Labor and Delivery Nursing, Second

Edition: A Guide to Evidence-Based

Practice Michelle Murray (Editor)
Visit to download the full and correct content document:
https://ebookmeta.com/product/labor-and-delivery-nursing-second-edition-a-guide-to-
evidence-based-practice-michelle-murray-editor/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Introduction to Nursing Research: Incorporating

Evidence-Based Practice 6th Edition Carol Boswell

https://ebookmeta.com/product/introduction-to-nursing-research-
incorporating-evidence-based-practice-6th-edition-carol-boswell/

Brown's Evidence-Based Nursing: The Research-Practice

Connection, 5th Edition Emily Nowak

https://ebookmeta.com/product/browns-evidence-based-nursing-the-
research-practice-connection-5th-edition-emily-nowak/

Statistics for Nursing Research A Workbook for

Evidence-Based Practice 3rd Edition Susan K. Grove

https://ebookmeta.com/product/statistics-for-nursing-research-a-
workbook-for-evidence-based-practice-3rd-edition-susan-k-grove/

Guide to Evidence Based Physical Therapist Practice 5th

Edition Dianne V. Jewell

https://ebookmeta.com/product/guide-to-evidence-based-physical-
therapist-practice-5th-edition-dianne-v-jewell/
Evidence Based Practice of Cognitive Behavioral Therapy
Second Edition Deborah Dobson

https://ebookmeta.com/product/evidence-based-practice-of-
cognitive-behavioral-therapy-second-edition-deborah-dobson/

Gynecologic Oncology Handbook An Evidence Based

Clinical Guide 3rd Edition Michelle Benoit Md

https://ebookmeta.com/product/gynecologic-oncology-handbook-an-
evidence-based-clinical-guide-3rd-edition-michelle-benoit-md/

Nursing Diagnosis Handbook: An Evidence-Based Guide to

Planning Care 11th Edition Betty J. Ackley

https://ebookmeta.com/product/nursing-diagnosis-handbook-an-
evidence-based-guide-to-planning-care-11th-edition-betty-j-
ackley/

Making Sense of Evidence-based Practice for Nursing: An

Introduction to Quantitative and Qualitative Research
and Systematic Reviews 1st Edition Debra Evans

https://ebookmeta.com/product/making-sense-of-evidence-based-
practice-for-nursing-an-introduction-to-quantitative-and-
qualitative-research-and-systematic-reviews-1st-edition-debra-
evans/

Orthopaedic and Trauma Nursing: An Evidence-based

Approach to Musculoskeletal Care, 2nd Edition Sonya
Clarke

https://ebookmeta.com/product/orthopaedic-and-trauma-nursing-an-
evidence-based-approach-to-musculoskeletal-care-2nd-edition-
sonya-clarke/
Michelle L. Murray
Gayle M. Huelsmann

LABORand
DELIVERY
NURSING
A Guide to Evidence-Based Practice

Second Edition
 Register Now for Online Access to
Your Book!

Your print purchase of Labor and Delivery Nursing, Second Edition includes
online access to the contents of your book—increasing accessibility, portability, and
searchability!
Access today at:
http://connect.springerpub.com/content/book/978-0-8261-8476-4
or scan the QR code at the right with your smartphone
and enter the access code below.

FBN5U2BJ

If you are experiencing problems accessing the digital component of this product, please contact our
customer service department at cs@springerpub.com Scan here for
The online access with your print purchase is available at the publisher’s discretion and may be
quick access.
removed at any time without notice.
Publisher’s Note: New and used products purchased from third-party sellers are not guaranteed for
quality, authenticity, or access to any included digital components.

SPC

View all our products at springerpub.com

Michelle L. Murray, PhD, RNC-OB, is an international educator, author, journal editor, and expert in obstetric
nursing. She has taught nursing students and nurses in the United States, Canada, and Bahrain. Dr. Murray
has spent the majority of her career as a labor and delivery nurse and as an educator of nursing students and
practicing labor and delivery nurses, certified nurse midwives, family medicine physicians, and obstetricians. She
is a recognized obstetric nursing expert.
Dr. Murray’s company, Learning Resources International, Inc., produces clinical and continuing education
products for labor and delivery nurses. Her work has been published in journals such as the International Journal
of Childbirth as the editor in chief; Birth: Issues in Perinatal Care; The American Journal of Maternal Child Nurs-
ing (MCN); Journal of Perinatology; Journal of Nursing Care Quality; and Journal of Obstetric, Gynecologic,
and Neonatal Nursing (JOGNN). Dr. Murray was also a contributor to the Association of Women’s Health,
Obstetric and Neonatal Nurses (AWHONN) publication, Nursing Management of the Second Stage of Labor.
Her best-selling books include Antepartal and Intrapartal Fetal Monitoring (Third Edition) and Essentials of
Fetal and Uterine Monitoring (Fifth Edition). Her books and products are available at www.fetalmonitoring.com
or directly from Springer Publishing Company.
Dr. Murray has been an active member and officer of the AWHONN as well as the American Nurses Asso-
ciation’s New Mexico Nurses Association. She is an award winner in education from AWHONN (formerly the
Nurses Association of the American College of Obstetricians and Gynecologists), and from the nursing honor
society, Sigma Theta Tau.

Gayle M. Huelsmann, BSN, RNC-OB, C-EFM, is certified in inpatient obstetrics and holds a certificate of added
qualification in electronic fetal monitoring from the National Certification Corporation in Chicago, Illinois. She
has been an antepartal nurse and a labor and delivery staff nurse for 35 years. During her 21 years as a maternal
air transport nurse with fixed wing and rotor wing aircraft, she was awarded the PRIDE nurse distinction from
Presbyterian Hospital for her exemplary contribution to patient care. Ms. Huelsmann has published on a variety
of topics related to labor and delivery nursing and is the coauthor of Essentials of Fetal and Uterine Monitoring
(Fifth Edition) and the monograph on Uterine Hyperstimulation: Physiologic and Pharmacologic Causes With
Results From a Survey of 1000 Nurses with Dr. Michelle L. Murray. Ms. Huelsmann is an experienced Lean Six
Sigma Green Belt for quality and performance improvement projects in healthcare organizations.
Labor and Delivery Nursing
A Guide to Evidence-Based Practice

Second Edition

Michelle L. Murray, PhD, RNC-OB

Gayle M. Huelsmann, BSN, RNC-OB, C-EFM
Copyright © 2021 Springer Publishing Company, LLC

All rights reserved.

First Springer Publishing Company edition 2008

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company,
LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood
Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, info@copyright.com or on the Web at www.copyright.com.

Springer Publishing Company, LLC

11 West 42nd Street, New York, NY 10036
www.springerpub.com
connect.springerpub.com/

Acquisitions Editor: Elizabeth Nieginski

Compositor: S4Carlisle Publishing Services

ISBN: 978-0-8261-8475-7
ebook ISBN: 978-0-8261-8476-4
DOI: 10.1891/9780826184764

20 21 22 23 / 5 4 3 2 1

The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information
that is accurate and compatible with the standards generally accepted at the time of publication. Because medical science is
continually advancing, our knowledge base continues to expand. Therefore, as new information becomes available, changes
in procedures become necessary. We recommend that the reader always consult current research and specific institutional
policies before performing any clinical procedure or delivering any medication. The author and publisher shall not be liable
for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the
information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external
or third-party Internet websites referred to in this publication and does not guarantee that any content on such websites is,
or will remain, accurate or appropriate.

Library of Congress Cataloging-in-Publication Data

Names: Murray, Michelle (Michelle L.), author. | Huelsmann, Gayle, author.

Title: Labor and delivery nursing : a guide to evidence-based practice /
Michelle L. Murray, Gayle M. Huelsmann.
Description: Second edition. | New York : Springer Publishing Company,
[2021] | Includes bibliographical references and index.
Identifiers: LCCN 2020018446 (print) | LCCN 2020018447 (ebook) | ISBN
9780826184757 (paperback) | ISBN 9780826184764 (ebook)
Subjects: MESH: Obstetric Nursing--methods | Delivery, Obstetric--nursing |
Evidence-Based Nursing | Labor, Obstetric
Classification: LCC RG951 (print) | LCC RG951 (ebook) | NLM WY 157 | DDC
618.2/0231--dc23
LC record available at https://lccn.loc.gov/2020018446
LC ebook record available at https://lccn.loc.gov/2020018447

Contact us to receive discount rates on bulk purchases.

We can also customize our books to meet your needs.
For more information please contact: sales@springerpub.com

Publisher’s Note: New and used products purchased from third-party sellers are not guaranteed for quality, authenticity, or
access to any included digital components.

Printed in the United States of America.

Knowledge comes from learning.
Wisdom comes from experience.

—Anonymous
Disclaimer
This book is not intended to replace your hospital’s
policies, procedures, guidelines, or protocols. It is not
intended to dictate a standard of care. We recom-
mend that the reader always consult current research
and specific institutional policies before performing
any clinical procedure. This book is intended for use
during the process of orientation of nurses in the la-
bor and delivery setting, and to bring experienced
nurses up to date with regard to current practice and
research findings. It can also be used as a reference or
as a study guide by nurses preparing to take a certifi-
cation examination in the field of inpatient obstetrics
or labor and delivery.
This book does not include directions for equip-
ment use or specific tests. These must be learned in
the hospital setting, preferably with a mastery-based
skills checklist. In addition, care should be individual-
ized to the patient.
True/false questions appear at the end of each
chapter as a complement to the learning process.
Each chapter contains the information necessary to
answer the questions.
The content of this book was based on the best
available research at the time it was written. Some
studies may appear dated and may have been the
only study on the subject that was readily avail-
able at the time of this publication. Every attempt
was made to provide current information that is
evidence-based.
Neither the author nor the publisher shall be liable
for any special, consequential, or exemplary damages
resulting, in whole or in part, from the readers’ use of,
or reliance on, the information contained in this book.
The publisher has no responsibility for the persistence
or accuracy of URLs for any external or third-party
Internet websites referred to in this publication and
does not guarantee that any content on such websites
is, or will remain, accurate or appropriate.
Contents

Preface ix 8. Presentation, Position, and Station 225

Acknowledgments xiii
9. Powers: Force and Physiology 243
1. Advocacy, Communication, Chain of
Command, and Evidence-Based Practice 1 10. Psyche During Pregnancy, Childbirth, and
Postpartum 275
2. Assessment to Create an Individualized Plan
of Care and Informed Consent 25 Appendix A: Abbreviations 301
Appendix B: Abbreviations to Avoid in
3. Labor and Birth 65 Documentation 309
4. Pain, Pain Reduction, and Evidence-Based Appendix C: Hospital Labor and Delivery
Practice 115 Orientation Fundamentals 311
Appendix D: Orientation Checklist 315
5. Positions for Labor and Birth 147
Appendix E: Orientation Log Chart 321
6. The Passageway, Passenger, Placenta, Glossary 325
and the Umbilical Cord 161
Index 335
7. Passenger–Passageway Problems 199
Preface
The interests of the patient are the only interests to
be considered.
—William Mayo
Learning about labor and birth requires effort.
Reading books such as this one is one way to learn
evidence-based concepts. In addition, learning about
childbearing care practices that will keep patients safe
and optimize outcomes can also occur from decades of
experience prior to confirmation by research. Nurses
with decades of experience know, for example, that
the chain of command involves communication that
can take many forms. For example, notifying a nurs-
ing leader of your patient’s vital sign abnormalities
is a form of the chain of command. When the nurs-
ing leader comes to the bedside to confirm that and
any other abnormalities and assists the primary nurse
in formulating a plan of care to optimize maternal
and fetal outcomes, that is also part of the chain of
command.
To be an effective care provider, nurses must have
courage, confidence, and competence. They must
communicate with the patient, nursing leadership,
and the obstetric care providers. In some cases, there
may be barriers to their patient advocacy. That is why
the courage to speak up and base care on evidence-
based concepts, including physiology, is critical to pa-
tient safety.
All healthcare providers need to be aware of their
cognitive biases and keep an open mind and an ac-
cepting attitude. They need hands-on skills and a
broad and deep understanding of the research related
to pregnancy, labor, and birth. That means they are
lifelong learners and their work environment allows
them to provide evidence-based practice (Scott-Find-
lay, 2007).
The best care will be evidence based and result in
good outcomes. Therefore, the goal of this book is
to provide you with the information to develop an
evidence-based practice of labor and delivery nursing.
Labor and delivery nursing requires critical thinking,
constant caring, listening to your inner voice, anticipa-
tion of the needs of many, teamwork, communication,
and collaboration (see Box 1). Translators are often
family members or friends who speak the language
of the childbearing woman. They are not certified in-
terpreters. It is also important to listen to significant
others who accompany the childbearing woman and
may have important information to share.
Proper surveillance and care of the fetus and
mother during labor and delivery depend on compre-
hensive data acquisition, attention to detail, adequate
knowledge to properly understand and interpret the
meaning of data, verbal and nonverbal cues, and
teamwork. This book was created with these elements
in mind. Figure 1 illustrates the nursing process from
admission to delivery. If possible, review the patient’s
prenatal record before she arrives.
BOX 1 Some characteristics of a critical thinker
1. States the question or concern clearly
2. Creates order in complex situations
3. Diligently seeks relevant information
4. Focuses on the concern at hand
5. Persists until results are obtained in spite of
difficulties
6. Is inquisitive, well-informed, open-minded, and
flexible
7. Acknowledges personal biases
8. Bases judgments on analysis of data (clinical
decision-making)
9. Is willing to reconsider
10. Is clear regarding the issues
x ■ PREFACE

Labor and delivery nurses provide patient-cen-
tered individualized care. Care is both “high tech”
and “high touch” and can occur in settings such as
a family birthing center with labor-delivery-recovery-
postpartum rooms, a labor-delivery-recovery room,
or simply a labor room. It can occur in a large room
with stretchers or beds separated by a curtain or even
in one large room with multiple laboring women on
mats on the floor.
Labor and delivery nurses are masters of anticipa-
tion, supporters of natural childbirth, and monitors
of safety practices because they are the first line of
defense in preventing injury. They must understand
maternal and fetal physiology, know the purpose and
physiologic impact of their actions, and be able to
evaluate their patients’ responses to those actions.
In addition, effective intrapartal nurses are fearless
when advocating for their patients.
Modern obstetrics requires both high-touch and
high-tech skills. “High-touch” care can be thought of
as “labor support,” empathy, and use of touch. Labor
support may play a part in shortening a woman’s la-
bor, decreasing her use of analgesia and anesthesia,
labor augmentation, possibly decreasing the need for
an operative vaginal delivery or a cesarean delivery,
and increasing satisfaction with the birthing experi-
ence. Labor and delivery nursing or intrapartal nurs-
ing is part of the culture of obstetrics and this culture
has its own myths, taboos, artifacts, and traditions.
Nurses need the knowledge and skills to properly
use different types of machines and equipment. For
example, the high-tech aspect of labor and delivery in-
cludes tests to confirm the rupture of membranes; the
use of the electronic fetal monitor and its components
(such as a spiral electrode); insertion of an IV cath-
eter and administration of IV fluids, blood, or blood

