Labor & Delivery Nursing: The Good, The Bad, & The Truth

When I was getting ready to graduate nursing school, I would hear all the time how hard it was to get into labor & delivery and NICU. And if you wanted dayshift… you better be willing to wait for someone to retire, move, or die. Until recently, turnover in L&D was historically low nationwide. Especially when compared to other nursing units in the hospital.

Well, in this post Covid (wait, are we really POST Covid?) era in healthcare, that is not the case. Our unit has been facing a major staffing crisis. Turnover higher than ever recorded, unit full of travel nurses, not enough charge nurses, and not enough preceptors. But, that means, if it’s something you are interested in, it can be a good time to get into a speciality. Read more to see about the good, the bad, and the truth about labor & delivery. And why it’s so much more than the “happy place of the hospital”.

Healthcare Transformation

Healthcare has changed. And it’s still changing. The Covid-19 pandemic showed the public how important healthcare workers are and how hard out job really is. But, it also showed healthcare workers how quickly we turn from heroes to villains.

In May 2020 we were healthcare heroes. Companies and individuals sending us coffee and lunch. Helping donate the PPE we needed and couldn’t get. But after a year and the pandemic wasn’t ending as quickly as we wanted, after people no longer enjoyed working from home and the decreased traffic on the road, we started to transition to the villains. I read and heard so many vile comments from patients, family members, and online: the nurses and hospitals are lying about Covid to hide what is really killing patients, we were making more money from Covid so we didn’t want it to end, refusing to wear masks even though nurses were still seeing so many people dying.

Read more here about my opinion on “Healthcare Heroes”

If the initial stress, anxiety, and depression at the start of pandemic didn’t push nurses from the bedside, the lack of appreciation both verbally and monetarily, would.

I am not sure how long it took the mass turnover to start on the medical units and ICU after March of 2020. I know within the first 6 months, I heard of many nurses having to leave or change to part time due to severe mental health crisis’. After working full time, helping my daughter with virtual schooling and figuring out childcare for her since she was home all the time, I almost lost my mind. I decreased to what we call “3/4 time”. Its five 12 hour shifts in a pay period instead of six. It’s still considered full time, so my benefits and such don’t change. 

It took a while for this massive turnover rate to hit our unit. Partly, because we were not as affected by Covid-19 patients. Sadly, we had many pregnant moms who were very sick with Covid and some who didn’t make it through their battle with the virus. But we weren’t experiencing nearly the stress and death at our med-surg and ICU’s. It was stressful when all the Covid babies started to be born. Our unit was busy and simultaneously, nurses were out for 5-10 days if they tested positive themselves. But when it hit, it snowballed quick. It has been pretty miserable for those of us who stayed. 

Travel Nursing

If you’re a bedside nurse reading this, or in management, you know how bad turnover has been for nurses all over the country in this past year. As far as I always knew, travel nurses were mostly young and single nurses. Nurses who aren’t tied to somewhere specifically; someone who wants to explore and adventure, and who can take this opportunity to stack some cash. Recently, nurses realized there were travel nursing assignments paying double and triple what they are making at their current position and they were plentiful. Many of my former co-workers found travel assignments less than two hours away, some even in the neighboring counties. So with the stress of Covid-19 and bedside nursing in general these last few years, the treatment of nurses after being regarded as healthcare heroes for 3 months, and not receiving the raises or hazard pay we deserved for all we have went though in the hospital, why not leave? Why not make a lump sum of money quickly, pay off some debt, save for your wedding fun, etc?

Also, being that nursing positions are so abundant, the fear of not being able to return to your job or something similar in your hometown, was nonexistent. This started a vicious cycle for nursing units and I’m sure on management and upper administration. People leave to take travel assignments, so you have to hire travel nurses to fill those positions. Other nurses hear how much their friends are making and how much these new travel nurses are making to do the same job, so guess what? They leave too. So the hospital has to hire more travel nurses to fill those positions. I am quite sure it has been pretty expensive to staff units. I would guess much more expensive than giving staff nurses the raises we deserve. 

Concern for the State of Healthcare

In my opinion, it’s a scary time for healthcare. With so many experienced nurses leaving to take travel assignments or leaving the bedside, there are hospital units run by new nurses. And those new nurses were trained by other fairly new nurses and travel nurses. And not all travel nurses are created equal. Many of the travel nurses we have had left their home unit to travel after only a year or two of labor and delivery experience. And in labor and delivery, especially high risk, that’s just barely enough to feel comfortable… if you are self aware and honest with yourself. Of course, there are plenty of great nurses that have left our unit to travel and they are wonderful. But, travel nurses are given about a 3 day orientation to the unit and let loose to fly solo. A scenario just asking for errors. 

