Labor and Delivery and Antepartum — Unit 34 and 35

Labor and Delivery (L&D) is a Baby Friendly® designated procedural area and consists of 27 beds, operating on a 24-hour basis, 7 days a week, on the third floor of the Patient Services Building of the North Tower. The unit is adjacent to the Antepartum Unit (3500), and Neonatal Intensive Care Unit (3300).

The beds are allocated in the following manner:

  • 5 Outpatient Triage Beds
  • 15 Labor, Delivery, and Recovery (LDR) Beds
  • 3 Operating Rooms (OR)
  • 4 Recovery Rooms (PACU) Beds

*One of the LDR’s is a negative pressure isolation room for patients requiring respiratory isolation.

On average, Labor & Delivery arrives 20-25 patients per day and record ~7 births per day.  The average number of deliveries per month is 220. In addition to deliveries (vaginal and cesarean) performed on L&D.   Outpatient procedures are completed daily, including triage visits, non-stress tests, biophysical profiles, PUBS, cerclage placements, and amniocentesis.  There are approximately ~4000 Triage visits to L&D annually. The average triage length of stay varies widely, ranging from 2 hours to 12 hours, depending on the needs of the patient.

Equipment on this unit is provided for the purpose of maintaining mother and baby in a safe environment with consideration for pain management, performing diagnostic and therapeutic procedures, and facilitating the birth process.

Each bedside has the capability for Electronic Fetal Monitoring.  In each labor room, cabled and wireless fetal monitors allow tracings to appear on a centralized surveillance screen in both the Nurses Station, Nursing Lounge, & Resident Staff Lounges.  A fetal monitor is available in the South Tower ED for patients unable to transfer to L&D immediately for care.  This mobile fetal monitor can be centrally monitored in L&D. Two other mobile units are available for patients admitted to other services that require an L&D RN at the bedside for continuous monitoring.

Description of Patient Population

Women of childbearing age who are 20 weeks or greater in gestation with actual or potential pregnancy-related problems are evaluated and/or treated on this unit. Vital signs and /or EKG monitors are present at each bedside for gravid patients. Anesthesiologists are available 24 hours a day, 7 days a week. Electronic pumps, separate and distinct from medication pumps, are provided for controlled administration of epidural medications. The Anesthesia Department in conjunction with the hospital maintains all standard equipment required in the 3 Operating Rooms. Neonates, if stable, remain skin to skin with their mothers from birth to two hours of age; or until transfer to the Mother-Baby Unit or NICU based on the medical needs of the baby. Efforts to provide a family-centered birth experience in a safe environment are promoted.  As a tertiary care center, staff are focused on prevention of primary and secondary complications through the prompt detection of emergent conditions.  When perinatal death is inevitable, the patient and her family receive compassionate, supportive care. Every effort is made to maintain this patient on the 3rd floor until discharge, unless medically contraindicated.

Patients are admitted and seen in Labor and Delivery on a 24/7 basis. There is a Chief Resident as well as an Attending Obstetrician available in house to supervise and assist with the care provided by the OB resident staff.  The provider team also includes 2 fulltime midwifes. Patient care assignments are principle-based and designed to accommodate the dynamic nature of caring for women during labor and birth. The assignments are based on AWHONN Staffing Guidelines and include evaluation of the census, acuity, anticipated workload, and experience level of those on duty. Due to the unpredictable and rapid changes in census and workload in Labor and Delivery staffing needs are assessed throughout the shift and a minimum number of staff are present to manage emergent care for both the mother and fetus.  Voluntary on-call shifts are posted in the electronic scheduling program to help meet census requirements.

Nursing Care

Registered Nurses in the Labor and Delivery unit meet the basic requirements for registered nurse staff in accordance with the unit-based job descriptions, as described in the Hospital Plan for Nursing Care. Additional requirements for the RN include completing a neonatal resuscitation course (NRP), American Heart Association Basic Life Support certification or annual adult CPR check off in the Nursing Education Department, Fetal Monitoring, Breast Feeding Education, and OB simulation training. Ongoing competency requirements for the Labor and Delivery staff include: circulating for OR cases, PACU skills, triage, scrub nurse skills, and fetal monitoring. Responsibilities of the Labor and Delivery nurse include the initial evaluation and admission of patients in labor; continuing assessment and evaluation of patients in labor, including continuous assessment of the fetus, recording vital signs, observing the fetal heart rate, observing uterine contractions, supporting the patient; and supervising the performance of nurses with less training and expertise. The nurses are skilled in the recognition and nursing management of complications of labor and delivery. L&D nurses are expected to provide support, guidance, direction, and education related to childbirth to the patient, family, and coaches throughout the labor process.