CREATION OF DATABASE Prenatal Record

♦ Collect Data From Patient

♦ Physical Assessment of Family Members

Mother, Vital Signs, and
Fetal Assessment
Translator

Communicate with CNM

and/or Physician

Develop Plan of Care

that is Patient-Centered

Assess and Collect Data, for example, maternal

status, labor progress, fetal tolerance

Intervene PRN

Communicate with CNM Evaluate Maternal and/or

and/or Physician Fetal Response

Modify Plan of Care

Delivery

Spontaneous Cesarean
Vaginal Delivery Section
Operative
Vaginal Delivery

FIGURE 1 The nursing process from admission until delivery. Documentation should reflect each
step of this process.
CNM, certified nurse midwife; PRN, as needed.

products; use of suction and oxygen equipment; and
procedures such as amnioinfusion. This book is not
intended to be a procedure or equipment manual, nor
was it designed to replace hands-on bedside training.
Instead, it is our hope that the information gained
from reading this book will help labor and delivery
nurses make wise decisions in their choices of inter-
ventions, in the creation of patient-centered plans of
care, and in their communications with other mem-
bers of the obstetrics team.
For those beginning their career as a labor and de-
livery nurse, Ray Spooner, RN, BSN, an experienced
labor and delivery nurse, has suggested, “Be yourself.
Especially, do not feign knowledge. It is better to ask
a stupid question than to make a stupid mistake”
(Spooner, 1995).
In addition to this book, we hope nurses becoming
oriented to the practice of labor and delivery nurs-
ing will read the philosophy, policies, procedures, and
protocols of their facility. We encourage new nurses
to ask for guidance, information, and demonstrations
of procedures when they need help. We also encour-
age open communication with patients and other
healthcare providers. Often the patients are the only
ones who have the answers to your questions.
Benjamin Franklin once said, “The best investment
is in the tools of one’s own trade.” Intrapartal nurses
need to own equipment that aids them in their patient
care (see Box 2). It is helpful to have a fetoscope in
your locker, especially for those times when a patient
refuses the fetal monitor or there is a power failure.
As your career develops, you may find other tools that
enhance your ability to meet your patient’s needs.
PREFACE ■ xi
BOX 2 Some “tools” of the labor and delivery nurse
1. Stethoscope
2. Reflex hammer
3. Two hemostats
4. Bandage scissors
5. Pen light
6. Gestational wheel
7. Measuring tape
Our combined nursing experience totals more than
50 years. The majority of our clinical time has been
spent in labor and delivery settings. We hope that our
experience and education as intrapartal nurses and
educators will be transmitted to you in this book and
that it will provide you with the information you need
to make informed decisions and provide evidence-
based care.
Michelle L. Murray, PhD, RNC-OB
Gayle M. Huelsmann, BSN, RNC-OB, C-EFM
REFERENCES
Scott-Findlay, S. (2007). Fostering evidence-
based practice: Strategies for nurse leaders.
Nursing for Women’s Health, 11(3), 250–252.
doi:10.1111/j.1751-486x.2007.00155.x
Spooner, R. (1995). Gentle reminder. American
Journal of Maternal Child/Nursing, 20, 166.
doi:10.1097/00005721-199505000-00018
Acknowledgments

We were helped in writing this book about concepts Garla DeWall, MSN, RNC-OB
that are core to the nurses who work in a labor and Manager, Patient Experience
delivery setting. Our reviewers are thoughtful nurses Presbyterian Hospital
who dedicated their work to the safe care of women Albuquerque, New Mexico
during the childbirth process. Each of these review-
ers provided feedback on chapters in this book’s first Becky Dunham, RNC-OB
edition or second edition. They are listed below in al- Staff Nurse, Labor and Delivery
phabetical order: Dublin Methodist Hospital
Dublin, Ohio
Jennifer L. Atkisson, RNC-OB, MSN
Clinical Nurse Leader and Clinical Educator Donna McAfee Frye, RN, MN
Women and Children’s; Providence Clinical Director
Willamette Falls Medical Center Women’s and Children’s Clinical Services
Oregon City, Oregon Nashville, Tennessee

Susan Mocsny Baker, RNC-OB Hannah Furie, RN, BSN

Staff Nurse Care Manager
University of Massachusetts Memorial Albuquerque, New Mexico
Medical Center
Worcester, Massachusetts Aurora Gumamit, RN, MSN, CNS
Charge Nurse, Labor and Delivery
Darcie Beckwith, RNC-OB, MSN Corona Regional Medical Center
Clinical Practice Specialist Corona, California
The Birthing Inn
Inova Loudoun Hospital Julie Holden, RN, BSN, MA
Leesburg, Virginia Nurse Manager
Beverly Hospital
Lynne Brengman, RNC-OB, BSN, MBA Beverly, Massachusetts
Education Department
PeaceHealth St. Joseph Hospital Theresa Hyland, RNC-OB
Bellingham, Washington Yale New Haven Hospital
New Haven, Connecticut
Cindy Curtis, RNC-OB, IBCLC, CCE
Staff Nurse and Director of the Lactation Wanda Jeavons, RNC-OB, MSN, PNNP
Center Perinatal Outreach Coordinator
Culpeper Regional Hospital Andrews Women’s Hospital
Family Birth Center Baylor All Saints Medical Center
Culpeper, Virginia Fort Worth, Texas
xiv ■ ACKNOWLEDGMENTS
Suzanne Ketchem, RNC-OB, CNS, MSN
Senior Director, Women and Children’s
Service Line
Poudre Valley Hospital - Medical Center of
the Rockies
Fort Collins, Colorado
Reta M. King, RNC-OB, BSN
Staff Nurse, Labor and Delivery
University of New Mexico Medical Center
Albuquerque, New Mexico
Nanci Koperski, RNC-OB, LNCC, MBA,
MHSA
Legal Nurse Consultant
Phoenix, Arizona
Alexandra Sam Lee, RN, BSN
Trilingual nursing professional
Mills-Peninsula Health Services Family Birth
Center
Burlingame, California
Michelle McEwen-Campbell, RNC-OB,
DNP, FNP, LNC, CNE
Lecturer
School of Nursing
University of North Carolina Wilmington
Wilmington, North Carolina
Debra Mills, RN, CNS, BSN, MSN
Clinical Nurse Specialist, Family Birth
Center
Methodist Hospital
Sacramento, California
Jeanne M. Mitchell, RNC-OB, CCE, BSN
OB Nurse Director and Director of
Education
AMITA Health Adventist Glen Oaks
Hospital
Glendale Heights, Illinois
Angela Murphy, RNC-OB
Charge Nurse, Family Birthing Center
Presbyterian Hospital
Albuquerque, New Mexico
Sarah Patel, RN, C-EFM, MSN
Undergraduate Student Success Coordinator
and Lecturer
University of New Mexico College of
Nursing
Albuquerque, New Mexico
Nancy Powell, RNC-OB, PhD, MSN, CNM
Director of Professional Development
AtlantiCare Regional Medical Center
Pomona, New Jersey
Linda M. Shinn, RNC-OB, MAS, BSN,
C-EFM
Adjunct Clinical Faculty, School of Nursing
California State University San Marcos
San Marcos, California
Wendy Sinanan, RN
Former Staff Nurse and Charge Nurse,
Labor and Delivery
Mt. Sinai Hospital
Toronto, Ontario, Canada
Ann Weed, RNC-OB, CNS, MSN
Clinical Nurse Specialist
Mary Washington Hospital
Fredericksburg, Virginia
Diana Wigham, RNC-OB, MSN
Staff Nurse, Labor and Delivery
Saint Francis Medical Center
Hartford, Connecticut
 1
C H A P T E R
Advocacy, Communication,
Chain of Command, and
Evidence-Based Practice
A positive childbirth experience fulfills or exceeds a woman’s prior personal and
sociocultural beliefs and expectations, including giving birth to a healthy baby in
a clinically and psychologically safe environment with continuity of practical and
emotional support from a birth companion(s) and kind, technically competent
clinical staff.
—World Health Organization (2018),
Intrapartum Care for a Positive Childbirth Experience

INTRODUCTION To maximize safety and reduce the possibility of

A safe childbirth is a physiologic process that is ac-
complished without complications (World Health
Organization [WHO], 2018). Safety requires nurs-
ing advocacy, communication, appropriate use of
the chain of command, and evidence-based practice
(EBP). However, optimal health and well-being are
not guaranteed if care providers fail to advocate for
patient safety, fail to communicate with the interdis-
ciplinary team, and fail to invoke the chain of com-
mand when it is needed to optimize maternal and
fetal health. The lack of competence, adequate staff-
ing, and an organizational culture that does not em-
brace safety creates a safety hazard and increases the
risk of adverse outcomes.
A nurse, physician, or midwife who is simply in and
out of the patient’s room and who briefly reviews a short
part of the fetal/uterine monitor tracing or performs a
cervical examination and leaves or who is not fully in-
formed of risks, facts, and changes in the maternal and
fetal status creates a safety hazard that increases the
risk of adverse outcomes. They will lack a full data set
upon which to make clinical decisions. An uninformed
care provider cannot provide informed consent. Orga-
nizational cultures and care systems will need to change
to ensure patient safety and minimize errors (Curtin,
2019; Moeller, Westrate, & Araujo, 2019).
an adverse outcome, obstetricians need to be present
in the hospital during their assigned duty times. They
need to analyze the labor curve throughout that time.
The presence of an obstetrician, continuous analysis
of the labor curve, creation of an individualized plan
of care, interdisciplinary collaboration and educa-
tion, and timely and appropriate actions decreases the
incidence of neonatal hypoxic-ischemic encephalopa-
thy (HIE) and death (Tolcher et al., 2016). Competent
nurses should also be able to analyze the labor curve
in the absence of an obstetrician (Figures 1.1 and 1.2).
These competent nurses will individualize the plan of
care and inform the obstetric care provider of threats
to maternal and fetal safety so that interventions are
customized to prevent adverse outcomes.
■ EVIDENCE-BASED PRACTICE
EBP is essential to maximize safety and minimize
adverse outcomes. EBP needs to be efficient and eq-
uitable. Efficient care means waste is avoided when
one uses equipment, supplies, ideas, or energy during
a treatment or procedure. Equitable care means that
the care you provide does not vary in quality because
of the patient’s gender, ethnicity, country of origin,
or socioeconomic status. Evidence-based care means
2 ■ LABOR AND DELIVERY NURSING

FIGURE 1.1 Example of two partographs or labor curves based on dilatation of the cervix. As can be seen,
the top plot is of a multiparous (multigravida) woman and the bottom plot is of a nulliparous primigravida
woman.

FIGURE 1.2 Labor curve of a nulliparous primigravida woman who was not overweight (bottom line) and
labor curve of an obese (300 pounds; 136.1 kg) nulliparous primigravida woman (top dotted line). Note the
different dilatation at the onset of the active phase of labor. Also, note the presence of a deceleration phase
that lasted more than 2 hours (protraction disorder) in the woman who was obese.