One of my best friends started traveling pretty early in this time of huge change. She has shared with me the conditions at some hospital were very scary. She often left her assignment early, in fear for her license. That said, I am very thankful to the new nurses that still decided to become a registered nurse, because by this point, they started their nursing school journey after March of 2020. But these nurses need to learn how to be a great nurse from other great nurses. And I am sure with all the stipulations listed above, that can be a challenge. 

Burnout for Nurses Who Remain

You can’t stop labor patients at the door. No matter how staffing is or how busy you already are, a baby is going to come when it wants. I’ve heard of hospitals condensing and even closing some units because they don’t have the staff. Elective surgeries can be cancelled to reduce the amount of patients and patients get sent home earlier with more home health support or closer follow up. Not ideally, patients are also stuck in the emergency departments for hours and hours, sometimes days waiting for a room to open up. We can’t do that. So how do we get the staff? In addition to hiring travel nurses, we take call shifts.

Since you really can only plan the patient numbers but so much in labor & delivery, we have nurses on call. When you have to be on call and called in, it’s not fun. But, when you’re at work and drowning, it’s valuable and comforting to know you have back up that can come in. What our unit does is open up the calendar to sign up for call shifts voluntarily, but then depending on how short staffed we remain, the on call shifts become mandatory. Making anything mandatory is going to cause animosity. Thankfully, we have hired many nurses who will actually be apart of our staff (as opposed to travelers), so the amount of mandatory call shifts have decreased.

Advice From Real Deal Labor and Delivery Nurses

When I started this post, I thought I would have sections about “the good”, “the bad”, and “the truth” of labor and delivery. But as I go, I realize, that it really is all tied and mixed together. What is bad to some nurses, may be good to others. Everyone has different truths.

I am thankful that we have hired new nurses. Many that we have hired are ones without any labor and delivery experience. Some have been great additions, some barely lasted a year past orientation. I don’t think many nurses really know what labor and delivery nursing is like. They know they don’t like what they are doing, and want something different. L&D sure is different from most other types of nursing, but do people think it’s easier? I took to my IG page to poll labor and delivery nurses, what they would want potential L&D nurses to know.

Here Are the Answers…

“You’ve got to be ok with high stress environments!”

“Got to be flexible! L&D nurses take on a lot of different roles”

“You deal with a lot more death than you think”

“It’s a completely different world than med-surg, not easier at all, just completely different!”

“If you don’t want to spend a lot of time at the bedside, find another job”

“Our primary job is to take care of the mamas, the babies are just a nice added bonus”

“It’s emotionally and physically exhausting”

“There are deliveries and inductions where we already know the baby has died before we even start”

“A desire to be at the bedside the majority of the day is a must”

Now, Whose Going to Train all these New Nurses?

On a good day, our unit staffs with 16 to 18 nurses a shift. Right now, we have days where there are 8 nurses with new employees to train/orient. And by the time we get people off orientation, someone else has left, so there are new people to train. Experienced nurses are getting burnt out from the constant orienting. I had a shift last Friday that was magical.

Between orienting new nurses and being in charge, I rarely get to have my own labor patient. We are also a high risk transfer center, so we have many patients to take care for conditions other than labor. I had a wonderful family in for an induction having their fourth baby, and got to help them through a regular ole’ labor and delivery. Oh, and a surprise gender at that! The anticipation and excitement of a surprise gender is one of my favorite things to experience at work. It was their fourth boy BTW. 

Recently, our hospital finally got their act together and gave us pretty decent raises. I am very appreciative, but unfortunately, it came at least a year too late. My manager, who is one of the best, shared with me what a bad financial situation our healthcare system is in right now. They are closing units, despite the fact that flu and RSV season is starting, purely so they can phase out the need for travel nurses. She told me that our units staffing crisis is what pushed HR and administration over the edge. We used to be the unit in the hospital with the lowest turnover rate year after year. 

Hopefully, we can go uphill from here. 

