Frustrations as an OB nurse - Mothering Forums
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#1 of 27 Old 02-20-2007, 05:38 AM - Thread Starter
 
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I'm an OB RN and I was recently off on maternity leave for the last 6 months and have been doing tons of reading on MDC (while I pump). I really do get so much joy out of my profession, but I've recently started to feel even more apprehensive about some of the interventions we are forced to do by policies and insurance companies, especially around electronic fetal monitoring. I work at our community hospital's birth center which is pretty alternative (we do waterbirths, VBACs, have staff doulas, wireless FHM, low epidural rate...) but nonetheless I don't like having to hook moms up to FHMs because if we see anything besides a perfect strip we have to do continuous monitoring. I hate this! I also hate when I see every breech baby go to section. I also hate trying to keep a labor on "schedule" with a Freedmans curve and starting Pit after someone is "stuck" at 6 cm for two hours! WTF? The thing is our doctors don't like a lot of this stuff either, but we are all required to do these things because of possible lawsuits down the road...:

I initially went into OB nursing so I could help make a difference and advocate for natural childbirth, but I feel so strapped sometimes by legal requirements. I just try my best to tell my mamas that they can decline any and everything and am very big on giving informed consent, but so many just go along with standard procedure and don't even question anything. This frustrates me! Now that I'm back to work I'm really noticing how much I just don't like so many of the practices we do. Anyhow, I guess I just needed to vent to people that may understand where I'm coming from.

Any OB nurses out there?

Mama to DS & DD, 4 years old TWINS 
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#2 of 27 Old 02-20-2007, 06:09 AM
 
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But I wanted to try and help you out. Do you have places where pamphlets are around for patients so they can grab and peruse while waiting at admitting or anything. Or would it be possible to keep some "Your Rights" pamphlet with regard to informed consent, IVs, yadda yadda --- in your pocket and you could mention to her that you have this pamphlet that if she just briefly looked over it so she has a better understanding of all of her options... ?

Would that be a feasible idea?

GREAT MOM to dd (5) and )ds( [sept 26 2006]
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#3 of 27 Old 02-20-2007, 10:51 AM
 
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Wow, this sounds like a dream hospital to me! I live in a city/state that has pretty much gotten rid of VBACs... so forget about waterbirth, wireless anything, and on staff doulas. We don't even have a hospital with a CNM in this area. (I can only think of 1 birth center in the whole state.) I'm so glad there is a nurse out there watching out for the moms. THANK YOU! I like the post that suggested the "Your Rights" pamphlet. But I think the biggest way to prevent unnecessary procedures, etc is educating the patient well before labor ever begins. If the docs don't like the protocols either.... (I'm in shock but happy) they are just the ones who can changes things and influence these soon-to-be-mamas before they ever arrive in labor.
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#4 of 27 Old 02-20-2007, 12:23 PM
 
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I'm not a nurse but I do all of my doula work in a hospital and work closely with them. I see their frustration, similar to yours, where they are tied to policies that have no basis in the well being of mothers and babies but are rather CYA practices to avoid lawsuits... I also see others who are slaves to the system and have been working in it soooo long that they see it as The Only Way, and if clients come in wanting minimal or no intervention and natural birth they are not treated nicely... it IS frustrating!
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#5 of 27 Old 02-20-2007, 12:33 PM
 
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I am soon to be in a similar situation as you, I'm in my last semester of nursing school and plan to work in L&D before returning to grad school. I know that its hard to work where the culture and practice of the unit and docs is awful. I work in out-of-hospital birth now and have for awhile, so the hospital policies or practices really were even more shocking to me than I expected. I have had some rotations in different hospitals in my area.

My suggestion to you and other nurses is don't just follow orders! Change them! Be an agent of change. Know your policy and procedures book like the back of your hand because sometimes there is wiggle room there. Also, know that you don't have to automatically follow orders if you believe they are unsafe (for example-- outraggeous pit orders). Get on a committee in your hospital for evidence based practice. Stay on top of the latest evidence based practice guidelines by nursing organizations (I belong to AWHONN http://www.awhonn.org/) and try to implement them.