nurses will have knowledge of credible research find- process. Evidence-based care should be related to re-
ings and will base their practice on research evidence search findings that are related to improved outcomes.
to optimize maternal and fetal outcomes and to pro- For example, routine episiotomy was found to be no
mote a woman’s sense of safety during the childbirth longer advisable because it contributed to trauma,
 1. ADVOCACY, COMMUNICATION, CHAIN OF COMMAND, AND EVIDENCE-BASED PRACTICE
pain, and suffering (Eason & Feldman, 2000). How-
ever, that does not mean a provider cannot apply the
unique facts related to the patient. Episiotomy, when
needed, does allow faster delivery of the baby’s head
in some cases.
Childbirth safety also requires competent, unbi-
ased, compassionate, and vigilant care. Care should
be based on research evidence and provided by in-
dividuals and teams who have the interpersonal and
personal characteristics and skills to keep women and
their babies safe (Price & Archbold, 1995).
Physical and emotional safety during labor and
birth requires mindful care providers who lack bias
and who are not racist. They need to establish a con-
nection with their patients (Lyndon, Malana, Hedli,
Sherman, & Lee, 2018). They will understand the
values and wishes of their patients which is part of a
just and safe culture. When this occurs, the childbear-
ing woman will be fully informed and an equal part-
ner in a shared decision-making process if an ethical
decision-making model is adopted by the healthcare
system (Krick & Chabra, 2018).
Competent nurses will have technical skills and
will be able to provide continuous labor support, to
intermittently auscultate the fetal heart tones, and to
use different technology systems to collect data; they
will communicate, exchange and use data in a timely
manner; coordinate care; and improve patient safety
(Association of Women’s Health, Obstetric and Neo-
natal Nurses [AWHONN], 2018a, 2018b). Compe-
tent nurses will work to eliminate preventable harm
by engaging in critical thinking. Critical thinking is
a clinical judgment process that begins with obser-
vation (assessment), followed by reasoning based on
knowledge and experience, resulting in clinical judg-
ment. A competent nurse will then be able to fore-
see the impact of clinical decisions, prioritize patient
needs, communicate with other members of the inter-
professional team, and coordinate and document pa-
tient care to keep patients safe (Gelinas, 2019). They
will identify and interpret symptoms, plan care to al-
leviate complications, and optimize the childbearing
woman’s physical, psychological, and spiritual health.
They will do what it takes to keep their patients safe.
Competency of nurses requires specialized knowl-
edge and skills and ongoing education, training, test-
ing, and review of performance. Team training, with
nurses, midwives, and physicians, through simula-
tions and/or drills can impact competency develop-
ment and patient outcomes.
Nurses may not be able to provide competent,
evidence-based care if they are overworked and over-
whelmed. For example, it was found that the risk of
neonatal death was higher on the weekend possibly
due to lower hospital staffing and reduced availability
of service (Hamilton & Restrepo, 2003).
■ 3
Competent nurses will apply the best available
evidence from research to optimize maternal, fe-
tal, and newborn health. They will evaluate their
own practice behavior and recognize their impact
on outcomes (AWHONN, 2018b). They will ac-
cept accountability and responsibility for the qual-
ity of their practice. They will take ownership of
their actions as an individual and as a member of
a team. They will work within their nursing scope
of practice and will comply with standards and fol-
low evidence-based policies, procedures, and pro-
tocols (Sherman & Cohn, 2019). These nurses will
communicate information clearly and accurately
under leaders who maximize the activities of team
members by ensuring team actions are understood.
These leaders will ensure changes in information
are shared and necessary resources exist. They
will actively scan and assess situations and main-
tain awareness by monitoring situations. They will
anticipate and support team members through ac-
curate knowledge about their responsibilities and
workload (Agency for Healthcare Research and
Quality [AHRQ], 2013).
■ BIAS CREATES INEQUITIES
Bias can create inequities or unequal treatment
of childbearing women and result in more mater-
nal deaths or adverse perinatal outcomes (Howell
et al., 2018). A competent nurse will provide eq-
uitable care and equal treatment that promotes
nurturing, inclusion and tolerance, and eliminates
bigotry, bias, and discrimination (American Acad-
emy of Pediatrics [AAP], 2018). Everyone has
biases and therefore purposeful action is needed
to acknowledge and eliminate bias during patient
care. To eliminate bias, the nurse must recognize
and acknowledge what the bias is and be willing to
change (Cudé & Winfrey, 2007).
To keep patients safe, caregivers will demonstrate
a lack of racist ideology (Lowe, 2018). They will un-
derstand the role of race, ethnicity, language, poverty,
literacy, culture, and other social determinants of
health. They will work to build a culture of equity
within their organization. They will work to ensure a
timely and tailored response to patients’ needs, espe-
cially when inequity or disrespect by other caregivers
is observed. They will support shared decision-mak-
ing and autonomy of the childbearing woman’s
right to decide how they will be treated when it is
appropriate.
Nurses who provide evidence-based and safe care
will recognize that their own understanding, actions,
and decisions may be based on bias that is uncon-
scious. They may even need cognitive and behavioral
4 ■ LABOR AND DELIVERY NURSING
interventions to reduce bias. These interventions in-
clude mindfulness and individuation. Individuation is
intentional focus on an individual patient’s information
in communication with a patient in a way that connects
a provider’s humanness with the patient’s humanness
(Howell et al., 2018). Remember the baby is also hu-
man and the fetal heart rate pattern is the fetal voice.
■ COMPASSION
Competent nurses are compassionate. Compassion is
an essential element in quality patient care (Sinclair et
al., 2017). Compassion is both cognitive and affective.
It is a reflection of one’s awareness of another person’s
distress coupled with a desire to alleviate that distress.
It includes affective empathy with emotional resonance,
affective understanding of a person’s experience, and
a person-centered response (Foster, 2009; Sabo, 2006;
Sinclair et al., 2017). Just as EBP should be patient cen-
tered, compassion must also be patient centered.
Compassion satisfaction occurs when care pro-
viders feel connected with their patients and feel a
sense of achievement in their work (Hunsaker, Chen,
Maughan, & Heaston, 2015). The compassionate
nurse will choose to act to alleviate pain. They will
do what they can to provide comfort for their pa-
tients and family members. They will imagine what
their patients are going through and will react to meet
their patients’ needs (Bivins, Tierney, & Seers, 2017).
■ COMPASSION FATIGUE
Fatigue is a safety hazard. Fatigue affects skills and
communication (The American College of Obste-
tricians and Gynecologists [ACOG], 2018). Com-
passion fatigue is a state of exhaustion resulting in
physical, emotional, and spiritual depletion and bi-
ological, psychological, and social dysfunction as a
result of caring for patients in significant emotional
pain and physical distress. It is a result of prolonged
exposure to compassion stress (Cocker & Joss, 2016;
Lombardo & Eyre, 2011).
Compassion fatigue is an occupational hazard
that occurs when a healthcare worker is exhausted.
Fatigued nurses may have decreased alertness, mood
changes, decreased energy, decreased ability to con-
centrate, lack of stamina, lack of motivation, poor
judgment, and an inability to learn (Francis, 2018).
Nurses with compassion fatigue will have a reduced
ability to feel sympathy and empathy. They may be
angry and irritable. They will dread working with
certain clients or patient and will have a diminished
sense of work enjoyment. They may have heightened
anxiety and irrational fears or intrusive imagery or
dissociation. Nurses who have compassion fatigue
will be hypersensitive or insensitive to emotional ma-
terial. They will have difficulty separating their work
life from their personal life. Nurses who have com-
passion fatigue will experience absenteeism and an
impaired ability to make decisions and care for clients
or patients. They will have problems with intimacy or
in personal relationships and may increase their use
of alcohol or drugs. They may demonstrate cynicism
at work and have a loss of enjoyment. Some nurses
who have compassion fatigue will be depressed or
experience stress-related illness (Mathieu, 2007). To
diminish the risk or impact of compassion fatigue, be-
come mindful of your feelings, including painful feel-
ings that have pushed you out of your comfort zone.
Crying may be an expression of your emotions. Seek
out support to share your emotions and focus on the
positive. Take care of yourself (Dzubak, 2018).
■ VIGILANCE
Competent nurses are vigilant. Vigilance is the cog-
nitive ability to maintain focus and actively and de-
liberately direct attention to what is believed to be
important (Pattyn, Neyt, Henderickx, & Soetens,
2008). For example, vigilance will include the ability
to ignore nonactionable auditory alerts or alarms but
to act on actionable alerts and alarms. Vigilance and
your attentiveness can be enhanced when you prac-
tice being mindful and work to be physically, spiritu-
ally, and financially well (Allan, 2018).
Vigilance includes motivation to pay attention to
the details and is optimized by a well-rested nurse
who sleeps 7 to 8 hours and who takes rest breaks at
work. Vigilance can be optimized when clinicians nap
at work when possible, but nap less than 45 minutes
(which is usually frowned upon in the United States
of America; Oken, Salinsky, & Elsas, 2006; Pattyn
et al., 2008; Rogers, 2008). To optimize vigilance, a
nap prior to the night shift has been recommended.
Other recommendations include exercising when pos-
sible; ingestion of caffeinated beverages at the begin-
ning of a shift or about an hour before an anticipated
decrease in alertness, for example, between 03:00 and
05:00; and avoidance of fatigue, staffing shortages,
and 12-hour shifts (Rogers, 2008).
The vigilant nurse will recognize, act, and verbal-
ize to promote safety. That nurse will know that the
fetal heart rate (FHR) pattern changed over time from
a normal, reassuring pattern reflective of fetal well-
being to one with decelerations and/or a decrease
in baseline variability with the absence of accelera-
tions. That type of FHR pattern represents potentially
hazardous acidemia and it can develop in as little as
1 hour (Paker & Ikeda, 2007). Vigilance decreases in
 1. ADVOCACY, COMMUNICATION, CHAIN OF COMMAND, AND EVIDENCE-BASED PRACTICE
20 to 30 minutes and therefore one cannot “always”
or “constantly” watch a computer screen to detect
these changes. The paper tracing can be held and
shared with other, more rested care providers. Second
opinions can be obtained. The nurse who knows the
research related to the fetus will know that the fetus
can promptly deteriorate and demonstrate deeper de-
celerations or even bradycardia. They will not think,
“Oh that’s just a little common deceleration” or “I’m
reassured because I still have some variability.” The
competent, well-informed nurse will think “Wow,
the fetus needs better cerebral blood flow and oxy-
genation. There is only one blood vessel that brings
blood and oxygen to the fetus (the umbilical vein). I
need to act now and communicate these changes to
the provider.”
■ VIGILANCE FATIGUE
Vigilance fatigue is also known as vigilance decre-
ment (Pattyn et al., 2008). Vigilance fatigue impacts
decisions and is similar to intoxication with slowed
reaction times or an increase in errors, especially dur-
ing tedious monitoring tasks. The impact of vigilance
fatigue can include information processing deficits,
poor decision-making, impaired performance, and
clinical errors (Rogers, 2008). Care providers who
are experiencing vigilance fatigue will have slowed
reaction times, may disengage from a task, or may
experience attention withdrawal (Körber, Cingel,
Zimmermann, & Bengler, 2015; Pattyn et al., 2008).
Researchers found impaired vigilance begins to occur
after 20 to 30 minutes of time on a task, which can
result in a failure to detect critical changes (Pattyn
et al., 2008). Reduced vigilance may precede clinical
errors and injury to the mother or her baby (Körber
et al., 2015; Oken et al., 2006; Rogers, 2008).
■ FATIGUE AND FAULTY COMMUNICATION
Successful decision makers and communicators are
well rested, not driven by pressures, and aware of their
biases. To eliminate bias, you must recognize and ac-
knowledge what the bias is and be willing to change
(Cudé & Winfrey, 2007). Being well rested may be a
difficult goal, but it is an important goal that prevents
errors and patient injuries. Research shows that error
rates increase when nurses work more than 12 hours
a day, or more than 40 hours a week (Rogers, Hwang,
Scott, Aiken, & Dinges, 2004). Unfortunately, nurses
often work more than 40 hours a week. Some nurses
work more than 6 days in a row and many rotate
shifts (Trinkoff, Geiger-Brown, Brady, Lipscomb, &
Muntaner, 2006). If you do the same, you increase
■ 5
your risk of becoming overtired, chronically stressed,
or injured—and you therefore increase the risk of in-
juring a patient. For example, sleep-deprived military
gunners hit their targets but shot at the wrong target
(Kushida, 2005). An error-prone environment is one
that has inadequate staff to get the job done, rude
coworkers or supervisors, insufficient resources, ever-
changing technology, too little training, excessive pa-
perwork, and communication failures (Welker-Hood,
2006). If you work in an error-prone environment,
share your concerns with nursing management.
Clinical reasoning, good problem-solving, sound
judgment, and effective clinical decision-making re-
quire clear thinking, knowledge, and experience
(Croskerry, 2003, 2005, 2006). Experience will help
you develop your clinical reasoning. Good clinical
reasoning means inductive, fast, and intuitive recog-
nition of a problem. Some people call this “having a
gut feeling.” However, it is based on knowledge and
experience, not just a feeling. For example, when a
pregnant woman presents with decreased fetal move-
ment, frequent mild contractions, a non-reassuring
fetal heart rate pattern, a closed cervix, and blood in
her shoes (known by skilled nurses as “the positive
shoe sign”), an experienced nurse will think there is
a placental abruption. The obstetrician will be called
and the patient will be prepared for surgery.
Other decisions are a result of a slower, rational,
deductive, rule-based, analytical process. This process
takes more time, but is valuable because it results in
fewer errors (Croskerry, 2006). Errors in our deci-
sions increase when we are uncertain, hurried, pres-
sured, or have biases (Croskerry, 2003). Therefore,
if you are new to the practice of labor and delivery
nursing and/or you feel something is amiss, or you
feel hurried but lack the confidence, knowledge, or
motivation to make a decision or to call the midwife
or physician, it is best to admit you need help and
confer with a more experienced nurse or your charge
nurse. By constantly expanding your experiences and
knowledge base, you should become a better decision
maker and communicator, and you will increase your
ability to see the broad range of possibilities in any
given clinical situation.
■ ADVOCACY
Advocacy requires a nurse to recognize, verbal-
ize, and mobilize. Advocacy requires the ability to
make evidence-based decisions that are patient cen-
tered. Decisions about patient care should be based
on knowledge of maternal and fetal risk factors, re-
search, current assessments, changes in the maternal
or fetal status following interventions, and input from
the patient and her family. You must be able to face
6 ■ LABOR AND DELIVERY NURSING
problems head on and not delay decisions until it is
too late. Do you know the current plan of care the pa-
tient desires (birth plan)? Do you know the plan the
provider desires? If not, ask the midwife or physician,
for example, “What is the plan of care for Ms. Iamin-
labor?” Individualize the plan of care and educate the
childbearing client on what is probable, possible, and
not possible.
The individualized plan of care should be in the
best interest of your patient and her unborn baby. If
there is no clear plan of care, or if you cannot accept
it, discuss your concerns with the charge nurse and
midwife or physician. The plan of care must be pa-
tient centered and must prevent harm. If you believe
a decision is needed to deliver by cesarean section or
to expedite delivery with forceps or a vacuum ex-
tractor (an operative vaginal delivery), communicate
with the charge nurse or your supervisor first. Discuss
the clinical facts that support a change in the plan of
care. If you do not have a charge nurse or supervi-
sor, speak directly with the physician or midwife. It is
far better to be proactive and to help the midwife or
physician make a patient-centered decision now than
to wait for them to arrive at the bedside later and
make a decision at the last moment when the fetus is
decompensating.
COMMUNICATION EXAMPLE: Staff nurse to
charge nurse communication example: “I have
been seeing variable decelerations that are getting
deeper and longer but the baby is still at 0 station
with caput and molding. We have been pushing
for 2 hours. I am concerned about the need for
a cesarean section. I know the pregnancy weight
gain was 50 pounds and she is 5 feet tall. I’m
concerned the baby is just not going to fit. Can
you discuss my concerns with the physician? I do
not want to start an oxytocin infusion because
cephalopelvic disproportion is a contraindica-
tion plus she has enough contractions and we are
pushing. I don’t think more uterine power will
help. I think she needs a cesarean section.”
Advocacy requires support of a reasonable plan of
care, anticipation of potential problems, and knowledge
of what is normal and abnormal. You should know
what the fetal heart rate baseline was on admission. Is
the current fetal heart rate baseline rising or falling? A
rising baseline may be a fetal catecholamine (stress) re-
sponse to hypoxia. Falling baselines are usually a fetal
decompensation response. Both are abnormal.
Advocacy requires a nurse to mobilize the operat-
ing room crew to expedite delivery before fetal de-
compensation, neurologic injury, or death. However,
this is a rare event. Examples of acute events where
the fetus quickly decompensates include a ruptured
vasa previa when an amniotomy is performed, a uter-
ine rupture, or an amniotic fluid embolism. In those
cases, it will be obvious that delivery needs to be ex-
pedited. Inform the charge nurse of actions that have
been taken and the current maternal and fetal status
to ensure a safe and expeditious delivery. When ce-
sarean sections are not performed on your labor and
delivery unit, you will need to inform the operating
room crew through your house supervisor that you
need to mobilize them if the pattern continues or
worsens. Ask the physician to come to the bedside. If
there is fetal tachycardia, especially with decelerations
or minimal or absent variability and no accelerations,
the fetus is in jeopardy. Initiate intrauterine resuscita-
tion measures. Communicate to mobilize resources. If
you have no charge nurse, ask another nurse to pre-
pare the operating room and mobilize the crew while
you call the physician to come to the bedside. Call
the anesthesia provider and the neonatal team so that
they are on their way to the hospital. You will need
to be proactive and request the presence of the obste-
trician at the bedside any time you see tachycardia,
bradycardia, or decelerations that last more than 30
seconds, especially if they are becoming deeper and
longer. Communication among the healthcare team
members is imperative to help ensure the individuals
required to provide safe care to the mother and baby
or babies are available in a timely manner.
■ COMMUNICATION
Within the subculture of labor and delivery are the
people with whom you may need to communicate.
They may be difficult to communicate with if they
are know-it-alls, passives, dictators, “yes” people, “no”
people, or gripers (see Table 1.1).
Nurse-to-Patient Communication
Patients may also take the role of know-it-all, pas-
sive, dictator, griper, or someone who always agrees
with you or quickly disagrees with you. On the other
hand, they may be open, honest, and genuinely in-
terested in what you have to say. An assessment of
their interaction with other family members will help
you recognize their communication style and charac-
teristics. Communication with patients, family mem-
bers, and other healthcare providers is essential to
help you prevent adverse events (Joint Commission
on Accreditation of Healthcare Organizations, 2004).
Communication also creates relationships. Therefore,
you will need to find a way to relate to your patient
and her family and friends to maximize the effective-
ness of your communications. By developing your
 1. ADVOCACY, COMMUNICATION, CHAIN OF COMMAND, AND EVIDENCE-BASED PRACTICE ■ 7

TABLE 1.1 COMMUNICATOR PERSONALITY TYPES

Personality Type Characteristics and Suggestions for Communication

Know-it-alls Arrogant, usually have a strong opinion on every issue. When they’re wrong, they get defensive. Vali-
date their ideas. Tell them you see their point of view (if you can), then ask for their help in solving a
problem.