The Clinical Leader coordinates the orientation of the L&D staff. The orientation is accomplished with the support of the Nurse Manager, and staff nurses who serve as Preceptors. The Nursing Assistants, OB Surgical Tech, and Support Techs meet the basic requirements of their positions and function in accordance with their unit-based job description, as described in the Hospital Plan for Nursing Care.

A positive attitude toward family centered care and patient satisfaction is a focus of the Perinatal Care Team. The ability, willingness, and interest in working with the age appropriate needs of all patients are additional requirements for all who work on the Labor and Delivery Unit.

Health Care Team

The medical director of the Labor and Delivery Unit is an Obstetrician who is also board certified in Maternal-Fetal Medicine (MFM). The faculty and residents provide 24-hour medical care to the obstetric patient 7 days a week. MFM consult is available 24/7. The newborn patient is managed collaboratively with the Pediatrician and Neonatologist responsible for the Newborn Nursery and Neonatal Intensive Care Unit respectively. Multidisciplinary, comprehensive care is provided to the mothers and babies in Labor and Delivery by medicine, nursing, social work, and other services as indicated by the patients’ health status and identified needs. Support techs, nursing assistants, and obstetric surgical techs provide support for the patient. Nursing students and EMS Students, who are assigned to the unit, are under the direct supervision of their College Instructor.

Nursing management for the unit is comprised of a Nurse Manager and one Clinical Leader who have 24-hour accountability for unit operations and outcomes focused patient care. The Clinical Leader (CL) also provides clinical expertise and support to the staff; and an associate vice president of nursing provides administrative assistance. Hospital Nursing Coordinators provide additional administrative support on the evening, night, and weekend shifts.

The Nursing Leaders on the unit promote and foster autonomous, accountable nursing practice. Registered Nurses are encouraged to solve problems independently and exercise critical thinking while carrying out individual patient care assignments. The Nursing Staff in Labor and Delivery provide care using a Total Patient Care model; direct care providers in L&D are all RNs.

Staffing Plan

A charge nurse is assigned to provide leadership to each shift. Charge nurses are responsible for making patient assignments based on AWHONN Staffing Guidelines, needs of the patient, and the skill level of the nurse. The charge nurse is also responsible for anticipating staffing needs for the current shift and the following shift. The charge nurse is responsible for using the guidelines developed for flexible staffing to help meet the goal of providing cost efficient, safe, and effective patient care.

During cesarean birth, one nurse is assigned to the patient, as the circulating nurse, and a second nurse is assigned to the newborn.  An OB Surgical Technician or trained RN is available to scrub in and assist the surgeons during delivery. Hospital staffing guidelines for post anesthetic care are followed in labor & delivery.  Two staff nurses are assigned to the recovery room during Phase 1 care and generally during Phase 2 care if a newborn is present. The nurses in Labor and Delivery provide consultation, and support, as needed for obstetric patients on off-service units.

Unit FTE allows for flexible staffing during routine scheduled and emergent events. Additional staffing needs are met on L&D as described in the Hospital Plan for Nursing Care.

Charge nurses can accomplish flexing down by:

  • canceling extra or overtime shifts
  • floating staff to another unit within the hospital
  • converting staff to on-call basis
  • granting STOG – Refer to Utilization of Staff in Time of Low Census Policy

If additional staff are needed, the charge nurse may accomplish this by:

  • bringing in the on-call person (if that shift is designated for on-call)
  • requesting assistance from Central Staffing
  • receiving RN float from another unit in the hospital
  • calling in staff from off-duty, trying part-time staff first
  • negotiating with staff to work extra for overtime or in exchange for another shift off
  • maximizing assignments
  • mandatory extra shifts/overtime

The Labor and Delivery Unit will consider the use of mandatory extra shifts/overtime when voluntary coverage has been exhausted. This may occur during periods of high census, high patient acuity, decreased experience level of staff members, when the number of open positions becomes an issue, or individuals are on Paid Time Off, Short-Term Disability, or Long-Term Disability. Each variable is key in the assessment to institute mandatory extra/overtime on a unit or departmental level.  Only the Nurse Manager or her designee can implement mandatory overtime.

The staffing committee will initially review requests for Paid Time Off.  PTO is granted based on unit guidelines and the staffing needs of the unit. The Nurse Manager or designee approves the final schedule, in accordance to the Hospital Plan for Nursing Care.

Staff attendance at meetings, educational offerings, and other activities are coordinated so that the patient care coverage is continuous, as reflected on the shift assignment sheets.

In the event of an emergency such as severe weather conditions or other disasters, the unit follows the hospital disaster plan for staffing (A/B teams).