Its sad, but nurses are known for bitching and not doing anything about it. They don't speak up or advocate for change enough. My goal when I get in practice is to change everything I can or die trying! Ok, I'll step off the soapbox now!
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#6 of 27 Old 02-20-2007, 01:14 PM - Thread Starter
 
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I am soon to be in a similar situation as you, I'm in my last semester of nursing school and plan to work in L&D before returning to grad school...
I couldn't agree with you more! I'm contantly questioning our practices. Are they truly evidence based? If not, why are we doing them? Fortunatley the hospital I work at is completely independant from a parent hospital organization, therefore we have the right to make and change our policies at will, but they must be evidence based. Luckily I'm in an environment where keeping childbirth as natural as possible is the goal.

Its the fetal monitoring guidelines that drive me the most nuts. According to AWHONN, "high-risk" patients are to be monitored every 15 minutes during active labor and every 5 minutes during 2nd stage--that is A LOT--which basically means continuous monitoring. The problem is so many of what I consider to be normal patients are actually considered "high-risk" if you read the guidelines carefully (like anyone over age 35, anyone with low-socioeconomic status, unmarried mothers...). Give me a break! I swear continuous monitoring leads to complications. First of all it restricts a mothers movement which IMO can so often lead to asynclitic and OP presentations, and secondly, it just begs for more interventions, like IV boluses & O2.

Anyhow, jlpetitte, I'm glad to have found you. Good luck to you PM me anytime with ideas, concerns, etc! (oh, and I did belong to AWHONN until just recently...the cost of my materntiy leave and twins has taken all my $)

Mama to DS & DD, 4 years old TWINS 
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#7 of 27 Old 02-20-2007, 03:20 PM
 
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I really want to thank all you ladies for what you do, for your concern for babies and their families.

I am training to be a childbirth educator, doula and breastfeeding counselor. My biggest concern is that I speak my mind, to a fault, and I need to learn to be much more diplomatic about my views. I need to learn to offer information, teach families how to make decisions based on accurate information rather than scare tactics.

Any ideas on how to learn this skill? I need to learn to stop before I open my mouth, think through what the information is and decide how best to present it to this particular family so it will be understood. Is this a born trait, is it too late for me?
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#8 of 27 Old 02-21-2007, 12:20 AM
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I know what you mean! I am doing my leadership/synthesis whatever you call it- last clinical- in L & D right now. Although I love it, I also hate it. I hate when women come in at 39 and 5 to be induced. I ask them why and they say the doctor is worried because they haven't gone into labor yet and it's almost their due date : I mean, seriously! I would estimate that easily 80% of our patients (10000 a year!) are induced or scheduled c/s. No wonder the average gest age at birth has gone down. We don't have any overdue moms to balance it out. I have yet to see anyone more than 41 and 1 come in.

There is one CNM I met who actually tries to talk patient who want to go natural into epidurals. When the patient refused (with some encouragement from me!) she told the dad, "Well, you know she's going to scream when the baby comes out." WTF?

I have such a hard time, and I worry that I won't be able to find a job I enjoy. The hospital I gave birht in was fantastic but in another state and there appear to be none like it around here.
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#9 of 27 Old 02-21-2007, 02:41 AM
 
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I feel your pain, ladies. Or rather, FELT it.

Become a midwife.

My nursing experience was in level III hospitals. (jl, I think we've emailed a few times.) I worked in one while I was in graduate school. In retrospect, I don't know how I did it.

It took me a bit of time as a midwife, but when I heard some nurses talking about how a doctor treated her patient (read: HORRIBLY) I realized that I wasn't being exposed to that anymore, because I wasn't doing it. I've worked in a few different capacities, but I'm independent now, and my clients get intermittent monitoring, can eat and drink, don't get IV's, etc. That's, of course, for the hospital women; about half of my clients have their babies at home.

I love the advice of being an agent for change. My current role allows me to live in my happy little midwife world, but leadership in nursing has the potential for positive change in a different way. Either path is a way out of that awful state of impotent anger.

Let's keep fighting the good fight, but let's keep nurturing ourselves and each other as we change our crazy system!

Jennifer
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#10 of 27 Old 02-21-2007, 02:48 AM
 
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Really? You still do Friedman's curve?

I had a patient complete for eleven hours last week. Anywhere else she would have been sectioned. She ended up with a vaginal birth. I love my unit.