Passives Never offer ideas and never let you know where they stand. For example, they may perform a vaginal ex-
amination and then walk out of the room and not tell you their findings. Follow them out of the room.
Establish eye contact. Ask them to tell you their findings.

Dictators Bully and intimidate. They’re constantly demanding and brutally critical. Don’t try to be their friend. Just
be specific in what you would like them to do and ask them if they can help you. If they refuse, ask
your charge nurse or nursing supervisor to intervene or help you.

“Yes” people Agree to cover your patient while you are on lunch break and then never see your patient. When you re-
turn from your break and see they have not charted their observations, ask them to do so. If they do
not comply, notify your charge nurse or supervisor of their failure to see your patient. Document in the
record the time you expected them to see your patient and their name.

“No” people Quickly point out why something won’t work and are inflexible. Avoid these people unless you have to
interact with them. Keep your communications brief and clear.

Gripers All they do is complain. See all of the above.

emotional intelligence, you should be able to recog-
nize your feelings and the feelings of others, and then
regulate your personal feelings and expressions in re-
sponse to clinical situations (Stichler, 2006).
Your first nurse–patient interaction is critical in
establishing a trusting relationship with your patient
and her family and friends. Introduce yourself by stat-
ing your name and licensure, and state that you will be
her nurse for the next specified number of hours. When
your patient speaks to you, face her, listen closely, and
paraphrase what you hear. Make eye contact when it
is culturally accepted, do not interrupt her, and do not
multitask. It is extremely rude to look at a chart or a
computer screen instead of your patient.
COMMUNICATION EXAMPLE: “Hi, Ms.
Jones. I’m Michelle and I’ll be your nurse today.
I’m here for the next 12 hours. I understand
from Gayle, your night nurse, that you are 4-cm
dilated, that your plan is to have intravenous
medication later in the labor, and that your hus-
band wants to cut the cord after the birth. Is
that correct? Good. It looks like you are con-
tracting every 3 minutes and they feel strong to
me. Your baby looks good. I see there are accel-
erations in the heart rate. Is there anything you
need right now?”
Create an environment that is conducive to open
communication and low stress to enhance a feeling of
trust. You can enhance the environment by limiting
the number of visitors and other noise and distrac-
tions (Stichler, 2007a). Sit at eye level with your pa-
tient when you communicate. Pick your words wisely,
as words might upset patients and families. For exam-
ple, “failure to progress” or “noncompliant cervix”
are demeaning and disparaging (Katz, 2005).
You should use open-ended questions to assess
your patient’s knowledge of the labor and delivery
process. For example, you might say, “What ques-
tions do you have about what is going to happen to-
day?” Some patients believe they have no questions
because they have been watching birthing programs
on television. They will tell you they know everything
they need to know about their epidermal. In spite of
their misconceptions, it is important for you to dis-
cover their knowledge deficits and provide informa-
tion during teachable moments. For example, prior
to rupture of the membranes, you might want to
mention that the sac around the baby has no nerves.
One patient was terrified because she heard the nurse
say, “The doctor will be rupturing your brains.” An-
other patient reported she had condominiums “down
there.” She really had condylomata (warts). Try not
to laugh. Discover the source of your patient’s anxi-
ety and fear. Perhaps her sister, cousin, or mother had
a traumatic birth experience and she fears the same
thing will happen to her. You will need to reassure her
that you are there for her support and safety and will
be checking in frequently during her labor. Use hu-
mor sparingly and appropriately. Listen carefully to
her complaints and concerns because you may be the
8 ■ LABOR AND DELIVERY NURSING
first person she tells or the first person who recognizes
there is a problem.
To facilitate open communication, acknowledge
the partner and/or labor coach and any family mem-
bers present in the room. Ask them their names and
recognize their supporting roles. Be sure the primary
coach and the father of the baby eat and rest if there
is a long labor ahead. The father-to-be may wish to
play an active role during the labor process or no role
at all. Assess their needs and desires as well as your
patient’s needs and desires. Satisfaction with the sup-
port of their partner results in less patient stress, less
depression, and less anxiety for as long as 3 months
after delivery (McVeigh, 1997).
Support family-centered care, if that is desired, by
keeping the baby in the birthing room after delivery.
Support skin-to-skin contact between the mother and
her baby. If she chooses to breastfeed, you should sup-
port breastfeeding within the first hour of the baby’s
life (Phillips, 2003). Communicate with the patient to
learn her expectations for labor and birth.
If there is a written birth plan, read it and ac-
knowledge its contents. Sometimes desires or plans
are more like wishes that you may not be able to ful-
fill. You will need courage to do the right thing for
your patient’s safety and health, even when it seems
undesired or unpopular or goes against her birth plan
or wishes.
CLINICAL EXAMPLE: A nulliparous woman
in labor was four feet six inches tall. At about
5-cm dilation, her membranes spontaneously
ruptured. There was dark green, particulate
meconium in the amniotic fluid. Variable de-
celerations appeared on the tracing. The mid-
wife found there was a face presentation. The
physician was called into the room and decided
that a cesarean section was necessary. When the
patient was informed, she was sad because she
had planned for a vaginal delivery. The nurse
said, “I’m sorry but the baby didn’t read the
plan.” The patient said, “Neither did my sister’s
baby.” The nurse asked for clarification. The pa-
tient told her that her sister was also petite like
her and had a baby with a face presentation. In
this case, there was a good outcome for both
the mother and her baby.
Nurses who communicate to discover and respond
to patient needs prevent injuries (Kendig, 2006). To
protect patients and prevent injury, communication
should be purposeful and goal oriented. For example,
there may be people in the room who are watching
television and talking among themselves yet the nurse
perceives the laboring woman needs a quiet room
because she is preeclamptic, hyperreflexive, and hy-
pertensive. In this case, the nurse would explain the
patient’s needs and ask the visitors to leave or limit
their conversation. The hospital’s visitor policy should
provide the framework for information shared with
the people in the room.
ACOG (2011) believes that actively involving pa-
tients in their care will increase diagnostic accuracy,
patient satisfaction, and adherence to therapy, thus
resulting in improved health. They recommend that
healthcare providers (a) speak slowly and use plain,
nonmedical language; (b) limit the amount of in-
formation provided; (c) repeat information; (d) use
teach-back or show-me techniques; (e) create an at-
mosphere in which patients can ask questions; and
(f) provide written materials to reinforce oral expla-
nations. Naturally, if the patient does not speak Eng-
lish, a certified interpreter should be located. Record
the name of the certified interpreter or translation
service in the medical record.
Nurse-to-Nurse Communication and
Nurse-to-Provider Communication
Communication between team members is vital to
ensure patient safety and the continuity of care based
on an individualized care plan. When you receive the
change of shift or handoff report, you must know if
the amniotic fluid was clear but now has meconium
in it. You must know the baby’s normal baseline
level, what it is now, and time of the last accelera-
tion (a reflection of normal pH). The last acceleration
should have occurred within the last 90 minutes, even
if narcotics were administered. You must know how
to interpret the tracing, and over time you will be-
come more comfortable with its physiologic meaning.
The nurse is the conduit through which informa-
tion flows to the midwife and/or physician. It has
been said that the nurse is the “eyes and ears” of the
midwife and physician. You are the one who keeps
the charge nurse informed of changes. You have the
power to make a difference. Therefore, it is your duty
to advocate for the physician’s presence at the bed-
side when the parents have requested it. You have a
duty to update them at reasonable intervals so that
they stay abreast of the maternal and fetal condition
throughout the labor process.
■ SBARR
The letters S, B, A, R, and R represent the words situ-
ation, background, assessment, recommendation, and
response. The situation is the patient’s current con-
dition and your major concern. The background in-
cludes the pertinent facts from the patient’s history.
The assessment is what you think the problem is. The
recommendation is what you recommend the provider
 1. ADVOCACY, COMMUNICATION, CHAIN OF COMMAND, AND EVIDENCE-BASED PRACTICE
do. The response is what the provider said or did when
you made your recommendation (Cherouny, Federico,
Haraden, Leavitt Gullo, & Resar, 2005; Guise &
Lowe, 2006; Nunes & McFerran, 2005).
To help midwives and physicians make good deci-
sions, they need you to provide them with relevant
facts, abnormal findings or laboratory results, and
any other information that paints a complete picture
in their minds. For example, if there is fetal tachycar-
dia, you will also want to inform them of the mater-
nal pulse and temperature. Both are elevated when
there is chorioamnionitis. If there is vaginal bleeding,
they will need to know about contractions and de-
tails related to pain, such as the location of the pain,
whether it is constant or intermittent, sharp or dull,
how the patient is responding to the pain, and the
fetal status. If you need a physician or midwife at the
bedside, you might say “I need you to come to the
hospital now” or “The patient (fetus or mother) needs
you to come to the bedside now.” When the midwife
and/or physician respond to your request without de-
lay, they promote a safe, reliable organization that is
patient centered.
DOCUMENTATION EXAMPLE: Jane Doe,
CNM, notified at 2330 of patient with BP
156/92, facial and hand edema, pitting ankle
edema. Normal vision, not blurred and sees no
flashes of light. Hyperreflexive with no clonus.
Complains of unrelenting headache and heart-
burn. No vaginal bleeding. Contractions every
1 to 2 minutes lasting 30 to 40 seconds with
less than 1 minute between contractions. Pa-
tient reported no history of preeclampsia. Rec-
ommended CNM come to bedside immediately.
CNM informed this nurse she was on her way.
Recommended this nurse call obstetrician to
come to the bedside immediately. CNM agreed.
The change of shift report should be compre-
hensive (see Box 1.1). By the end of the report you
should know events that happened during the last
shift, changes in the mother’s or baby’s status, and the
interdisciplinary plan of care. You will need to decide
if the current plan of care is safe and reasonable for
your patient. If not, request a change in the plan of
care after you report your findings and share your
concerns.
COMMUNICATION EXAMPLE: Requesting
a change in the plan of care: “Dr. Iamallears,
may I speak with you a moment about the cur-
rent plan of care? I just learned in report that
your patient, Jane Doe, now has a fever. Her
temperature is 100.8 degrees. In addition, her
pulse is 116 beats per minute. She’s been di-
lated 5 centimeters for the last 3 hours. There’s
■ 9
caput at 0 station. There are variable decelera-
tions that are getting deeper. I just discontinued
the Pitocin infusion that was at 30 mU/minute.
Would you please come and evaluate her and let
me know if you’d like to make any changes in
the current plan of care?”
If a medication is due at the time of change of shift,
for example 7 p.m. or 19:00, the departing nurse
should administer that drug and inform the arriving
nurse that the medication was given. It is also impor-
tant to report the patient’s intake and output, and her
dietary restrictions.
Physical or psychological needs that promote pa-
tient well-being should be communicated to midwives
and physicians (Henrikson, 2006). Nurses should
BOX 1.1 Elements of a complete nurse-to-nurse report
1. Patient’s name and name of her partner or
guardian, patient’s age, gravida, parity, due date
or weeks of gestation, number of fetuses, and
reason for admission or diagnoses, height and
current weight.
2. Provider’s name, location, and telephone number.
3. Allergies, including allergy to latex, and Group B
Streptococcus status.
4. History of transfusion reactions or prenatal labo-
ratory results that might affect care during labor
or birth.
5. Current medications and past medications if they
affect or potentially affect her current condi-
tion or care, e.g., antidepressants after her last
delivery.
6. Maternal habits, e.g., alcohol, tobacco, or street
drug use.
7. Prenatal/obstetric and medical history.
8. Last vital signs and any abnormal findings.
9. Physical assessment of abnormal findings.
10. Fetal normal baseline rate (based on past non-
stress tests and/or the admission report).
11. Current fetal baseline rate and other features of
the fetal heart rate pattern.
12. Current uterine activity.
13. Last cervical examination, fetal station, status of
membranes, including color, amount, and odor
of amniotic fluid.
14. A review of progress using the plotted labor
curve of dilatation and descent, especially when
there was been a protraction or arrest of dilata-
tion and/or descent.
15. Last dose of medications, including prostaglan-
dins, oxytocin, antibiotics, narcotics, insulin, anti-
hypertensives, etc.
16. Current pain level and ability to cope with the
labor, and patient desires for pain management.
10 ■ LABOR AND DELIVERY NURSING
also communicate to clarify orders, discuss therapeu-
tic plans, report changes in the patient’s condition,
share questions the patient or her family members
have, and report abnormal or significant findings.
Strong nurse–physician relationships affect both
nurse and patient satisfaction. If nurses and physicians
have equal power within their respective practice ar-
eas and they collaborate to provide patient care, staff
nurses will continue to work at that hospital. In fact,
increased communication between nurses and physi-
cians reduces bad outcomes (McClure & Hinshaw,
2002). Communication and relating to others re-
quires a sense of social competency (Stichler, 2007b).
Social competence includes the ability to assess the
emotions of others and relate to them in a manner
that diffuses anger and conflict, provides encourage-
ment, or inspires them. Social management is part of
emotional intelligence or being intelligent in our rela-
tionships (Goleman, Boyatzis, & McKee, 2002).
If you work with certified nurse midwives, you
should work to develop a positive relationship with
them. It will help if you know that they probably are
limited in what they can do without the consultation
of the backup obstetrician (see Boxes 1.2–1.4).
Nurses must notify the midwife or physician when
an order should not be followed. The American Medi-
cal Association (AMA) supports communication be-
tween a nurse and a physician when the nurse finds
an order to be in error or contrary to customary medi-
cal or nursing practice. The AMA has opined that “the
physician has an ethical obligation to hear the nurse’s
concern and explain those orders to the nurse in-
volved. The ethical physician should neither expect nor
insist that nurses follow orders contrary to standards
of good medical and nursing practice” (AMA, 1997).
If you encounter a clinical situation in which you
believe a physician’s opinion, attention, or care is
BOX 1.2 Certified nurse midwife management without a
requirement for a physician consultation
1. Gestational diabetes (diet controlled).
2. Fetus that is 36 or more weeks of gestation.
3. Internal and external fetal monitoring, including
insertion of a fetal spiral electrode and intrauter-
ine pressure catheter.
4. Meconium with reassuring fetal heart rate
pattern.
5. Group B Streptococcus prophylaxis according to
protocol.
6. Urinary tract infection diagnosis and treatment.
7. Initiation of anesthesia request when a normal
spontaneous vaginal delivery is expected.
8. Amnioinfusion.
9. Episiotomy.
10. First- and second-degree laceration repair.
needed, discuss this with the midwife. If the midwife
refuses to communicate with the consulting physician
and you still feel a physician’s care is needed for your
patient, share your concern with the midwife in the
presence of a member of your chain of command such
as the charge nurse or house supervisor. The chain
of command is now a chain of resolution to solve a
problem. The charge nurse or supervisor should pos-
sess the authority and responsibility to act in the best
interests of the patient. If that nursing leader also
finds that a physician is needed, it is their responsibil-
ity to discuss the need for a physician evaluation with
the midwife and they may even call the physician if
the midwife refuses to do so or fails to do so.
To improve your communication abilities, develop
your emotional intelligence. Stay calm when people
try to provoke you. In the event you work with a
“know-it-all” who hangs up the telephone or walks
away from you while you are speaking or before you
have finished communicating, or before you make
BOX 1.3 Examples of certified nurse midwife intrapartal
management that may require a physician consultation
(consult your hospital’s requirements)
1. Grand multiparity or great grand multiparity
2. Severe anemia (hemoglobin <9 mg/dL)
3. Estimated fetal weight >4500 g
4. Postterm pregnancy (gestation of 42 weeks or
more)
5. Pregnancy <36 weeks completed weeks of
gestation
6. Induction of labor
7. Augmentation of labor
8. Maternal fever with or without suspected
chorioamnionitis
9. Preeclampsia
10. Thick and/or particulate meconium-stained amni-
otic fluid
11. Regional anesthesia in the presence of dystocia
(protracted or arrested dilatation and/or descent)
12. Arrest of dilatation or descent
13. Second stage >2 hours especially when there was
a protraction of dilatation during the first stage
of labor, a protraction or arrest of descent, or any
suspicion of cephalopelvic disproportion
14. Fetal heart rate pattern that requires intrauter-
ine resuscitation (tachycardia or bradycardia;
absent or minimal variability; variable, late, pro-
longed and/or spontaneous decelerations; few to
no accelerations)
15. Vaginal bleeding
16. Conditions that may require physician interven-
tion: Fetal malposition, compound presentation,
or the need for the application of forceps, a vac-
uum extractor, or a cesarean section