New-Grad Nurses

I have had the opportunity to participate in the interview and hiring process of brand new graduate nurses for labor and delivery. Oh, side note. We have also had to hire double the new grads at a time then we ever have, and for the first time, we are hiring mid year new grads, because the need for staff nurses is so great. Ok, back on track. I have really enjoyed the interview process. I have had a new grad nurse to orient every year for the past 5 years, so it makes sense to be able to give some input!

Like I said earlier, it used to be pretty challenging to start right into L&D as a new grad nurse. It was usually highly recommended to first do a year of med-surg nursing. Times, they are a changing.

These are my 10 tips for your interview process on Labor & Delivery

Disclosure: these are just in my opinion and things I do and don’t like to hear from candidates, other managers and nurses may have different criteria.

1. Don’t say, “I want to work in the happy place in the hospital. The area where patients actually want to be in the hospital”
   • When asked why you want to work in L&D, that answer is a major turnoff for me. I know this is judgmental of me, but it automatically makes me think that you really don’t know what you are getting into and you are one of the people that think L&D is just that, laboring and delivering and holding babies. I go months with never holding a baby, between skin to skin time and transferring our patients to a postpartum unit. 
   • Also, many of our patients do NOT want to be in the hospital. They might be inducing a fetal demise, they might be in an unexpected preterm labor, the thought of the baby coming might remind them that they have no help to care for the baby, or maybe they are getting admitted for long term observation and missing their other children at home.
2. Know what kind of hospital and unit you are applying for
   • L&D units vary widely, some delivering 500 patients a year, some delivering 5,000. Some only work with private practice docs and their patients, some are teaching hospital where you work with residents and patients from all walks of life. 
   • This is important for a couple of reasons. First, of course you want to make sure its a size, risk level, pace that you wanting for yourself so you get the best experience you can get as you start your nursing career. Second, some knowledge shows your interest and sets you up to appear as a “go-getter”.
   • Different hospitals and different units may have a significant difference in patient population. If you aren’t prepared to set your bias at the door and take care of the lower socio-economic, maybe less educated, patients just as well as your rich, two parent household patient who has taken all the birth classes, then please DO NOT apply to that unit. These patients need just as much care, if not even better care and more help and that is what a nurse is. Their support and advocate.
3. Go deep. Talk about your whole self
   • An interviewer really isn’t supposed to ask a candidate about their family life and such, but it helps me get a clearer picture of you as a person. 
   • The best teams have all sorts of different personalities and types of members. Share about yourself, and what you bring to the team. Not everybody has to be the confident leader. If that is the only type of member a team has, no one can make a decision because the ability to compromise might be lacking.
4. Tell them your knowledge, experience, or passion for women’s health in general, not just in labor
   • A nurse we just interviewed and I am happy to say offered a position to, mentioned her passion for women’s health and rights and helping to change healthcare for women.
   • My manager always shares how she feels called to do this work, how she feels its her duty to serve. It is very inspiring, but she also says that when we hadn’t gotten raises. And I’m like uh I feel you, but I need to be paid for my passions work too!. To me, it just shows a more well rounded interest, which on our unit with high risk antepartum patients, is helpful. 
5. Be confident but not cocky
   • Confidence is attractive. Have a strong voice practice eye contact.
   • Address the interviewer that asked you the question first and direct, then turn to the rest of the room with more details (this was given to me by one of the new grads I have recently interviewed and am now helping precept!)
6. Really think and research if this is the specialty for you
   • It is overwhelming. It’s different than any other type of nursing. Many new nurses I’ve talked to said they mine as well not even have had a maternity section in school, because they feel like they didn’t learn a thing. It is very complex. 
   • You are also many different nurses: labor nurse, newborn nurse, antepartum nurse, & OR nurse. 
7. Prepare your own questions
   • Most of the candidates I interviewed on this go round came prepared and I loved it. They had a folder with their resume and a list of questions to ask. 
   • We want this to be a great fit for the all of us. So, if there is something that is a deal breaker for you, better to know it now!
   • Ask if you are being hired for nights or days, what are the weekend requirements, how is the dynamics of the unit, on call requirements, etc. 
8. Share your plans for your career, or even your lack of plans**
   • **Now, this again, is probably more specific to my needs. But TBH, I am getting annoyed of training new people and them staying for 1-2 years and rolling out. 
   • Training a new nurse to L&D, especially a new grad, is very time consuming and very expensive. At our hospital, we give the new grads, or as they are called now Nurse Residents (very fancy), a six month orientation. Which is needed. As I said, you are training to be many kinds of nurses and take care of all sorts of patients. Also, our new grads take a lot of classes, so that does take away from time on the unit.
   •  In this past year, the rotation of staff has been so frustrating so I have wanted to ask candidates, “hey, are you going to leave in a year to get your masters? Or are you getting married in 6 months and going to move with your husband out of state?”. Which I know is inappropriate. But that’s why it would be nice if you share if you have plans to stay and get lots of experience!
9. In case you’re asked for your biggest weakness, prepare for that question with a real answer
   • If I hear someone say, “I care too much” or “I am too hardworking” all I see are red flags. All of us have flaws. Show that you took time to reflect on yourself.
   • I mean maybe it’s not the best idea to share that you were fired from your last position because you were late all the time, but if that’s you, please work on that. Its really annoying for your relief to habitually come late.
10. Try to relax
    • Be yourself. This may not be everywhere, but when I tell you my manager is so caring and chill, I mean it. We want to see who you really are, not answers you googled the night before. 
    • We can teach almost anyone the skills and the knowledge. But we can’t always teach people to have passion and the wanting to care for patients and serve their population. So just show who you are. People will appreciate your honesty.