Here's how I see it: most women birth in hospitals. One of the key roles as an OB nurse is to act as patient advocate and negotiate between the health care system and the patient's preferences, while still maintaining both patient safety and nurse safety. The hospital system isn't perfect. But most women birth in it, and I believe we serve a vital role as mediator between oftentimes competing interests. Who better than nurses, since we spend most of the time acting as intermediaries between docs and the real world anyway?

It's such a privilege to see a baby's first face, to watch them rocket through evolution to become land mammals. I can put up with a lot of crap to get to see that every frickin' time I go to work.

mama to Max (2/02) and Sophie (10/06); wife to my fabulous girl
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#11 of 27 Old 02-21-2007, 11:45 AM
 
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Become a midwife.

While I think this is good advice, some of the time, it doesn't tell the whole story.

Maybe you'll become a midwife, get very few interviews out of school (because you live in a region where there are far more midwives than open jobs, midwives can not by law own their own practice, physicians regularly decide one day, upon review of the budget, that there is no room for midwives, and there is no such thing as a birth center or CNM assisted home birth), and end up working in an assembly line clinic. Where the midwives try to establish centering style prenatal care, but it's discontinued despite rave patient reviews, because it's not a cost-effecient use of the midwives' time.

Or if your patient falls off the curve, you HAVE to consult your back up physician (written into the hospital bylaws), and then you have to beg the physician to "give her a chance." And, if you get the reputation for pleading your case too often when it doesn't turn out favorably (ie, the mom eventually gets a c-section anyway, but at 3 am), then your back-ups stop listening to what you are saying anyway, so you might as well be just a "if everything is going exactly by the book" birth attendant.

All this while still working in the office, explaining to perhaps 8 tired pregnant women a day that, "no, we don't do elective inductions...yes, we'll consider inducing you when you are about 10 days overdue....yes, I know that's harsh...yes, I'm sorry that you are uncomfortable, but it really is better if you go into labor on your own."

Perhaps you'll work somewhere else, where this isn't your reality. Or perhaps you'll be an exhausted agent of change within a broken system. But, it's not as simple as it sounds.
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#12 of 27 Old 02-21-2007, 11:54 AM
 
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Wow, this sounds like a dream hospital to me!...I'm so glad there is a nurse out there watching out for the moms. THANK YOU!
:

You are doing valuable work! Keep it up!
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#13 of 27 Old 02-21-2007, 11:56 AM
 
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If I had to birth in your hospital I sure hope I'd have you as my OB nurse
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#14 of 27 Old 02-21-2007, 12:23 PM
 
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Really? You still do Friedman's curve?

I had a patient complete for eleven hours last week. Anywhere else she would have been sectioned. She ended up with a vaginal birth. I love my unit.

Here's how I see it: most women birth in hospitals. One of the key roles as an OB nurse is to act as patient advocate and negotiate between the health care system and the patient's preferences, while still maintaining both patient safety and nurse safety. The hospital system isn't perfect. But most women birth in it, and I believe we serve a vital role as mediator between oftentimes competing interests. Who better than nurses, since we spend most of the time acting as intermediaries between docs and the real world anyway?

It's such a privilege to see a baby's first face, to watch them rocket through evolution to become land mammals. I can put up with a lot of crap to get to see that every frickin' time I go to work.

This is more my experience as well. Our hospital does some pretty darn nice hospital births. I wish this was the reality in all hospitals, so women choosing hospitals births could expect to get the best care, physician and nursing, and not have to fear being told things that aren't true and being pushed through the system.
I've seen the other side, though, and still do occasionally. I've seen what BetsyS talks about as well - in my non-midwife-friendly state especially. Even in my own practice, which in many ways is ideal, I'm sometimes fighting against the prevailing practice in the OB world and listening to client after client tell me that their friend's doctor will induce anytime after 38 1/2 weeks, so why am I forcing them to stay pregnant?
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#15 of 27 Old 02-21-2007, 01:44 PM
 
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While I think this is good advice, some of the time, it doesn't tell the whole story.