 1. ADVOCACY, COMMUNICATION, CHAIN OF COMMAND, AND EVIDENCE-BASED PRACTICE
BOX 1.4 Examples of midwife and physician intrapartal
collaborative management (consult your hospital’s
requirements).
A physician should come to the bedside:
1. Insulin-dependent diabetic or not well-controlled
gestational diabetic without suspected fetal
macrosomia
2. Known intrauterine growth restriction
3. Fetal heart rate patterns that require intrauter-
ine resuscitation but do not improve with these
interventions:
a. Discontinuation of the oxytocin infusion
b. Position change to a lateral position to opti-
mize cardiac output
c. Correction of hypotension (e.g., administra-
tion of ephedrine 5–10 mg slow IV push)
d. Hyperoxygenation (using a tight-fitting sim-
ple face mask at 10 or 15 L/minute for a non-
rebreather mask with an oxygen reservoir)
e. Stop pushing or push with every other
contraction
f. Tocolysis (e.g., IV bolus or terbutaline 0.25 mg
SQ or slow IV push)
4. Preeclampsia with “mild” laboratory
abnormalities
5. Excessive bleeding during labor
6. Fetal malpresentation or malposition
7. Greater than 30 minutes during the third stage
of labor (delivery to placenta time)
8. Protracted or arrested descent during the second
stage of labor
9. Vaginal birth after cesarean section
10. Excessive uterine tenderness or rigidity
11. Suppression of preterm contractions
12. Sickle cell anemia or disease
a reasonable request for your patient, do not chart
“Provider hung up on me” or “Provider walked away
as I was speaking.” Instead, notify your nursing leader
in your chain of command of the situation and ex-
plain your patient’s needs that are not being addressed
by the provider. Ask your nursing leader to make the
next call. This action is a form of advocacy. It is invok-
ing the chain of command that has also been called
the chain of communication or chain of resolution.
A chain of resolution describes what staff members
and leaders are doing to resolve issues and concerns
regarding patient care and safety. It may also address
resolving issues related to environmental needs, equip-
ment, or other things (Hardie, 2012). If there is no
charge nurse or nursing leader, ask another nurse to
listen on another telephone line (if possible) and call
the “know-it-all” again. In the second call, communi-
cate that your colleague is listening in. Your colleague
■ 11
should say, “hello.” Then you should ask the provider
again for what your patient needs. If the provider
hangs up or refuses to come in, activate the chain of
command and record who you notified in the chain.
■ CHAIN OF COMMAND
Each hospital should have a chain of command
policy, procedure, or protocol. These have also been
called the Chain of Command or Chain of Resolution
policies, procedures, or protocols. You may need to
activate your chain of command to resolve conflicts
over patient management plans (Mahley & Beerman,
1998). The chain of command is a process that is used
when the nurse feels that ethical or practice standards
are not being maintained or there are unresolved con-
flicts or clinical issues that affect patient well-being.
Prior to invoking the chain of command, every ef-
fort should be made to clearly and fully communi-
cate with the midwife, resident, or physician directly
involved in the patient’s care. If the communication
fails, the chain of command policy must be followed.
Unresolved conflicts often involve a disagreement
in patient care, such as the need to apply oxygen or
a spiral electrode. The chain of command or chain of
communication is invoked as the patient’s safety net.
Your role as a patient advocate creates an ethical duty
to prevent harm, and requires courage to acknowl-
edge the disagreement and seek its resolution. You
might say to the midwife or physician (away from
the patient’s bedside), “We have an unresolved dis-
agreement here. I’ve asked the charge nurse to help us
resolve this issue.” You can also say, “I’m activating
our chain of command policy.” The charge nurse may
decide to assume care of your patient or assign an-
other nurse to care for your patient. The charge nurse
can be asked to speak with the midwife and may need
to speak with the next highest level in the chain, that
is, the midwife’s backup physician or the attending
physician. If the provider is the Chief of Obstetrics,
involve your nursing chain of command, for example,
the charge nurse and nurse manager. If the Chief of
Obstetrics is also the Chief of the Medical Staff, in-
volve your charge nurse or supervisor, who may need
to involve the Vice Chief of the Medical Staff to re-
solve the conflict.
Documentation of the chain of command should
include the observations and events that created a
need to use the chain of command, specific facts, and
the time of events and communications.
DOCUMENTATION EXAMPLE: Dr. Knowitall
ordered oxytocin. Physician was informed at
nurses’ station at 1205 that patient was con-
tracting every 2 minutes × 50 to 70 seconds,
moderate to palpation. Order to administer
12 ■ LABOR AND DELIVERY NURSING
oxytocin was questioned. Charge nurse Sally
Smith informed of communication with physi-
cian. Nurse Smith spoke with physician who in-
sisted on oxytocin administration. Chief of OB
Dr. Iknowmore was called by charge nurse at
1210. Nurse Manager Tanya Doitright updated
by Sally Smith.
The nurse’s responsibility and duty is to advocate
for the patient’s safety. It is imperative that the nurse
continue to communicate with the charge nurse or su-
pervisor until the conflict is resolved. The nurse must
act to prevent injury. Patients really want a nurse who
cares for them as if they were a family member. They
want a nurse who is responsive to their needs, includ-
ing their physical, emotional, and spiritual needs.
They want a nurse who is willing to do extra things
and who follows through on promises (Trossman,
2007). Sometimes our communications are ineffec-
tive in moving toward a patient-centered goal. For
example, what would you do if the physician asked
you to do something in front of the patient that you
felt was not best for the patient or her baby?
If you receive a verbal order at the bedside, but
are concerned that following the order may harm the
patient, do not follow the order. Before the provider
leaves the room, repeat the order to clarify their in-
tent and understanding of the facts. For example, an
order you should question is “Begin oxytocin per pro-
tocol on this patient” but you know the patient has
a baby in a transverse lie. When the provider leaves
the room, follow him or her. In the hallway ask if
he or she wanted oxytocin to be administered to this
patient who has a transverse lie. If the answer is yes,
FIGURE 1.3 Sample chain of command with the staff nurse as the first link in the chain.
do not follow the order. Instead, speak to your charge
nurse or supervisor and inform them of the order, the
provider’s response, and your concerns. The charge
nurse or supervisor has the responsibility and author-
ity to speak with the provider so that the order is
changed. Your responsibility is to continue to care for
your patient.
In your career, there will be times when you will
need to initiate the chain of command and involve
your charge nurse or house supervisor—or even the
Chief of Obstetrics. If you have a clinical nurse spe-
cialist, they often work with the Patient Care Man-
ager as a dyad and may also be able to help you
obtain the care you need for your patient. In some
cases, the Director of Maternity Services or Mater-
nal Child Services, the Assistant Vice President for
Women and Children’s Services, or the Executive
Vice President for Patient Care Services will be called.
When the Chief Nursing Officer is called, the entire
nursing chain of command will be involved.
You can develop your own list of names and phone
numbers of people in your chain of command. It is a
good idea for the hospital to give you a copy of the
chain of command policy. It is your responsibility to
find it if you do not receive it. From time to time you
may want to return to the policy for guidance or to re-
fresh your memory. In general, there are two “chains”
of command that compose the overall chain of com-
mand: the nursing chain of command and the medical
chain of command (see Figures 1.1 and 1.2).
Activate the chain of command or chain of commu-
nication whenever there are unresolved issues related
to patient care or if you have concerns related to a pro-
vider (Figures 1.3 and 1.4). If resolution of the conflict
 1. ADVOCACY, COMMUNICATION, CHAIN OF COMMAND, AND EVIDENCE-BASED PRACTICE
Team
Leader/ Physician/
Staff RN Provider
Charge
Nurse
Nurse
Manager or
Supervisor
Chief
Nursing
Officer
Reasons to Activate the Chain of Command or Chain of Communication
1. Issues requiring communication.
2. Issues surrounding patient care.
3. Concerns related to physican/provider.
FIGURE 1.4 Example of the chain of command, chain of communication, chain of resolution with
the staff nurse as the first link in the chain.
or issue is not achieved at any step up the chain of
command, continue up the chain until a mutual resolu-
tion is achieved. During this process, the childbearing
woman must still receive care to prevent an adverse
outcome. Perhaps only once in your entire career will
you follow the chain all the way to the top (Chief
Nursing Officer and Hospital Medical Director).
If discussions with the midwife or physician do not
result in appropriate care, the nurse is responsible to
ensure timely and appropriate actions (Simpson &
Chez, 2001). Advocacy for the patient may require
you to invoke your hospital’s chain of command.
A retrospective review of 90 risk manager files
from 1995 to 2001 revealed that adverse outcomes
are directly related to procedures and people (White,
Pichert, Bledsoe, Irwin, & Entman, 2005). Half of
those files were related to labor and delivery; the rest
were related to gynecologic surgery (38%) and am-
bulatory care (12%). Communication failures were
associated with 31% of the adverse events. For exam-
ple, there were disruptions in the flow of critical infor-
mation from one caregiver to another, or there were
communications that upset the patient or her family.
EXAMPLE: Failure to invoke the chain of com-
mand resulting in an adverse outcome: Dina was
multiparous. She arrived in labor and delivery
with a thick, closed cervix and a full-term fetus
at a -3 (floating) station. Within 6 hours she was
dilated 5 cm but there was an arrest at 5 cm for
another 3 hours. During that 3 hours, the FHR
pattern deteriorated and lacked any sign of fetal
well-being. Intrauterine resuscitation measures
■ 13
Department Chair
and Program
Medical Director
Chief of Medical
Staff and
Administrator
On-Call
were undertaken without improvement in the
FHR. The attending family medicine physician
was called and a telephone order to begin an
oxytocin infusion was received.
Instead of withholding the oxytocin, the
nurse administered it. Within 30 minutes there
were late decelerations. By that time, the attend-
ing physician was present and the nurse shared
the tracing and pointed out the late decelera-
tions. The physician insisted the oxytocin infu-
sion be resumed.
Instead of withholding the oxytocin infusion
and using the chain of command to obtain the
care of an obstetrician, the nurse administered
oxytocin again. However, the nurse did inform
the attending family medicine physician that
the on-call obstetrician would be asked to come
to the bedside for a second opinion.
The on-call obstetrician arrived; ordered the
oxytocin infusion to be discontinued and it was.
Both physicians remained on the labor and de-
livery unit but no cesarean section was ordered.
Three hours later, Dina’s cervix dilated to
an anterior lip but the fetal heart rate became
bradycardic with late and prolonged decelera-
tions. The nurse never informed another nurse
or a nursing leader of this emergency. The nurse
never advocated for a cesarean section.
One hour later, the cervix was completely
dilated and the attending physician applied a
vacuum extractor in Dina’s labor room. There
was no double set up in an operating room.
The baby’s head was delivered but there was
14 ■ LABOR AND DELIVERY NURSING
a shoulder dystocia and the baby could not be
delivered vaginally. A Zavanelli maneuver was
performed and Dina was moved to an operat-
ing room for a cesarean section. Apgar scores
were 0 at 1 minute, 3 at 5 minutes, and 3 at
10 minutes. The newborn weighed 4,345 grams,
was asphyxiated, and brain damaged.
Dystocia is derived from the Greek word for “abnor-
mal” or “difficult” and the Greek word tokos for “la-
bor” or “delivery.” A difficult delivery of the shoulders
was encountered in this example. In fact, all maneuvers
failed to deliver the baby. Shoulder dystocia could have
been avoided had oxytocin not been used to force the
fetus down into the pelvis, the nursing chain of com-
mand had been activated when Dina’s baby was brady-
cardic but remote from delivery, and an obstetrician had
ordered and performed an emergency cesarean section.
The plan of care should be more than “monitor
the patient” or “expect vaginal delivery.” It should
be individualized and provide a road map toward a
safe outcome. Sometimes the plan of care is in con-
flict with the patient’s needs. To resolve clinical issues
related to patient care conflicts, your hospital should
have a “Resolution of Clinical Issues” or “Resolution
of Conflict” procedure. This procedure should define
the channels of communication and decision-making
that you should follow when there are questions or
concerns regarding medical or nursing care. Knowing
your patient should be the basis for clinical decisions
and judgments and individualized care.
When orders deviate from the plan of care or cus-
tomary or safe practices, discuss the situation and
your concerns with the midwife and/or physician(s)
responsible for the patient. If the issue needing clarifi-
cation is not resolved, the chain of command should
be initiated and your charge nurse or immediate super-
visor must be notified. The charge nurse or supervisor
will discuss the concern with the midwife or physi-
cian. If the issue remains unresolved, other individu-
als in the “chain of command” will become involved
so that the conflict can be resolved. Avoid documen-
tation that reflects a disagreement between yourself
and others. Instead, document your assessments,
plans, actions, evaluations, and communications.
EXAMPLE: Inappropriate documentatio reflect-
ing disagreement between a nurse and a physician:
Dr. Disreguarde aware of lack of fetal well-being
throughout second stage of labor. Dr. desires no
interventions at this time. Nurse manager in room.
Dr. orders pushing to continue. Dr. informed of
meconium and lack of fetal well-being. Dr. asked
if pediatrician and neonatal nurse should be called
for cesarean section. Dr. said no. Dr. reminded of
particulate meconium and lack of fetal well-being.
Dr. said there is no meconium.
EXAMPLE: Appropriate documentation re-
flecting disagreement between a nurse and a
physician: Frequent discussions with Dr. Disre-
guarde during second stage about FHR pattern,
including meconium and lack of fetal well-be-
ing at this time. No new orders. Practice coor-
dinator (charge nurse) in the room at this time
speaking with physician. Nurse manager called
the pediatrician, anesthesia provider, and nurs-
ery nurse to attend delivery.
The first narrative demonstrates the lack of col-
laboration and teamwork. The second demonstrates
how well the chain of command worked to secure
personnel for delivery.
■ DISRUPTIVE BEHAVIOR
Disruptive behavior hinders effective communication.
Disruptive behavior is personal conduct, whether ver-
bal or physical, that affects or potentially may affect
patient care negatively (Lazoritz & Carlson, 2008).
Disruptive behavior includes intimidation, violence,
inappropriate language or comments, sexual harass-
ment, and/or inappropriate responses to patient or
staff requests. Hanging up midsentence or refusing to
come in are examples of disruptive behavior.
Nurses must not participate in disruptive behavior
and should report it to their leader(s). Disruptive be-
havior diminishes the capacity of all team members to
provide safe care. If someone verbally threatens you,
that is disruptive behavior. Throwing things such as
instruments or lap sponges in your direction is disrup-
tive behavior. No person with whom you work should
ever hurt you. Abuse and battery must not be toler-
ated—and must always be reported. If you feel you
are the victim of disruptive behavior in the workplace,
speak with your nurse manager and discuss the inci-
dent. Disruptive behavior cannot and must not be tol-
erated and silence on your part is not an option. Speak
to the “disrupter” privately with your supervisor pres-
ent. In the meeting, state the disruptive behavior by
explaining what you found to be disruptive. Keep
your statement brief, factual, and descriptive. Also
share how you felt when the disruptive behavior oc-
curred. When confronted, the disrupter may argue or
yell or dispute what you say. If this happens, politely
thank the disrupter for their time and leave. Write an
occurrence or problem/resolution report and include
the disrupter’s response. Continue to act profession-
ally, even if the disrupter is rude to you. If the behavior
continues, follow the same plan: Meet, discuss, report.
The report provides an opportunity for the disrupter
to change their behavior (Lazoritz & Carlson, 2008).
Advocating for patient safety can be difficult
when a physician or any other care provider is sleep
 1. ADVOCACY, COMMUNICATION, CHAIN OF COMMAND, AND EVIDENCE-BASED PRACTICE
deprived and/or fatigued. This impacts performance.
The fatigued and/or sleep-deprived care provider
may demonstrate a change in their normally pleasant
mood. They may not retain information, may have
slower performance than usual, and may not commu-
nicate effectively which can result in errors that hurt
patients (ACOG, 2018).
A family member may be disruptive either from
fatigue or from a belief system. For example, a
husband may refuse to let his wife have a cesar-
ean section because he is concerned it will mutilate
her body. Empathy is needed to defuse disruptive
behavior. Try to understand these concerns and
inform the physician. Your responsibility is to de-
escalate the situation to maximize patient safety.
Remember the family’s stress and that they may act
out for many reasons. Work from the onset of the
first meeting to establish rapport. Listen carefully
to what they say and what is not said, and look for
a theme. Observe their body language. Do not raise
your voice. You may say, “I’m here to keep your
wife (loved one) safe” or “We’re on the same team
and we can work together.” Do not think of it as “us
versus them” but all as important members of the
healthcare team. Offer explanations; be realistic;
pay attention to your behavior; avoid anger, closed
body language, and aggression. Stay calm; keep a
relaxed posture, and if culturally acceptable, make
eye contact. Keep your hands visible. You also may
want to ask another staff member to be with you
(Jubb & Baack, 2019).
■ EXPECTED AND UNEXPECTED
COMMUNICATION WITH THE PROVIDER
