Saturday, May 9, 2015

Thoughts of an L&D Nurse: An In-Depth Interview

Thoughts of an L&D Nurse: An In-Depth Interview with Nurse Monica Mitchell |
Nurse Monica: Voted Best Nurse in Johnson County in the Best of the Best Awards, 2014

In honor of National Nurses' Week, I met up with local OB nurse Monica Mitchell, RNC-OB, C-EFM for margaritas and some conversation.  We talked everything from birth plans to homeschooling but I really wanted to get her take on doulas, why she does what she does and where she sees room for improvement.  I wasn't disappointed!  I left on fire- her passion for what she does is contagious- and feeling incredibly lucky that we have such great providers in our area. 

Q: Tell me a little about yourself.

A:  Well, I always knew I wanted to do something medical.  It was in high school that I realized it was nursing that I wanted to do.  I went to Southwestern Adventist University and worked at John Peter Smith first in telemetry/cardiac nursing.  I made myself go and learn that first and get that experience.  It was ultimately the birth experience of my 3rd child that lit the fire in me to go back to school to be an OB nurse.

Q:  So, how did you make the transition to L&D?

A:  Nursing is a family profession.  My Aunt told me to go to a county hospital or to the military and nothing will ever scare me.  In training as an OB nurse, you do research and you study evidence based practice.  But, I would go out on the floor at JPS and see they were doing things much differently.  JPS is high-risk, but everyone got put on a monitor and put in bed.  I questioned the norms and I felt from the beginning that it wasn't the place for me.  I even got written up a few times for getting people up and out of bed but I stayed for 6 years.  It just so happened that I met Carla Morrow while she was at JPS working on getting her DNP.  When I found out she was down at Cleburne, I felt ready to leave JPS but it took a couple of years to make my way down there.

Q: Texas Health Harris Methodist Cleburne has been on the forefront of some excellent advances in maternity care.  Can you speak to some of the programs you've been involved in?

A:  I just presented at AWHONN on hydrotherapy.  I reviewed every single water birth we did at Cleburne- it took me nine months- and did a statistical comparison on things like lacerations, length of second stage, infection, APGAR scores.  What we discovered was that there was no statistical difference in APGAR scores, there were NO infections in any of our moms and babies- that's a big point of concern for opponents of water birth-, 2nd state of labor was much shorter- it averaged only 24 minutes- and we had a decrease in lacerations and the severity of those lacerations.

Cleburne was the first and is currently the ONLY hospital in the state offering nitrous and we're the ONLY nurse-driven nitrous option in the country.  Vanderbilt University, for example, has never quit using nitrous but the patients have to be assessed by anesthesia prior to administration.  By they time anesthesia gets to them and does the assessment, the need has usually passed, especially with repairs.  At Cleburne, we don't have access to 24-hour, in-house anesthesia and that worked in our favor as a selling point for making it nurse-driven in our hospital.  The difference is that our mixture is 50% concentration of oxygen/nitrous and needs negative pressure to deliver- it's not free flowing, and that makes it "minimal sedation" which RNs can administer.  We've found it VERY helpful for repairs- it keeps moms awake and alert for repairs as opposed to iv sedation which can knock them out for a couple hours, and they miss that critical bonding time with their baby.

Family Centered C-Sections is also something that we've worked hard to get going.  Carla Morrow started it- she had heard about it on a trip overseas- and just sort of said "this is how we're going to do it".  The biggest hurdle was getting anesthesia on board so we did a presentation of evidence with lots of literature supporting it.  The first time we did it was on a VBAC (vaginal birth after cesarean) mom that was devastated that she was going to have to have a repeat c-section.  We did it with her and it was great AND anesthesia realized that mom was much calmer with her baby with her.  Usually, mom gets anxious at the end and anesthesia ends up having to give meds to help calm her.  When they realize that doing it this way was making their job easier, they really started to get on board.

I really feel that surgical birth, when necessary, should be done in a way that parents are a part of, instead of something that is done to them.

Q:  What is something that you wish everyone knew about nursing life?

A:  I wish people knew how much of ourselves we put into it.  We go home and cry when things don't work out or we have a bad outcome, even when they don't get the birth they wanted.  I take it personally.

Q:  What is the hardest part about your job?

A:  Bad outcomes, of course.  But, trying to juggle rules and protocols and trying to make sure our patients have the outcome they want.  We have a great group of midwives and nurses there at Cleburne and we really don't take no for an answer!  We push for the change.