Maybe you'll become a midwife, get very few interviews out of school (because you live in a region where there are far more midwives than open jobs, midwives can not by law own their own practice, physicians regularly decide one day, upon review of the budget, that there is no room for midwives, and there is no such thing as a birth center or CNM assisted home birth), and end up working in an assembly line clinic. Where the midwives try to establish centering style prenatal care, but it's discontinued despite rave patient reviews, because it's not a cost-effecient use of the midwives' time.

Or if your patient falls off the curve, you HAVE to consult your back up physician (written into the hospital bylaws), and then you have to beg the physician to "give her a chance." And, if you get the reputation for pleading your case too often when it doesn't turn out favorably (ie, the mom eventually gets a c-section anyway, but at 3 am), then your back-ups stop listening to what you are saying anyway, so you might as well be just a "if everything is going exactly by the book" birth attendant.

All this while still working in the office, explaining to perhaps 8 tired pregnant women a day that, "no, we don't do elective inductions...yes, we'll consider inducing you when you are about 10 days overdue....yes, I know that's harsh...yes, I'm sorry that you are uncomfortable, but it really is better if you go into labor on your own."

Perhaps you'll work somewhere else, where this isn't your reality. Or perhaps you'll be an exhausted agent of change within a broken system. But, it's not as simple as it sounds.

:
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#16 of 27 Old 02-21-2007, 05:19 PM - Thread Starter
 
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Really? You still do Friedman's curve?

I had a patient complete for eleven hours last week. Anywhere else she would have been sectioned. She ended up with a vaginal birth. I love my unit.

Here's how I see it: most women birth in hospitals. One of the key roles as an OB nurse is to act as patient advocate and negotiate between the health care system and the patient's preferences, while still maintaining both patient safety and nurse safety. The hospital system isn't perfect. But most women birth in it, and I believe we serve a vital role as mediator between oftentimes competing interests. Who better than nurses, since we spend most of the time acting as intermediaries between docs and the real world anyway?

It's such a privilege to see a baby's first face, to watch them rocket through evolution to become land mammals. I can put up with a lot of crap to get to see that every frickin' time I go to work.
Heck no! We don't actually follow the Friedman's curve at our birth center, nor do we do a lot of what we are "susposed" to do according to what a lot of further education is saying regarding how a birth is "susposed" to go. In my first post it may have somehow sounded like I don't like the way our birth center does things; what I was meaning, is I don't like the direction hospital birthing is going. I truly love the unit I work in, which is far from the mainstream norm as far as the hospital birthing realm goes (we've actually been leading our state in alternative birthing practices for decades). Infact, I wish all hospital birthing units could be like ours! Argh, its the whole big hospital birthing system that irks me...its JACHO...it's the medicalized-problem-oriented approach that is being given to the most natural process in the world--BIRTH! ...and that medicalized view point is the standard we nurses are legally being held to (ie. what another reasonally prudent nurse would do).

Just the other day I was completing some of our required continuing education on EFM and in a quiz it asked us what to do if a woman has been at 6cm for 2 hours. First of all, the choices were all obserd--straight up medicalized, and the correct answer was to start pitocin! What about massage and soft music to help the woman relax, position changes, try laboring in the jacuzzi, a private shower with her partner, etc.? This is actually what stimulated my first post in this thread.

Aside from these problems with medicalizing birth, I absolutely love my work! It is such a true honor to be able to help women through such an intimate time in their lives and then to witness their babies looking around at their new world for the first time. I work hard to ensure that every birth is given the opportunity for its magic to glow, regardless of the amount of intervention involved.

BTW, I'm loving this thread! It's refueling my drives for advocacy!

Mama to DS & DD, 4 years old TWINS 
Birthing/Postpartum RN on my "free time".
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#17 of 27 Old 02-21-2007, 07:26 PM
 
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This is what scares me about being a CNM. I'm going to be doing clinicals in the hospital, with pretty much NO chance of changing anything, then working for a few years at a hospital in my hometown (where a CNM once told me she was the only person in the whole hospital that will let a mom even get to her due date) before I can afford to open my own birth center. There's a great CNM with a birth center half an hour outside of town that does homebirths, waterbirths, and VBACs - I keep focusing on her as a role model to remind myself that it CAN be done.

I'm just petrified that I'll see so much of the medicalization that I'll have a breakdown from the stress of trying to make things better and advocate for women.