Obstetric care providers expect four basic types of
telephone calls (see Box 1.5). If you are trying to de-
cide whether to call the physician or midwife, just
make the call. The time of day should not stop you
from sharing important patient information. Call
when the patient needs a medication, is not tolerant
of labor, is ready to push, or any time there is concern
for the fetus. Call for orders, to clarify orders, or to
change orders.
BOX 1.5 Telephone calls from a nurse to a physician or
midwife
1. Patient has arrived
2. Status update and request for new orders
3. New, significant findings and a need to come to
the unit to assess the patient
4. There is an emergency and we’re taking the pa-
tient to the operating room for a cesarean section
■ 15
When there are new and/or significant findings, it
is especially important that you report information
in a timely manner (meaning within a few minutes of
knowing the information) to the midwife or physi-
cian. For example, if your patient complains of con-
stant pain in the suprapubic area and her bladder is
empty, think about the fit of the fetal head in the pel-
vis. Is it pressing down above her pubic bone? Ask
the midwife or physician to come to the bedside and
evaluate this unusual pain. If you are given an order,
be sure you accept that it is safe to follow that order.
If you are concerned about a risk of harm, discuss it
with the person who wrote the order. It is your re-
sponsibility to question orders that may harm the pa-
tient and you must not follow harmful orders.
Communicate and collaborate with the primary
healthcare provider to ensure there is an appropriate
individualized plan of care and evaluation of the pa-
tient’s condition prior to beginning a procedure such
as cervical ripening or induction. For example, you
might say to the midwife or obstetrician, “I’m really
worried about the baby. Can you please come in and
evaluate the tracing for me?” If you do not get the
response you desire, it may be because you did not
communicate your degree of concern. State clearly “I
am concerned. I would like you to come to the bed-
side now. I need you to evaluate (tell them what you
need).” If you still do not get the response you desire,
use your chain of command process and inform the
provider “I am using the chain of command (com-
munication or resolution) because I need a provider
at the bedside now.” Alternatively, you can ask “I un-
derstand you are not available to come to the bedside
now. Who can I call in your place?” You might ask,
“Do you have remote viewing so that you can review
the tracing immediately?” Then, document that you
asked they review the tracing remotely and their re-
sponse to your request.
■ ORGANIZATIONAL CULTURES
Advocacy, communication, the chain of com-
mand, and evidence-based practice occur within
organizations that have an identifiable culture. The
healthcare organizational culture includes norms,
attitudes, values, assumptions, customs, and be-
haviors (Chervenak & McCullough, 2005; Lefton,
2007; Seren & Baykal, 2007).
A Culture of Safety
A high-reliability organization (HRO) has a culture
of safety where prevention of adverse events is an
obvious system-wide goal. Within that type of orga-
nization, nurses will not have barriers to report ad-
verse events. Adverse events will be investigated and
16 ■ LABOR AND DELIVERY NURSING
root causes that resulted in injury or death will be
identified. Changes in policies or procedures may be
enacted to improve or optimize safety and prevent
adverse outcomes.
A healthy organization has a culture that is
committed to honest business practices and is
focused on the needs of patients, community,
and society (Chervenak & McCollough, 2005).
Great leaders create an environment that en-
ables the best solutions and the best decisions
(Henrikson, 2007). In a healthy organization,
communication should occur among the pa-
tient, her partner, her friends and visitors, and
all members of the healthcare team (Simkin &
Ancheta, 2005).
Collaborative or Competitive Organizations
Healthcare organizations may also be collaborative
or competitive. In a collaborative organization, there
is teamwork and team management to reach a desired
goal. In a competitive organization, achievement, a
sense of superiority, excellence, and possessing tech-
nology that is better than other organizations will be
the goals. If the organization has a power culture, au-
thority will be the center of attention, and tasks will
be assigned by a manager.
Cynical Organizations
Cynical organizations have leaders who are not sup-
portive and who create a hostile work environment.
Communication in that type of organization can be
difficult or even intimidating. An unresponsive cul-
ture will have leaders with a dictatorial, top-down,
threatening, and punishing style of behavior. This
type of leadership creates communication barriers.
A submissive culture will be unresponsive, will have
minimal expectations and communication, and will
provide minimal feedback. A submissive, but respon-
sive, culture will have people who always agree with
you, who talk a lot but do not listen, who gloss over
performance issues, who only provide positive feed-
back, and who seek harmony (Lefton, 2007). It is im-
portant that you determine the type of organization
and culture within which you work.
A Culture of Civility
In a culture of civility, disruptive behavior is less
likely to occur. Leaders will be transformational.
Transformational leaders model behavior; encour-
age the heart; inspire a shared vision; enable oth-
ers to act; and challenge the process. They support
open communication, inspiration, enthusiasm, and
support positive change. They empower others
through shared decision-making (Clavelle & Prado-
Inzerillo, 2018).
In a culture of civility, patient needs are the num-
ber one priority. Nursing leaders support nurses and
do not tolerate or perpetuate workplace incivility. To
promote respect and civility, these leaders will social-
ize their prospective employees to inform them that
they expect civility and a respectful atmosphere; they
will conduct unit meetings to share civility norms
with new hires and current staff; they will create and
post staffing guidelines to ensure safe patient care and
a healthy work environment; and they will address
uncivil behavior and hold employees accountable for
their behavior (Smith, 2019).
A Toxic Culture
The opposite of a toxic culture is a culture of civility.
A toxic culture includes staff who gossip and who ex-
press negativity. The toxic culture has high absentee-
ism and turnover, bullying and incivility. Bullies are
cruel, uncaring, uncivil, and brutal to their colleagues
(Thompson, 2019). If you experience incivility, report
it to your leader(s) so that your concerns can be ad-
dressed in an ethical and fair manner. However, if you
work in a toxic culture, your concerns may never be
addressed and you may need to consider leaving that
environment and working elsewhere.
In a toxic culture, new staff will not receive a warm
welcome. There is a distrust of leaders, a lack of trans-
parency, and a failure to manage unmotivated staff.
There is no accountability for professional practice
in a toxic culture (Sherman, 2019). You may experi-
ence moral distress where you believe you know the
right thing to do but feel unable to pursue that course
of action due to constraints (Whitehead, Herbertson,
Hamric, Epstein, & Fisher, 2015). In a toxic culture,
there is a sense of a lack of psychological safety. Staff
do not feel safe to speak their minds. Errors will be
unreported and mistakes will be made. There is a lack
of teamwork (Sherman, 2019). Clearly, a toxic cul-
ture is unsafe and patients can be injured.
■ LABOR AND DELIVERY MODEL OF CARE
Within the dominant healthcare organization cul-
ture there are subcultures. For example, the culture
in postpartum care may be different from the culture
in the nursery or in labor and delivery. The norms,
attitudes, values, assumptions, customs, and behav-
iors within the subculture of labor and delivery affect
the quality and quantity of communication (Tucker
et al., 2006). Communication is also influenced
by the design of the care model. The four types of
 1. ADVOCACY, COMMUNICATION, CHAIN OF COMMAND, AND EVIDENCE-BASED PRACTICE
intrapartal services include the nurse-managed labor
model, the academic/teaching model, the nurse-to-
attending physician communication-on-site model,
and the nurse-to-nurse midwife communication-on-
site model (Simpson, 2005). For example, if you are
the primary patient care provider and the midwife
or physician is not in the building, you work within
a nurse-managed labor model. In that case you are
responsible for recognizing problems, evaluating la-
bor progress, providing hands-on care, and informing
other team members when they are needed.
In the nurse-to-nurse midwife or physician com-
munication-on-site model, it should be easy to com-
municate with the provider. However, even if the
provider is in the hospital, they may be distracted
by the needs of other patients. Since the labor nurse,
midwife, and physician are part of one collaborative
team, be sure to keep them up to date so that they
do not miss an opportunity to make clinical decisions
that promote patient safety. If you need them to come
to the bedside, ask them to do so.
DOCUMENTATION EXAMPLE: Spontane-
ous rupture of membranes, fluid clear, non-
foul, saturated 1/3 of linen protector. Variable
decelerations noted. Certified Nurse Midwife
(CNM) called on postpartum unit and in-
formed of spontaneous rupture of membranes,
clear fluid, variable decelerations. Requested
CNM come to bedside immediately to evaluate
patient. CNM stated she was on her way.
Perhaps you work with residents in an academic/
teaching model setting. In this setting, the residents
will assess the cervix and fetal station and insert
internal monitors such as the spiral electrode or in-
trauterine pressure catheter. Nurse-to-resident com-
munication may be hindered by the resident’s need to
control the decision-making process. However, that
does not mean you should withhold your findings or
concerns. If you feel the plan of care needs to change,
you must speak up.
Ineffective or inadequate communication is a
threat to patient safety. In fact, communication issues
were found to be the primary root cause that resulted
in injury during delivery and infant death after deliv-
ery (The Joint Commission, 2004). Other root causes
included organization culture as a barrier to effective
communication and teamwork, hierarchy and intimi-
dation, failure to function as a team, and failure to
follow the chain of communication. Other root causes
identified by The Joint Commission (2004) were staff
competency, orientation and training, inadequate fe-
tal monitoring, unavailable monitoring equipment
and/or drugs (resources), unavailable or delayed phy-
sician, and unavailability of prenatal information.
■ 17
COMMUNICATION CLINICAL EXAMPLE:
You observe late decelerations and no accelera-
tions, and the resident orders you to administer
oxytocin. You change your patient’s position
to her right side, place a tight-fitting non-
rebreather face mask with oxygen flowing at
15 L/minute, adjust the ultrasound transducer
and tocotransducer, and note the continuation
of late decelerations. You also note her blood
pressure is normal. You say, “I’d like to wait at
least 15 minutes to see if the baby’s heart rate
improves.” The resident dons a sterile glove,
rubs the fetal scalp, evokes an acceleration, and
insists you administer the oxytocin immediately.
You then say, “There have been no spontane-
ous accelerations for the last hour, variability
is absent or minimal, and the late decelerations
continue to persist in spite of the intrauterine
resuscitation actions.” You then call your team
leader or charge nurse to the room using the
patient call light. At that point, if the resident
continues to insist on the administration of oxy-
tocin, the charge nurse and the resident should
leave the room to continue the discussion about
the plan of care.
■ CARE COORDINATION
Care coordination ensures patient’s needs and prefer-
ences for health services and their health information
is shared with people at various sites over time (Mc-
Cammon & Francis, 2018). Optimal safety requires
care coordination and continuity of care with a lack
of chaos or rapid change. Feeling safe also depends
on a patient’s sense of connection and respect from
care providers. The organization also needs excellent
communication between and among members of the
healthcare team (Lyndon et al., 2018). The organiza-
tion must lack bias and demonstrate its cultural val-
ues and policies in order to reduce racial inequities.
There must be a lack of structural racism, systemic
racism, or institutional racism. There should be a cul-
ture of respect where actions are taken toward oth-
ers that protect, preserve, and enhance their dignity.
The organizational culture must be accountable and
include leaders that optimize the balance between the
individual and the system (a just and safe culture).
The just and safe culture will have a robust reporting
system where employees feel confident that the con-
tents of their report will remain confidential and lead
to system improvements not punishment (Howell
et al., 2018).
Unlike a just and safe culture, a culture of perfec-
tion will blame employees for mistakes, and shame
individuals. This will result in a decrease in the num-
ber of reports of errors (Zabari & Southern, 2018). A
18 ■ LABOR AND DELIVERY NURSING
high-reliability organization (HRO) is another name
for a just and safe culture. An HRO will have systems
in place to reduce the risk of error and support error
reporting. An HRO is a just, safe, and civil organiza-
tion that encourages error reporting. It will have lead-
ers who have a preoccupation with failure and who
work to make things right. These HRO leaders will
be aware of internal and external factors in the team,
technology, and environment; will possess a question-
ing attitude and challenge assumptions; will bounce
back from mistakes before there is more damage; and
will identify experts or those with the most experi-
ence in a situation (Moeller et al., 2019). There may
be interdisciplinary team huddles every 4 hours dur-
ing labor for FHR tracing review, which can improve
term fetal and neonatal health outcomes (Thompson,
Krening, & Parrett, 2018). Policies, procedures, and
protocols will be evidence based with research and
other references. Other safety huddles may be devel-
oped that include review of all of the patients (board
reports); individualized patient huddles (shift change
reports); and/or spontaneous huddles where the nurse
calls together the interdisciplinary team.
In any organization, women in labor have an in-
creased risk of HIE of their baby. Evidence-based
practice can reduce the incidence of HIE. For exam-
ple, it was found that implementation of a labor and
delivery safety bundle, especially for women who had
a high-risk pregnancy, reduced the risk of fetal brain
damage and neonatal HIE. In a study of outcomes
for 5,826 deliveries, researchers found fewer adverse
outcomes for women who had a high-risk pregnancy.
There was a reduction in uterine rupture, third- and
fourth-degree lacerations, HIE, and birth trauma.
The safety bundle that resulted in fewer adverse out-
comes required the obstetrician to physically be pres-
ent at all times during their scheduled duty shift and
required they review the labor curve (partogram) to
maintain situational awareness. Also, obstetricians
were informed of adverse outcomes as part of their
annual staff evaluation. In addition, as a result of
obstetrician presence and review of the labor curve,
there was a significant reduction in liability claims
and payments (Tolcher et al., 2016). If the obstetri-
cian is not present, there will be a lack of oversight
by the attending obstetrician and there may be inef-
fective communication among team members (a find-
ing of Tolcher et al. [2016] that was a root cause of
HIE of a neonate). Using this evidence from Tolcher
et al. (2016), prevention of adverse outcomes in the
absence of an obstetrician will require a competent
nurse who reviews and analyzes the labor curve and
who promptly reports abnormalities to the obstetri-
cian. The nurse must have the knowledge to prop-
erly interpret the labor curve and the fetal heart rate
and uterine activity tracing. The nurse must have the
foresight and courage to request the obstetrician’s
presence at the bedside to prevent adverse outcomes
in high-risk women. They must be willing to say, “I
am concerned. I am uncomfortable. This is a safety
issue” (AHRQ, 2013).
■ PROVIDER ROLES AND EXPECTATIONS
In order to know whom to call or with whom to
share information, you need to know the roles and
responsibilities of the other healthcare providers.
Your hospital should have policies and procedures
that define the maternal/child services for family
practitioners, residents, obstetricians, and anesthesia
providers. For example, family practitioners may be
credentialed to evaluate the condition of the mother
and infant, order medications, deliver the infant
when there is a cephalic presentation (or by using
low forceps or a vacuum extractor), and resuscitate
the infant. They may be credentialed to repair the
episiotomy, but must consult with the obstetrician
for certain conditions. An obstetrical consult may be
required for some procedures. An obstetrician may
need to be consulted for abnormal bleeding, a re-
tained placenta, preeclampsia, prolonged labor, mul-
tiple gestation, induction of labor, polyhydramnios,
before any obstetrical operation or breech delivery,
for medical or surgical complications, for preterm
labor and tocolysis, or for a trial of labor after a
cesarean section.
Obstetricians perform duties similar to family phy-
sicians, but they also usually have privileges for mid-
forceps and cesarean sections. Anesthesia providers
evaluate the condition of the mother prior to the ad-
ministration of an anesthetic agent, place and remove
indwelling epidural catheters, inject medication into
the epidural catheter, initiate continuous infusions ad-
ministered through the epidural catheter, and remain
immediately available during the induction of epi-
dural anesthesia. They rarely know how to interpret
the fetal heart rate pattern or uterine activity pattern,
and you should not expect them to do so. Therefore,
it is your responsibility to be sure the maternal and fe-
tal conditions are stable prior to the administration of
an anesthetic. If the mother or fetus is unstable, speak
to the obstetric care provider prior to the administra-
tion of analgesia or anesthesia.
Physicians and/or certified nurse midwives may
create the initial plan of care with informed consent
of the patient. The nurse is responsible for coordinat-
ing care, suggesting changes in the plan of care, and
knowing who else is on the team taking care of the
patient. An error can be committed if the wrong plan
is followed or there is a failure to complete a planned
action (Institute of Medicine, 1999). Therefore, you
 1. ADVOCACY, COMMUNICATION, CHAIN OF COMMAND, AND EVIDENCE-BASED PRACTICE ■ 19