35 Antepartum

The Antepartum Unit (35AP) is a 12 bed inpatient unit (3500) on the third floor of the Patient Services Building of the North Tower. One of the beds is a negative pressure isolation room for patients requiring respiratory isolation.   The unit is adjacent to Labor and Delivery (3400), and Neonatal Intensive Care Unit (3300). Patients admitted to 35AP are both medical-surgical and intermediate care IMC) level.

Description of Patient Population

Women of childbearing age who require hospitalization during their pregnancy are admitted to 35AP. Postpartum patients who have experienced a fetal or perinatal loss are also admitted to this unit. Every room is equipped with a fetal monitor to provide continuous or intermittent fetal monitoring, as ordered by the provider. Patients who require care greater than IMC level will be managed by L&D or ICU as appropriate.

Nursing Care

Registered Nurses in the Antepartum unit meet the basic requirements for registered nurse staff in accordance with the unit-based job descriptions, as described in the Hospital Plan for Nursing Care. Additional requirements for the RN include completing a neonatal resuscitation course (NRP), American Heart Association Basic Life Support certification or annual adult CPR check off in the Nursing Education Department, Fetal Monitoring, Breast Feeding Education, and OB simulation training. Ongoing competency requirements for the Antepartum staff include: fetal monitoring. Responsibilities of the Antepartum nurse include the initial evaluation and admission of patients, continuing assessment and evaluation of these patients, including continuous assessment of the fetus, recording vital signs, observing the fetal heart rate, observing for status changes, and supervising the performance of nurses with less training and expertise. The nurses are skilled in the recognition and nursing management of complications of the obstetric patient.

The Clinical Leader coordinates the orientation of the Antepartum staff. The orientation is accomplished with the support of the Nurse Manager, and staff nurses who serve as Preceptors. The Support Techs meet the basic requirements of their positions and function in accordance with their unit-based job description, as described in the Hospital Plan for Nursing Care.

A positive attitude toward family centered care and patient satisfaction is a focus of the Perinatal Care Team. The ability, willingness, and interest in working with the age appropriate needs of all patients are additional requirements for all who work on the Antepartum Unit.

Health Care Team

The medical director of the Antepartum Service is an Obstetrician who is also board certified in Maternal-Fetal Medicine (MFM). The faculty and residents provide 24-hour medical care to the obstetric patient 7 days a week. Multidisciplinary, comprehensive care is provided to the patients on 35AP by medicine, nursing, social work, and other services as indicated by the patients’ health status and identified needs. Nursing students, who are assigned to the unit are under the direct supervision of their College Instructor.

Nursing management for the unit is comprised of a Nurse Manager and one Clinical Leader who have 24-hour accountability for unit operations and outcomes focused patient care. The Clinical Leader (CL) also provides clinical expertise and support to the staff; and an associate vice president of nursing provides administrative assistance. Hospital Nursing Coordinators provide additional administrative support on the evening, night, and weekend shifts.

The Nursing Leaders on the unit promote and foster autonomous, accountable nursing practice. Registered Nurses are encouraged to solve problems independently and exercise critical thinking while carrying out individual patient care assignments. The nursing staff on 35AP provide care using a Total Patient Care model; direct care providers in 35AP are all RNs.

Staffing Plan

The charge nurse for L&D provides leadership to 35AP. Charge nurses are responsible for making patient assignments based on the needs of the patient and the skill level of the nurse. Continuous fetal monitoring is considered intermediate care (IMC) level, and factored into the staff assignments. The charge nurse is responsible for anticipating staffing needs for the current shift and the following shift. The charge nurse is responsible for using the guidelines developed for flexible staffing to help meet the goal of providing cost efficient, safe, and effective patient care.

Charge nurses can accomplish flexing down by:

  • canceling extra or overtime shifts
  • floating staff to another unit within the hospital
  • granting STOG – Refer to Utilization of Staff in Time of Low Census Policy

If additional staff are needed, the charge nurse may accomplish this by:

  • requesting assistance from Central Staffing
  • floating staff from L&D to 35AP
  • calling in staff from off-duty, trying part-time staff first
  • negotiating with staff to work extra for overtime or in exchange for another shift off
  • maximizing assignments

The staffing committee will initially review requests for Paid Time Off.  PTO is granted based on unit guidelines and the staffing needs of the unit. The Nurse Manager or designee approves the final schedule, in accordance to the Hospital Plan for Nursing Care.

Staff attendance at meetings, educational offerings, and other activities are coordinated so that the patient care coverage is continuous, as reflected on the shift assignment sheets.

In the event of an emergency such as severe weather conditions or other disasters, the unit follows the hospital disaster plan for staffing (A/B teams).

Revised January 2021