Mandy, )O(  Proud mommy of Taylor (1/6/05) jammin.gifand Abigail (4/21/11) slinggirl.gif
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#18 of 27 Old 02-22-2007, 12:32 AM
 
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Let's keep fighting the good fight, but let's keep nurturing ourselves and each other as we change our crazy system!
This is great advice Jen! I also do plan on becoming a midwife and fighting that fight someday as well!
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#19 of 27 Old 02-22-2007, 02:43 AM
 
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Maybe you'll become a midwife, get very few interviews out of school (because you live in a region where there are far more midwives than open jobs, midwives can not by law own their own practice, physicians regularly decide one day, upon review of the budget, that there is no room for midwives, and there is no such thing as a birth center or CNM assisted home birth), and end up working in an assembly line clinic.

All this while still working in the office, explaining to perhaps 8 tired pregnant women a day that, "no, we don't do elective inductions...yes, we'll consider inducing you when you are about 10 days overdue....yes, I know that's harsh...yes, I'm sorry that you are uncomfortable, but it really is better if you go into labor on your own."

Perhaps you'll work somewhere else, where this isn't your reality. Or perhaps you'll be an exhausted agent of change within a broken system. But, it's not as simple as it sounds.
You'r right-I didn't wake up after graduating and find myself in my current position. I know that my situation is idyllic-my entire life has been a series of happy accidents. That being said, all of the bold in the first paragraph has happened to me, and most of them more than once. I had to relocate to get a job out of graduate school, I've lost four jobs in five years, the states I came from and went to have no birthing centers, and I've worked in assembly line clinics. Thankfully, those settings were two of the fours jobs I lost. Thank god for small favors....

Practice-wise, my life is idyllic. In other ways it's damn scary. I'm running around without health insurance (ah, this great country of ours) and I'm in the uncertain world of self employment. Until last fall I had two other part time jobs to pay my bills (now I have one), and I've amassed another load of credit card debt while waiting for the business to become self sustaining.

To Betsy, Becki, and minkajane-I've experienced most of what you've posted about it. I know it's not simple because I've lived its complexity in the past six years that I've been a midwife, and before that as a nurse. I'm not a paragon of virtue-I've been extraordinarily lucky.

This, right here, right now, is what I mean by nurturing ourselves and each other. If my sister midwives and nurses are feeling beaten by the system, I need to reach out and help them back up again. Surely the time will come when I'll need that hand to help me up.



Thanks for being here!

Jennifer
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#20 of 27 Old 02-22-2007, 11:05 AM
 
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Jennifer--I'm saying this honestly, without snark--I'm very glad that there are people out there like you. People that are working within the system to make a difference.

For me, it got to be enough. I am a SAHM right now, but if I go back, it won't be to midwifery. I'm tired of having to fight for what I think and believe, tired of (depending on the town I live in) being told I'm alternatly "too medicalized" or "too laid-back" to be a good midwife (and yes, I've been told both, witht he same practice style). I just don't have the fight in me to be a good midwife.

And, yes, I should have known that this was the atmosphere out there. But, I went to school without a freakin' clue. I grew up in a town with midwives since 1978. They are actually still there, in an independent, hospital owned clinic. They hire out their back up, so the midwives aren't actually employed by the physicians (a very nice set-up). The community supports them, the hospital supports them, and I thought every town was like that. Ah, to know at 24 (when I went to midwifery school) what I know now.
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#21 of 27 Old 02-26-2007, 02:53 AM
 
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I feel your frustration. I'm an OB nurse as well, and it was especially tough going back to work after my homebirth. I work in a very high intervention hospital, just trying to make a small difference. I am always asking myself if I'm doing more good for women staying there and being an advocate or walking away from the system altogether. : I think about this every day.
Becoming a midwife isn't in the cards for me right now, but I have thought about becoming an IBCLC and working in my hospital. I don't know...
You sound like a very supportive nurse, your patients are lucky to have you. I wish you a smooth transition back into work. I'd love to hear how it goes for you. Congrats on your babies.
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#22 of 27 Old 02-26-2007, 05:30 AM
 
