Labor and delivery nurses walk a fine line, trying to do what’s best for the patient and being considerate of a physician or a midwife’s clinical practice. We struggle to know when is the right time to call a provider for delivery. Calling too soon can leave a physician or a midwife frustrated and impatient, but more importantly, can lead to unnecessary interventions for our patients. Calling a provider too soon for a delivery can produce a provider at your bedside that is eager to get back to their practice, leading to increased episiotomies, use of vacuums or forceps, and the dreaded “failure to descend” diagnosis. We also have to remember that providers have very busy clinic schedules, so we want to be considerate and minimize the time they are away from their practice. Icing on the cake is that we are giving our patients an opportunity to labor down. When the physician is at the bedside we feel obligated (and are often asked) to encourage the patient to push, regardless of station. I’ve seen almost every kind of midwife, and I’m verrrry lucky that where I work now the midwife is always at the bedside when the patient is pushing (and usually, throughout the whole labor), just being patient and supportive. But we’ve all seen a doc’s eyes start darting or their foot tapping…
So here are few things that have helped me through the years. But for any new labor and delivery nurse out there, know that we have all called the doctor too soon or not soon enough!! 🙂
- First and foremost, if you are ever concerned, have questions, or just want the physician or midwife at the bedside, do not hesitate to call. It doesn’t matter what time it is, if the physician implied they are busy, or if you are unsure if your feelings are founded. Just call. But if you aren’t worried or concerned and have a good fetal tracing, here are some other helpful tips. ..
- If the patient is a primip (it’s her first pregnancy) and she has a good epidural, call the provider when baby hair sticks and stays out of the vagina. This is perfect for a patient who has no urge to push.
- If the patient is a primip and does not have an epidural or has one that isn’t working well, call when the patient is complete and +1. While you’re waiting for the doctor, turn her into that sacred left lateral position.
- If the patient has had a baby before and has a good epidural, call when she is complete and +1 (for a good pusher) or +2 (if she isn’t).
- If the patient has had a baby before and does not have an epidural, let the physician or midwife know when she is 8cm, regardless of station. When you call the doctor or midwife, your report should absolutely include her gravida/parity, her membrane status, her vaginal exam, and the fact that she’s unmedicated. This will translate to: she will not be able to stop pushing. They will either start making their way to you (if they’re sensible) or tell you to call back when she’s complete (if they like to gamble). If they tell you to call back when she’s complete, call when she’s 9.5 and lie and say she’s complete. When you know they’re on their way, turn the patient left lateral until they get to you. They’ll barely have time to gown up when they walk into the room. Have gloves ready in case they decide to take their time 😉