her second dose of IV fentanyl.
While you're catching up on your hourly charting for Mrs. Lee's FHT and contraction pattern and Q15 charting for Mrs. Jones, Mrs. Jones calls out for her second dose of IV fentanyl. Before you administer the fentanyl, you perform a sterile vaginal exam for dilation. She is complete at +1 station. You step out and call the OB.
1700 - The OB arrives.
The room is set up for delivery, and you start pushing.
1830 - You are still pushing with Mrs. Jones.
While you're in this room, the midwife for Mrs. Lee comes by and checked her with your team leader. You get the update that Mrs. Lee is still 4cm, but her cervix has ripened a little. She inserted a Cook's catheter for mechanical dilating. Mrs. Jones is still pushing after an hour and a half, but the baby has still not moved.
1900 - Mrs. Jones is still pushing, and night shift has arrived.
You give report at the bedside. The provider starts chatting about using a Kiwi vacuum as the baby's head is starting to mold. You notify your team leader and your team leader calls the OR in case the Kiwi vacuum is inefficient and the patient needs a c-section.
Phew- what a day, right!? I'm only typing this imaginary day but I'm exhausted like I worked this day! Oh, and in a perfect world, you got to sneak away from a 30min lunch ;) I know its a lot. I just mainly did a brain dump of what a day on the LDR side could possibly look like. Of course, there are some days you get 2 inductions and you don't have to do anything for them beside chart, bring them their breakfast/lunch/dinner trays, and be a source of support for the other nurses in your pod. But there are also other days where your patient starts abrupting and you have to run to the OR, or a patient walks in and within 5 minutes of getting into the bed, the baby's head is crowning already.
In case of running to the OR with an emergent scenario, here are some things I always try to remember:
- Throw SCDs on the bed.
- Throw a foley on the bed, if the patient doesn't already have one.
- Try to keep the patient calm.
- Time is everything.
In case of a precipitous delivery:
- Always keep gloves on.
- Call out for help.
- Catch the baby if need be.
As for how I keep track of my patients, I don't use a report sheet or anything complicated. I use a folded sheet of paper, write down the room number and attach the patient's sticker. You really only need the most important things:
- Her gravita/para
- Medication/food allergies
- Current gestational age
- Blood type
- Other significant medical history
- GBS status
- Most recent cervical exam
- Contraction pattern
- Current plan of care
I hope this was helpful for you guys! Keep your eyes peeled for the 2nd part of this series coming soon! And as always, let me know if you have any questions, and also keep in mind that hospitals have varying policies/protocols for certain medications and scenarios. Let me know if you'd like a certain part of L&D in the next blogpost.