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I risked out of homebirth. So I am very, very glad there are nurses like you who can be understanding of those of us who would have a homebirth if we only could, even if you are more or less forced into some practices which are not ideal.
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#23 of 27 Old 02-26-2007, 01:30 PM
 
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I work at my hospital because the nurses were so incredible when my planned home birth became a section for breech, severe pre-e and HELLP.

mama to Max (2/02) and Sophie (10/06); wife to my fabulous girl
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#24 of 27 Old 02-27-2007, 08:57 PM - Thread Starter
 
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I have thought about becoming an IBCLC and working in my hospital. I don't know...
Ya, I'm thinking about becoming an IBCLC too, though probably not doing a whole lot beside continuing to educate myself in breastfeeding until my babies start school. I think its a great way to advocate for so much of what I believe in and I just love helping mamas and babies get started with nursing. Having extra breastfeeding challenges myself, I'm even more motivated now. I also see LC's (and breastfeeding assistance in general) as a vital link between traditional hospital practices and natural parenting.

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#25 of 27 Old 02-27-2007, 11:43 PM
 
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I, too, am an ex-labor nurse for a hospital that offered some great options. If I could've stayed in the Alternative Birthing Center part of the unit I would have been the happiest nurse. And I agree with how hard it is to advocate for women against an entire system, especially when women don't always advocate for themselves.
It's nice to know there are other great nurses out there struggling to do what we do. Some of my most rewarding moments have been from mom's who've seen me outside of the hospital after their births and told me how much it meant to have a great nurse. It really does make a difference.

Now I am blessed enough to be able to be a Home-birth nurse. I know not all nurses have such a great opportunity. It makes such a difference in my outlook to have a break from "fighting the system" and work with entirely like-minded individuals. I admire you women, both nurses and cnm's, for doing what you do, and not conforming to the mainstream mindset.

You rock!
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#26 of 27 Old 03-01-2007, 07:34 PM
 
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Wow!
I thought I was the only OB RN in the world who felt these things. I agree with pretty much everything that has been said about the sorry state of childbirth in most of our hospital settings, and am very glad to see that some of us can remain working L&D within the hospital and fight for change.

Unfortunately, I did not have that kind of emotional stamina. After I had my first daughter, a homebirth, while working L&D in a Level III hospital (yes, I tried not to tell anyone, and yes, they literally told me I was crazy and probably doubted my nursing judgment after that), I realized I couldn't go back to the policies & procedures that led to unhappy outcomes, which were accepted and expected, so I transferred to postpartum where I selfishly didn't have to deal directly with the orders and decisions that I felt were so wrong.

I was also in grad school at the time to become a CNM and I also realized that, at least in my state, becoming a CNM was not going to put me in a better position to help laboring women than I was already in as an RN. I have no idea why having a child myself made me see these things more clearly, but it did. Of course, everyone on my unit assumed I had a "traumatic" birth experience at home and so couldn't face laboring women anymore, which was SO not the case, as my homebirth was perfect.

The CNMs in Colorado seem to be stuck in the crossfire between docs/hospitals telling them they are too laid back, dangerous, and cause high insurance rates and bad outcomes, and those who realize the CNMs are forced to carry out all the medicalizations of the on-call backup within the hospital setting. So, I'm no longer in the CNM program, and unfortunately Colorado has a law that if you are an RN and want to become a lay-midwife to do homebirths then you have to give up your RN license. Thanks, state board of nursing, way to encourage midwifery. We don't have any hospital supported birthing centers, either. There is one CNM who has started her own birthing center in a house near a hospital, but this has happened in the past two years, so I am not too up on how it is going.

Anyway, thanks to everyone for posting. It's nice to know there are others within the hospital settings that are in the same boat.

Catherine
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#27 of 27 Old 03-02-2007, 03:19 AM
 
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I agree, becoming an LC does seem like a good way to bridge the two worlds. Problem is, the training is pretty intensive. I am considering a distance learning course, to combine with the hours we spend assisting moms. But when do I think I'll have time to study with an active toddler?
I wonder also if our hands are tied even as an LC. For example, the question of co-sleeping and the American Academy of Pediatrics. What can we say? Can we recommend it? What can we advocate for and what are we restricted on if we work in a hospital setting? I wonder if we would come up against the same wall as in L&D. Any LCs out there?
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