Q:  What is the most rewarding part of your work?

A:  Having a happy momma and happy baby.  Getting that thank you from a patient; them telling us that we made a difference for them.

Q:  What do you love/hate most about the current maternal care system?

A:  We have atrocious birth outcomes.  It's safer to deliver in Puerto Rico and it's not because of sub-standard care.  It's because 1/3 of our deliveries are sections.  It's fear driven.  It's said that it takes about 17 years for research to make it to the bedside- to see the changes happen but we need to make it happen faster!

We have a litigious atmosphere and it causes people to be scared.  You know, doctors and nurses don't do conferences together anymore and sometimes we don't even speak the same language.  We have OBs in this country that haven't taken classes since the 1970s and they literally are speaking a different language in regard to terminology.  It's also a paternalistic system and we continuously hear things like "Why are you getting induced?  Because I said so."  It needs to change.

Q:  Do you feel supported in regard to resources for continuing education?  Specifically evidence based information, since it continuously changing?

A:  YES!  100%!  I'm writing evidence based information and I'm passionate about it!  We have great management and leaders at the hospital.  We come to them with information and ideas and they hold us accountable; they expect us to do our homework and present them with the research.  We do and that's how change happens. 

Q:  How have you seen birth practices change over the course of your career and what do you think the driving force behind those changes have been?

A:  I haven't seen much change anywhere else.  In my 9 years, I've only seen the change at Cleburne.  I saw some things like delayed cord clamping at JPS, but not much.  I do think skin to skin is catching on.  People are starting to talk about gentle sections, even if they aren't in practice yet.   You know, when Medicaid stopped paying for elective sections before 39 weeks, we really started to see change.  Now the push is for 41.  Change is money driven and patients need to remember they are consumers.

Q:  As a doula, I focus on helping my clients prepare to have their best birth, whatever that may be.  What is something you wish every patient knew before having their baby, regardless of the type of birth they desire?

A:  I prefer for my patients to be educated and know what they want.  Also to know that plans can change.  This is your first experience at parenthood, realize that things can change!  I feel people sometimes think, especially with transfers, that we are the enemy but we aren't.  We really want them to get a birth that is as close to their plan as possible.  But, to get more educated parents, we need to be starting in high school.  Women need to know how birth affects their body, what is involved, educate them about breastfeeding (we need a social change to make that the norm).  I want women to know that they have options and that you don't have to just say yes to something because your doctor says so.  You can question your doctor and your nurse- it's your body!  Some people don't know the difference between good practice and bad- how much better it can be.  I also want NO shaming for their birth choices.  Care should be individualized to what they need, what they want.

Q:  What do you see patients doing to unintentionally hinder their relationship with hospital staff?

A:  People come in defensively.  I understand it and I hear their stories but it puts everyone's hackles up.  We try to explain, we acknowledge that things may not be going the way they want, but we truly do want to help them get the best birth they can.

Q:  What do you see doulas doing to unintentionally hinder the relationship with hospital staff?

A:  I think some doulas push too hard and pass judgement on their clients.  Care needs to be individualized and labor is unpredictable.  Support her when things change.  Sometimes the refuse to have a discussion.  We present them with options but we get a firm NO.  They aren't willing to entertain any.  I love working with doulas though- "ok, you rebozo and I'll doppler."  I'm in my happy place then.

Q:  What do you really think about birth plans?  

A:  Everyone should have one.  We are there to give patients a good birth experience, regardless, but they should know what they want.  If they don't have a birth plan, we help them realize their options.  We've have patients show up with no clue about their choices, only to have them get in the tub and have a baby when they didn't even realize that was an option!

I read the birth plans, no matter how long.  There isn't really an optimal length for me but make it easy to get to and easy for someone to reference.  Regardless though, I'm going to talk to the client verbally to confirm and get more information.  I'm going to go in and discuss and acknowledge their wishes and make sure we have a contingency plan- that's important.

Q:  Is there anything else you'd like to add?

A:  The nurses in Cleburne, and I've worked with great nurses, we are really passionate about what we do.  I think we need to push for change.  Patients must know their rights and advocate for themselves in order to make big, large-scale change.

Our problem now is that our birth culture needs to change.  I hear things like "well, my mom was induced so I'll probably need to be induced too."  The things that you as a doula discuss with your clients is something that everyone needs to know, dads included.  Until there is absolute demand for it, things won't change.  Some providers are pushing against the grain but we need a bigger demand.