The Happy Place in the Hospital

Here are the reasons why I CANNOT stand when people comment that we work “in the happy place of the hospital”. It diminishes all the hard work we do and the stress we go through. Also, I feel like it takes away from our expertise and critical thinking. Like I said earlier, I go months without holding a baby. I bet there are people out there that think being a labor and delivery nurse is a mix of counting and coaching women through pushing, calling doctors, holding babies, and getting ice chips and epidurals. We do some of that, but we do so much more.

My brain is exhausted when I get off work. We are constantly thinking, constantly watching and interpreting fetal heart rate tracings, on edge because things often change very quickly.  I guarantee I could show fetal heart rate tracings to hundreds of nurses and doctors from other specialty services and maybe 1% would even slightly be able to read and interpret it. 

Mental Exhaustion

We have a whole second patient that we cannot see, cannot touch, and cannot talk with. A second life to consider with all of our decisions and interventions. If our fetus is trying to show us they are in distress, we have to intervene on the mother and hope that intervention helps the baby. And we can only do but so much before we have to start focusing on how these interventions are effecting the mother. It’s tricky.

There are days when the “strip” or fetal heart rate tracing is not so cut and dry. It might not look good, but not bad enough to do a c-section. You are doing your interventions, and maybe it helps, maybe it doesn’t. You are stressed and getting annoyed with this baby who is keeping you on your toes. And you are constantly using your brain to continuously monitor the fetus, the mother, and anticipating what might be coming next.

Physical Exhaustion

Our hospital unit has consistently been ranked as one of the lowest c-section rates nationally. The Leapfrog Group survey’s states that approximately 51% of hospitals achieve the goal of a c-section rate lower then 24%. As of June 2022, our rate is 14%.

https://ratings.leapfroggroup.org

It is also very physically exhausting. There is a lot of standing, lifting, moving patients in bed, walking back and forth. And if you’re me, you do A LOT of walking back and forth. I forget things all the time. I walk to the supply room to get my patient a new gown and refill my supply of vomit bags and I remember, damn I meant to get a handful of IV flushes and alcohol swabs. So I go back. I come back to the room and the patients asks for water. I wish I could send the dad or support person, but our water is special. It is locked behind a door that only badge access can enter.

I sit down to catch up on some charting, go back in the room because I forgot to ask my patient a few more admission questions. I walk in, realize I never brought the water! You see what I am getting at here? Since increasing my Adderall dose, it has slightly helped me be lest forgetful at work. Or, maybe, it just helps me walk faster. 

Our hospital unit has consistently been ranked as one of the lowest c-section rates nationally. The Leapfrog Group survey’s states that approximately 51% of hospitals achieve the goal of a c-section rate lower then 24%. As of June 2022, our rate is 14%. That number comes with a physical toll. There are many factors that affect our c-section rate: up to date practice, great teamwork, patient physicians, and an ability to complete a stat c-section much faster than national standards (due to all the resources of a high level trauma center), so the docs can watch and wait a little longer before calling the section and sometimes that waiting helps to achieve a vaginal delivery that you wouldn’t think you could pull off. 

Bedside nursing skills, care, and time all help our low c-section rate. I came from a unit in Maryland where it was common to get a patient an epidural and lay them back on low semi-fowlers position. Maybe a left tilt here, right tilt there.

