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The Secret Work of Nurses

I distinctly remember thinking that if a few more minutes had gone by, he wouldn't have been holding a camera.
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Recently, I admitted a patient in early labor and the first thing she asked me was when her doctor would be there. In my head, I laughed. I had not seen her doctor all day, even though I thought her doctor would make rounds in the morning.

I knew there was a laundry list of reasons why she had probably not made it in by that afternoon: she had lucked out, and not a single one of her patients had delivered that morning, which would have forced her to come in. She had been unlucky before 7 a.m., and had three deliveries in the middle of the night, including a STAT section (it was her turn to be on call). Her daughter had called the unit two separate times asking if we had seen them, because she was waiting at practice to be picked up. And medical records had called looking for her, wanting signatures on a few unsigned orders.

There were a handful of people trying to hunt her doctor down. Instead of laughing, or trying to predict when her doctor would be there, I put on a sterile glove and told her to relax her knees. Because the patient had a beautiful strip and nothing bad to report, I would not see her doctor until she was complete and ready to push. She was contracting adequately and making cervical change, so I didn't need augmentation orders. She was GBS positive, so we treated her. I finally called her doctor when it was time for her to deliver. She pushed two times and required no repair (but I can't really take credit for that, she was a multip). And as soon as her doctor delivered her, she was gone again, off to see other patients. I controlled her pain, I provided breastfeeding support and encouragement and I tidied up her room before her guests arrived. I'm like a professional mother!

After the hundredth time of being asked by a recently-admitted patient, "Is my doctor coming now?" I started to realize that no one knows what we do, as nurses. I don't think patients realize how much influence we have over when they will deliver, how they will deliver and everything else in between. Doctors can't be on the unit all the time, so they rely on us to tell them if we think something is wrong, if the strip looks bad or if we notice any "changes." If we mess up, or are lazy, or do not pay attention, it could mean the difference between a mother who has a vaginal delivery or a cesarean delivery, a mother who has a stable delivery or an unstable delivery, or a baby who has a healthy birth or a traumatic one. Labor nurses are always watching their strips, and everyone else's -- because in a matter of minutes, a mom or a baby can deteriorate and the outcome can have life-long consequences.

I remember when I was still on orientation, my preceptor and I were laboring someone who had previously had a cesarean delivery. Her water was broken, she had a great epidural, and she had the most beautiful strip. As we walked back to her room, my preceptor was watching her strip from each computer that we passed. I was talking and laughing and really not paying attention. I mean, we were 20 steps away from her room. I remember her telling me, "Oh look, there goes a late decel. And there goes another one." By the third contraction, her baby's heartbeat was 60 bpm and would never come back up. It was the first time I had ever seen a prolonged decel. My preceptor walked calmly into her room, but my adrenaline had started to pump. Everything in me wanted to freak out. She was complaining of severe upper abdominal pain and her shoulder was hurting. She had one of those epidurals where she couldn't even move her toes, so my preceptor grabbed the pad beneath her, rolled her to her side and threw oxygen on her. Of course, other nurses came into the room. My preceptor told the OR tech to open up the back, she took the IV fluids off of the pump, capped off her epidural and started pulling monitor cables out so that they could transfer the patient in her bed to the OR. Then my preceptor looked at me and told me to go tell her physician that the patient's uterus was rupturing and we would meet them in the back.

When the physician opened up the patient's abdomen, the baby's hand was sticking straight out of her uterus. I wanted to shout out in the OR: My preceptor was right! It was a uterine rupture!!! But instead, I watched as she brought the baby to the warmer, limp, quiet and blue. The baby was born so quickly that the neonatologist was not there yet, but the nursery nurses knew what to do. Someone grabbed the base of the baby's umbilical cord, they stimulated him, they gave the baby some PPV and by the time I walked out of the OR, the baby was pink and crying and the father was smiling and taking pictures of his new baby. I distinctly remember thinking that if a few more minutes had gone by, he wouldn't have been holding a camera.

My heart was pounding so hard I could feel it in my throat. What if my preceptor had not been looking at the patient's strip while we were walking down the hallway? I mean, I was talking about what I was going to eat for lunch, I totally wasn't paying attention. What if she had not turned her to her side and put oxygen on her? Did that buy us those few precious minutes? What if we had called the doctor first and waited for the doctor to get there before determining that the patient needed to be taken to the OR? What if the nursery nurses did not know how to pink up that baby and make him breathe? The outcome could have been devastating for that family. In just a few delayed minutes, that baby could have died before even getting to the operating room.

So if you are a nurse, don't ever forget that every single moment of every day that we work, we hold our patients' lives in our hands. We have to keep watching, we have to be aware, we have to keep getting better, because we want the very best outcome for our patients and their babies. What we say to our physicians is crucial, and how we say these things is just as important... but this is something that we all already know.

If you are a patient, know that your nurse leaves their own house before their family wakes up. If we eat breakfast or lunch, it's based on what you are doing at any given point in time, and even then, we are watching you. We go to work and never know what our day is going to be like, or what kind of patient we are going to have. We are on constant guard, protecting you and your baby and trying to give you the healthiest delivery possible. We know it's just a matter of minutes that have the potential to change everything. We're telling your doctor everything we see and what we think, and we're careful in how we tell them these things, because this too has the potential to change everything.

If you were the patient who heard your baby's heartbeat plummet, if you were the patient who found herself with an oxygen mask on her face or if you were the patient who had to be rushed to the OR for a quick delivery, know that your nurse has to know what to do even before your doctor gets there. Your doctor is usually responding to information that we are providing to them. What we say and how we say it has the ability to alter every outcome. That's the secret work of nurses that no one ever talks about.

P.S. I never just pass a computer monitor with a fetal monitor strip without watching it now.

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