TABLE 1.2 GENERIC NURSING PLAN OF CARE ELEMENTS

1. Problem: Alteration in self-perception related to anxiety.

Outcome: Patient will understand procedures and processes and adapt without undue additional anxiety.

2. Problem: Alteration in comfort related to progress in labor and delivery.

Outcome: Patient will become comfortable.

3. Problem: Potential for infection related to rupture of membranes.

Outcome: Patient will be free of infection.

4. Problem: Alteration in maternal and/or fetal perfusion and oxygen delivery related to contractions and labor
process.

Outcome: Patient will progress through labor and delivery without complications.

5. Problem: Alteration in self-perception related to expanded role.

Outcome: Patient will experience time to bond with her infant after delivery.

6. Problem: Potential for hemorrhage following delivery related to altered hemodynamics.

Outcome: Patient will recover without unusual blood loss.

must know the plan of care and communicate with
other healthcare team members often during your
shift to accomplish that plan of care or to change the
plan of care. As the patient’s condition changes, the
plan of care must also change.
■ AN INDIVIDUALIZED EVIDENCE-BASED
PLAN OF CARE
A generic nursing plan of care is not individualized
and may not even be evidence based. However, both
should include a nursing diagnosis. Some nursing di-
agnoses were approved by the North American Nurs-
ing Diagnosis Association International (NANDA).
For example, labor pain is a NANDA-approved nurs-
ing diagnosis. Your hospital may have a list of other
nursing diagnoses; you might also create a nursing
diagnosis. Nursing diagnoses are the problem or po-
tential problems (see Table 1.2).
■ CHANGING THE INDIVIDUALIZED PLAN
OF CARE
EBP that is patient centered should optimize health
and reduce the risk of harm to childbearing women
and their babies. Nurses communicate with provid-
ers when they have assessed evidence, formed a nurs-
ing diagnosis, and realize the plan of care needs to
change to optimize maternal and fetal health and
to prevent harm. Nurses also identify care issues
that need ethical, legal, or risk intervention. Once
the nurse realizes the plan of care needs to change,
communication with the nursing leader or provider
(in the absence of a nursing leader such as a charge
nurse) is required. Advocacy for a change in the plan
of care may be needed if the nursing leader or pro-
vider is unresponsive to the nurse’s request. If com-
munication with a provider intimidates you, talk to
your charge nurse or a more experienced nurse and
ask for help communicating to change the plan of
care. Once you have communicated patient data and/
or their request(s), document it in the medical record.
Include the time you communicated, to whom you
spoke, what you said, what that person or persons
said, and any actions taken by you, your supervisor,
or the provider.
DOCUMENTATION EXAMPLE: Subtle late
decelerations, fetal heart rate baseline sinusoi-
dal-like. Dr. Seinwave called at home. Informed
of baseline 130 to 140 bpm, recurrent subtle
late decelerations, contractions every 2 min-
utes lasting 50 seconds, moderate to palpation.
Telephone order for oxytocin received and read
back to physician. This nurse did not act on the
oxytocin order. This nurse did request the phy-
sician to come to bedside now to evaluate the
fetal-pelvic fit and the fetal heart rate and con-
tractions. Charge Nurse Ima Responsible noti-
fied of the above. Patient notified the physician
was called regarding concerns.
20 ■ LABOR AND DELIVERY NURSING
DOCUMENTATION EXAMPLE: Recurrent
variable decelerations with baseline 140 bpm,
minimal variability. Dr. Listo called to the bed-
side and is en route. OB Hospitalist called to the
bedside. This nurse reviewed tracing with OB
Hospitalist Dr. Aqui. Cesarean section ordered
and clinical care coordinator (charge nurse) no-
tified of urgent cesarean section order.
Nurses recognize, verbalize, and mobilize. “In
emergencies, when prompt action is necessary and
the physician is not immediately available, a nurse
may be justified in acting contrary to the physician’s
standing orders for the safety of the patient” (AMA,
1997). Staffing should be based on the acuity of pa-
tients and standardized protocols should be followed
for emergencies (Fariello & Paul, 2005). Therefore,
if you recognize a problem, notify other nurses, and
tell them what you want them to do. Remain calm,
maintain a patient safety focus. A pilot once said, “In
a turbulent storm, just keep the wings level. Tough it
out. Fall apart after you land.”
CONCLUSIONS
For women and their children to be safe, healthcare
providers must have compassion, be vigilant, and
practice evidence-based care within a healthcare sys-
tem that has a culture of safety. Effective, closed loop
communication is necessary to provide the best care
for patients and to prevent errors and injury (Cher-
ouny et al., 2005). Cognitive errors with a lack of
critical thinking and appropriate decisions can occur
and do occur and result in poor communication and
documentation. Cognitive errors can and do result in
the lack of individualized plans of care, needed ac-
tions, injury, and death of patients. To optimize out-
comes and maximize safety, find a place of work that
has a healthy culture. Determine if it is an HRO with
safety as a priority and open and collaborative com-
munication among team members. If concerns con-
tinue or issues related to care arise, own your ethical
duty to be a patient advocate. Consult members of
your chain of command/communication/resolution
as you see a need. You are a vital part of the health-
care team. You are responsible for the safety and well-
being of the people you care for.
REVIEW QUESTIONS
True/False: Decide if the following statements are
true or false.
1. Childbirth safety requires competent, compas-
sionate and vigilant care but bias is not a factor.
2. An exhausted healthcare worker may have com-
passion fatigue.
3. Attention to detail (vigilance) can decrease in
20 to 30 minutes resulting in vigilance fatigue, a
safety hazard.
4. One element of a complete nurse-to-nurse report
at the beside is a review of the labor curve and
any abnormalities.
5. A time to communicate with a midwife or physi-
cian is when the patient has a physical or psycho-
logical need.
6. Patients can provide valuable information to
increase the ability of physicians to diagnose their
condition.
7. A toxic culture has high absenteeism, incivility,
bullying, but a low turnover of personnel.
8. Chain of command is invoked as a nurse’s ethi-
cal duty as a patient advocate to promote patient
safety and prevent harm.
9. The last R in SBARR stands for the patient’s
response to interventions.
10. Patients want a nurse who follows the physician’s
orders even when they have the potential to harm
the patient.
REFERENCES
Agency for Healthcare Research and Quality. (2013).
TeamSTEPPS® 2.0 pocket guide (AHRQ Pub. No.
14-0001-2). Rockville, MD: Author.
Allan, S. H. (2018). Nurse perception of alarm fatigue
impacts compliance with alarm management.
Education can help nursing staff gain control and
improve patient safety. American Nurse Today, 13(5),
26–28.
American Academy of Pediatrics. (2018). AAP diversity
and inclusion statement. Pediatrics, 141(4), e20180193.
doi:10.1542/peds.2018-01777
American College of Obstetricians and Gynecologists.
(2011). Partnering with patients to improve patient
safety (Committee Opinion Number 490). Washington,
DC: Author.
American College of Obstetricians and Gynecologists.
(2018). Fatigue and patient safety (Committee Opinion
Number 730). Washington, DC: Author.
American Medical Association. (1997). Code of medical
ethics: Current opinions and annotations. Chicago, IL:
Author.
Association of Women’s Health, Obstetric and Neonatal
Nurses. (2018a). Health information technology for the
perinatal setting. Washington, DC: Author.
Association of Women’s Health, Obstetric and Neonatal
Nurses. (2018b). Standards for professional nursing
practice in the care of women and newborns (8th ed.).
Washington, DC: Author.
Bivins, R., Tierney, S., & Seers, K. (2017). Compassionate
care: Not easy, not free, not only nurses.
BMJ Quality & Safety, 26, 1023–1026. doi:10.1136/
bmjqs-2017-007005
Cherouny, P. H., Federico, F. A., Haraden, C., Leavitt
Gullo, S., & Resar, R. (2005). Idealized design
 1. ADVOCACY, COMMUNICATION, CHAIN OF COMMAND, AND EVIDENCE-BASED PRACTICE
of perinatal care. (IHI Innovation Series White
Paper) Cambridge, MA: Institute for Healthcare
Improvement.
Chervenak, F. A., & McCullough, L. B. (2005). The
diagnosis and management of progressive dysfunction
of health care organizations. Obstetrics & Gynecology,
105(4), 882–887. doi:10.1097/01.AOG.0000156302
.37189.2f
Clavelle, J. T., & Prado-Inzerillo, M. (2018). Inspire others
through transformational leadership. American Nurse
Today, 13(11), 39–41.
Cocker, F., & Joss, N. (2016). Compassion fatigue
among healthcare, emergency and community service
workers: A systematic review. International Journal of
Environmental Research and Public Health, 13, 618.
doi:10.2290/ijerph13060618
Croskerry, P. (2003). Cognitive forcing strategies in
clinical decision-making. Annals of Emergency
Medicine, 41(1), 110–120. doi:10.1067/mem.2003.22
Croskerry, P. (2005). The theory and practice of clinical
decision-making. Canadian Journal of Anesthesia, 52,
R1. doi:10.10.1007/BF03023077
Croskerry, P. (2006). Critical thinking and
decision-making: Avoid the perils of thin-slicing.
Annals of Emergency Medicine, 48, 720–722.
doi:10.1016/j.annemergmed.2006.03.030
Cudé, G., & Winfrey, K. (2007). The hidden
barrier. Gender bias: Fact or fiction? Nursing
for Women’s Health, 11(3), 255–265.
doi:10.1111/j.1751-486X.2007.00165.x
Curtin, L. (2019). Errors, care, and the bottom line.
American Nurse Today, 14(2), 44.