I have learned so much since moving to North Carolina. Peanut balls, hands and knees, Tailor sitting with a peanut ball under the legs. And now the positions have fun names thanks to Spinning Babies. Spinning Babies offers classes you can take to help with labor positions for specific fetal positions. We be all up in the labor rooms shaking apples or some shit. Exaggerated runners position, side lying release, and reverse cowgirl… wait, that’s not right. Let me look that up. Ok, flying cowgirl, my bad. Have a dense epidural? Don’t worry, we will get more people in there to help move you. Now do you see why we are so exhausted and sore? But we do it because we love it. Love the challenge, and the success when you got a baby out the way the patient wanted and you know your methods helped. 

Emotional Exhaustion

Along with physical and mental, we have to deal with emotional exhaustion. There are pregnancies and labors that don’t end with a happy, healthy, or alive baby. Less often, but even more horrific, there are pregnancies that don’t end with a healthy or live mother. The whole hospital has to deal with death. And I don’t know how nurses in the emergency department or ICU’s do it when it happens so frequently. But on L&D, death isn’t “supposed” to happen. It’s always unexpected and gut wrenching. Unfortunately, incidences like these are only going to increase. The United States has the highest maternal mortality rate above any other industrialized nation.

The Good

Reading this post, you might be thinking, well why would anyone want to in labor and delivery. It’s exhausting, mentally, physically, and emotionally. Being a nurse in general seems to be under-appreciated, even after the world got a sneak peek view of what hardships nurses really experience.

I’ve done a lot of thinking about my career lately. I still don’t feel like I know what I want to be when I grow up. The upward projection for nurses has many different paths. That is one of the best things about nursing: if you are bored or hate where you are, there are so many different avenues. Nurses can go into supervisor or management roles, back to school to get a masters in education or an advanced practice degree like a nurse practitioner or a midwife. I don’t want to do any of those things.

For now, is being a bedside nurse after 13 years that bad? Do we all have to have a goal in an upward projection? Would I want to do another type of nursing other than labor and delivery? I have also given this a lot of thought. Once, I tried an OB/GYN office, to get more of a normal schedule and off holidays. I hated that. I have no clue how people can work Monday through Friday and drive in rush hour.

ADHD Tangent

Speaking of Monday through Friday… I have another tip. A thing to never say to a hospital bedside nurse. This is right up there with “you work in the happy place in the hospital”. Don’t say, “but you only work three days a week”. Don’t get me wrong, I am grateful for my three 12 hours shifts. How the hell do you get anything done when you work Monday through Friday? When do you go to the dentist?!

But those three days will take the life out of you. After working even just two in a row, you need a day to recover. When we are working those 12 plus hours, usually we are working. I go full days without eating, days where the first time I pee isn’t until 3 pm, and sometimes those patients we are flipping and moving have BMI’s of over 50. Meanwhile, I know some of those 9-5’ers are getting their morning started drinking coffee and chatting and taking hour lunch breaks.

OK, Back on Topic

What else can a labor and delivery nurse do? I do not want to be a midwife. Definitely do not want to go back to school. I don’t want to work at an office. Straight out of nursing school, I went to postpartum and L&D, so I certainly do not want to, or would feel qualified, to do a total different specialty. And would I even want to work somewhere different? A male patient that isn’t a newborn ready for his circumcision… no thank you.

In moments like this, it’s helpful to navigate away from the negative. Recount and focus on the positive. I enjoy it when I know that worked hard and that hard work helped my patient get the vaginal delivery they wanted. I take pride in my expertise of the operating room and training new nurses. Have you ever had a newborn baby named after you? I have. These are all factors that keep me going. This is just a small sample of the good and great aspects of labor and delivery nursing.

In Conclusion

So there you have it. A sample of the good, the bad, and the truth of being a labor & delivery nurse. After over 13 years, I could give so many more examples and supporting details. But everyones journey is different. OMG, did I just type journey? Time to rethink this blog thing. I sound like a tool.

Ok, anyway, I hope you found this post helpful, especially if you or someone you know has been considering going into labor and delivery. It is hard, it is challenging, but it is rewarding, and it is something special. You can help give me a hit of dopamine and encourage this blog writing process by commenting if you enjoyed the article. Also, let me know if there are any other topics you may be curious about and share with others who might be interested. I would appreciate it.

ashley, RN

Mental Mommy Nurse