As an RN for 25 years and in high-risk labor and delivery for 15 years, I feel compelled to respond to the “Code Blue Birth” article [May 15]. My heart goes out to Ms. Isaacs for her loss and the way her daughter was treated.
I worked at one of the major teaching level-three university hospitals in the Chicago area (which I will not name, but the shoe fits) and left in disgust.
Isaacs’s article is only the tip of the iceberg. When I started, there was great RN staffing and nurses ran labor management. Then the American health system hit the skids, and American nurses hit a brain drain due to women entering other fields. L & D nurses went on to become midwives and advanced practitioners in maternal-fetal nursing. But the sexism, lack of power only got worse for staff RNs. The university rewarded the “quiet, unquestioning, docile RN.” Foreign nurses who were afraid to rock the boat were desired. It was just deplorable. By the time I left, there were LPNs staffing in high-risk OB, clerks were “trained” as OR techs, high school students were used as clerks in a high-risk OB area (that’s the person who directs all communication, initiates pages, deals with public), janitors were used as translators on off shifts and weekends–informed consent? Doesn’t exist. Patients have no “rights.”
It’s enough for ten articles, but to address the Pitocin and induction issue–well-off women can afford the latest “trends”–doesn’t make it safer, but they have more options. Poor women are fodder for “studies” and have no choice. When I started OB, women were automatically given huge medio-lateral episiotomies–there was no good study to support this barbaric procedure, sometimes done without anesthesia, and when there were so many deliveries I didn’t call the resident until too late to cut one, actually they would say, “Damn, didn’t get to cut the epis,” even though the woman delivered with an intact perineum. All L & D nurses were skilled at who were the “butchers” and who used clinical judgment. While having no real power to protect our patients, we were advocates and damn proud.
Our hospital switched to “room deliveries” but no new equipment was purchased, so there were half as many infant resuscitation beds as there were delivery rooms. Nurses fought to get “the bed”–they broke often as they were not meant to be moved. Still no new neonatal resuscitation beds have arrived. Also short supply of sterile instruments, gloves, IV poles, anesthesia carts, blood pressure cuffs, blankets, pillows, slippers, etc. The real sadness is the fetal monitoring equipment, absolutely necessary in labor induction: broken, missing pieces–ordered from a “bottom line” low-bid company so the external uterine pressure piece never worked, forcing the overuse of internal pressure catheters, which also sometimes didn’t work.
You cannot run a Pitocin induction safely with broken equipment. That causes many unnecessary vaginal exams, increases infection rate, raises the C-section rate. You need sharp, skilled RNs. OB worships the monitor. Now nurses and MDs sit and “watch” the monitor through telemetry. They are taught this, they often do not touch or look at the patient. But nurses are still not treated as colleagues, asked their input. My charting was never read except by other nurses. Attending rounds were conducted by totally ignoring the primary nurse of the patient, the person who spends the actual time. It is very dangerous if Anesthesia runs in two liters of IV fluid without informing the primary RN, who is running the fluid totals of the patient. We had several incidences of “pulmonary overload.” No kidding.
When you take a postpartum nurse, a neonatal nurse, and “float” them to L & D, you are courting disaster. They can’t “troubleshoot” the equipment, don’t know what’s broken or how to make the best of what they have safely. This downsizing and “cross-training” destroyed the knowledge base of the specialty nurse. It took me years to become really good at working with Pitocin and learning the subtle warnings inherent in high-risk labor and delivery. All that experience ignored by appalling management practices. It became more common to see inductions lasting for days and days with the Pitocin not turned off. The mother was exhausted and often septic when going finally for C/S. Nurses were forced to care for neonates at the bedside (to get rid of the nursery nurse) as they recovered the C-section mother who was sectioned for distress. It became nearly impossible to give the high-risk mother who had surgery and sometimes profuse blood loss–now septic–close care when the staffing is so short you are also monitoring a baby at risk and one or two other labors! (With short supplies and unreliable equipment that you must use to make critical decisions.) Residents were competing with RNs to “run” the Pitocin, accusing RNs of not “turning up” the Pit fast enough, aggressive nurses were praised, subtle changes in the fetal heart rate that a worried nurse reported were ignored. It was like OB became so full of themselves. And Pitocin became the rule instead of the exception. And along with no hand washing before doing vaginal exams (a glove is no substitute), sloppiness prevails. A level-three hospital should not have broken equipment; people were transferred in to get the “best.” The gross, contaminated equipment was often used between patients. Because there weren’t enough pieces.
I finally broke after we caused an unnecessary maternal death. It would have never happened “in the old days.” Nursing had no power to put the brakes on a situation that got out of hand. One especially appalling practice was the order from the top–“Pitocin till distress.” Overdose the Pitocin until the fetus bottoms out and a stat C-section is justified. No regard was given to the maternal response, just to get the delivery over–no regard was given to the family or mother undergoing the “Keystone Kop fire drill to the OR,” operating on someone in a crash-bam ER fashion after causing the distress to begin with. I’d often ask the resident who had to follow the attending order (made by a maternal-fetal specialist, mind you), “Would you like your baby to be ‘stressed’ to the point of emergency surgery?” Of course, when classism, racism, and sexism give you the impression that women are not valuable, anything can be done for data for a study, to boost an ego, to publish, to impress your superiors.
There is little good science in modern medicine, and what science there is in nursing is ignored.
After 25 years, I could fight no more. The American health care system is collapsing. Sound the alarm, as Ms. Isaacs has–and see a midwife first. Iatrogenic (physician-caused) poor outcomes are more frequent than people know and the “science” of academic medicine is poor, the infighting and scrambling for prestige clouding the most obvious solutions.