Dzubak, J. L. (2018). Nurses cry, too: What happens
when we can’t fix everyone. Strategies for processing a
patient’s death. American Nurse Today, 13(6), 50–51.
Eason, E., & Feldman, P. (2000). Much ado about a
little cut: Is episiotomy worthwhile? Obstetrics &
Gynecology, 95(4), 616–618. doi:10.1097/00006250
-200004000-00027
Fariello, J. Y., & Paul, E. (2005). Patient safety issues
in a tertiary care hospital’s labor and delivery
unit. Nursing for Women’s Health, 9(4), 321–323.
doi:10.1177/1091592305280876
Forster, D. (2009). Rethinking compassion fatigue as
moral stress. Journal of Ethics inMental Health, 4(1),
1–4.
Francis, R. (2018). Nurse fatigue: A shared responsibility.
American Nurse Today, 13(11), 26.
Gelinas, L. (2019). Nursing care: The quest to
eliminate preventable harm. American Nurse
Today, 14(2), 4.
Goleman, S., Boyatzis, R., & McKee, A. (2002). Primal
leadership: Realizing the power of emotional
intelligence. Boston, MA: Harvard Business School
Publishing.
Guise, J. M., & Lowe, N. K. (2006). Do you speak
SBAR? Journal of Obstetric, Gynecologic,
and Neonatal Nursing, 35(3), 313–314.
doi:10.1111/j.1552-6909.2006.00043.x
Hamilton, P., & Restrepo, E. (2003). Weekend birth and
higher neonatal mortality: A problem of patient acuity
or quality of care? Journal of Obstetric, Gynecologic,
and Neonatal Nursing, 32(6), 724–733.
Hardie, R. (2012). Chain of resolution: A bold new way
to go. Journal of Obstetric, Gynecologic, and Neonatal
Nursing, 41, S98. doi:10.1111/j.1552-6909.2012
.01361.c
■ 21
Henrikson, M. (2006). Great leaders are made, not born.
AWHONN Lifelines, 10, 335–338. doi:10.1111/
j.1552-6356.2006.00064.x
Henrikson, M. (2007). Great leaders are made, not born:
Conclusion of a four-part series. AWHONN Lifelines,
10(6), 510–515. doi:10.1111/j.1552-6356.2006
.00101.x
Howell, E. A., Brown, H., Brumley, J., Bryant, A. S.,
Caughey, A. B., Cornell, A. M., … Grobman,W.A.
(2018). Reduction of peripartum racial and ethnic
disparities: A conceptual framework and maternal
safety consensus bundle. Journal of Obstetric,
Gynecologic, and Neonatal Nursing, 47(3), 275–289.
doi:10.1016/j.jogn.2018.03.044
Hunsaker, S., Chen, H.-C., Maughan, D., & Heaston,
S. (2015). Factors that influence the development
of compassion fatigue, burnout, and compassion
satisfaction in emergency department nurses. Journal
of Nursing Scholarship, 47(2), 186–194. doi:10.1111/
jnu.12122
Institute of Medicine. (1999). To err is human: Building
a safer health system. Washington, DC: National
Academies Press.
The Joint Commission. (2004). Sentinel event alert #30.
Oakbrook Terrace, IL: Author.
Joint Commission on Accreditation of Healthcare
Organizations. (2004). Preventing infant death during
delivery. (Sentinel Event Alert No. 30) Oak Brook, IL:
Author.
Jubb, J. M., & Baack, C. J. (2019). Verbal de-escalation
for clinical practice safety. American Nurse Today,
14(1), 5–7.
Katz, A. (2005). Think before you speak. AWHONN
Lifelines, 9(2), 105–106. doi:10.1111/j.1552-6356
.2005.tb00760.x
Kendig, S. (2006). Primary care safety. AWHONN
Lifelines, 10(6), 502–509. doi:10.1111/j.1552-6356
.2006.00100.x
Körber, M., Cingel, A., Zimmermann, M., & Bengler,
K. (2015). Vigilance decrement and passive fatigue
caused by monotony in automated driving. Procedia
Manufacturing, 3, 2403–2409. doi:10.1016/
j.promfg.2015.07.499
Krick, J., & Cjabra. S. (2018). On “end-of-life decision
making for parents of extremely preterm infants”.
Journal of Obstetric, Gynecologic, and Neonatal
Nursing, 47, 415–417. doi:10.1016/j.jogn.2018
.01.007
Kushida, C. A. (2005). Sleep deprivation: Clinical issues,
pharmacology, and sleep loss effects. New York, NY:
Marcel Dekker.
Lazoritz, S., & Carlson, P. J. (2008). Don’t tolerate
disruptive physician behavior: Bad behavior harms
both staff and patients. Reporting it benefits everyone.
American Nurse Today, 3(3), 20–22.
Lefton, C. (2007). Does your workplace culture need
CPR? American Nurse Today, 32–35.
Lombardo, B., & Eyre, C. (2011). Compassion
fatigue: A nurses’ primer. The Online Journal of
Issues in Nursing, 16(1), 3. doi:10.3912/OJIN
.Vol16No01Man03
Lowe, N. K. (2018). Disparities in the health of women
and children. Journal of Obstetric, Gynecologic, and
Neonatal Nursing, 47, 273–274. doi:10.1016/j.jogn
.2018.04.001
Lyndon, A., Malana, J., Hedli, L. C., Sherman, J., &
Lee, H. C. (2018). Thematic analysis of women’s
22 ■ LABOR AND DELIVERY NURSING
perspectives on the meaning of safety during hospital-
based birth. Journal of Obstetric, Gynecologic, and
Neonatal Nursing, 47, 324–332. doi:10.1016/
j.jogn.2018.02.008
Mahley, S., & Beerman, J. (1998). Following the
chain of command in an obstetric setting: A nurse’s
responsibility. Journal of Legal Nurse Consulting, 9(1),
7–13.
Mathieu, F. (2007). Running on empty: Compassion
fatigue in health professionals. Rehabilitation and
Community Care Medicine, 4, 8–10. Retrieved from
http://www.compassionfatigue.org
McCammon, S., & Francis, R. (2018). Moving forward
with nurse-led care coordination. American Nurse
Today, 13(5), 23.
McClure, M. L., & Hinshaw, A. S. (Eds.). (2002).
Magnet hospitals revisited: Attraction and retention of
professional nurses. Washington, DC: American Nurses
Association.
McVeigh, C. (1997). Motherhood experiences from the
perspective of first-time mothers. Clinical Nursing
Research, 6(4), 335–348. doi:10.1177/
105477389700600404
Moeller, D., Westrate, R., & Araujo, M. (2019). Safety
culture: A journey to zero. American Nurse Today,
14(2), 44–46.
Nunes, J., & McFerran, S. (2005). Perinatal patient safety
project. Permanente Journal, 9(2).
Oken, B. S., Salinsky, M. C., & Elsas, S. M. (2006).
Vigilance, alertness, or sustained attention:
Physiological basis and measurement. Clinical
Neurophysiology,117(9), 1885–1901. doi:10.1016/
j.clinph.2006.01.017
Parer, J. T., & Ikeda, T. (2007). A framework for
standardized management of intrapartum fetal heart
rate patterns. American Journal of Obstetrics and
Gynecology, 197(1), 26.e1–26.e6. doi:10.1016/
j.ajog.2007.03.037
Pattyn, N., Neyt, X., Henderickx, D., & Soetens, E.
(2008). Psychophysiological investigation of
vigilance decrement: Boredom or cognitive fatigue?
Physiology& Behavior, 93, 369–378. doi:10.1016/
j.physbeh.2007.09.016
Phillips, C. (2003). Family-centered maternity care.
Sudbury, MA: Jones and Bartlett.
Price, V., & Archbold, J. (1995). Development and
application of social learning theory. British Journal
of Nursing, 4(21), 1263–1268. doi:10.12968/
bjon.1995.4.21.1263
Rogers, A. E. (2008). The effects of fatigue and sleepiness
on nurse performance and patient safety. In R. G.
Hughes (Ed.), Patient safety and quality: An evidence-
based handbook for nurses (pp. 2-509–2-545).
Rockville, MD: Agency for Healthcare Research and
Quality.
Rogers, A. E., Hwang, W., Scott, L., Aiken, L., & Dinges,
D. (2004). The working hours of hospital staff nurses
and patient safety. Health Affairs, 23(4), 202–212.
doi:10.1377/hlthaff.23.4.202
Sabo, B. M. (2006). Compassion fatigue and
nursing work: Can we accurately capture the
consequences of caring work? International
Journal of Nursing Practice, 12(3), 136–142.
doi:10.1111/j.1440-172X.2006.00562.x
Seren, S., & Baykal, U. (2007). Relationships between
change and organizational culture in hospitals.
Journal of Nursing Scholarship, 39(2), 191–197.
doi:10.1111/j.1547-5069.2007.00166.x
Sherman, R. O. (2019). 4 steps to repairing a toxic culture.
Psychological safety, shared vision, staff ownership, and
success celebration. American Nurse Today, 14(3), 5.
Sherman, R. O., & Cohn, T. M. (2019). Promoting
professional accountability and ownership. American
Nurse Today, 14(2), 24–26.
Simkin, P., & Ancheta, R. (2005). The labor progress
handbook (2nd ed.). Oxford, UK: Blackwell Publishing.
Simpson, K. R. (2005). The context and clinical
evidence for common nursing practices
during labor. MCN: The American Journal
of Maternal Child Nursing, 30(6), 356–363.
doi:10.1097/00005721-200511000-00002
Simpson, K. R., & Chez, B. F. (2001). Professional and
legal issues. In K. R. Simpson & P. A. Creehan (Eds.),
AWHONN’s perinatal nursing (2nd ed., pp. 21–52).
Philadelphia, PA: Lippincott Williams & Wilkins.
Sinclair, S., Beamer, K., Hack, T. F., McClement, S.,
Bouchal, S. R., Chochinov, H. M., &Hagen,N.
A. (2017). Sympathy, empathy, and compassion:
A grounded theory study of palliative care
patients’ understandings, experiences, and
preferences. Palliative Medicine, 31(5), 437–447.
doi:10.1177/0269216316663499
Smith, J. (2019). Establishing norms of respect—Strategies
for nurses and managers. American Nurse Today,
13(6), 44–46.
Stichler, J. F. (2006). Emotional intelligence.
A critical leadership quality for the nurse
executive. AWHONN Lifelines, 10(5), 422–425.
doi:10.1111/j.1552-6356.2006.00083.x
Stichler, J. F. (2007a). Is your hospital hospitable? How
physical environment influences patient safety.
Nursing for Women’s Health, 11(5), 506–511.
doi:10.1111/j.1751-486X.2007.00226.x
Stichler, J. F. (2007b). Social intelligence: An essential trait
of effective leaders. Nursing for Women’s Health, 11(2),
189–193. doi:10.1111/j.1751-486X.2007.00144.x
Thompson, L., Krening, C., & Parrett, D. (2018).
Interdisciplinary team huddles for fetal heart rate
tracing review. Nursing for Women’s Health, 22(3),
240–249. doi:10.1016/j.nwh.2018.03.002
Thompson, R. (2019). What if you’re the bully? Self-
awareness and honest feedback can help you make a
change. American Nurse Today, 14(1), 22–25.
Tolcher, M. C., Torbenson, V. E., Weaver, A. L., McGree,
M. E., El-Nashar, S. A., Nesbitt, K. M., …Famuyide, A.
O. (2016). Impact of a labor and delivery safety bundle
on a modified adverse outcomes index. American
Journal of Obstetrics & Gynecology, 214, 401.e1–401.
e9. doi:10.1016/j.ajog.2016.01.155
Trinkoff, A., Geiger-Brown, J., Brady, B., Lipscomb,
J. U., & Muntaner, C. (2006). How long
and how much are nurses now working?
American Journal of Nursing, 106(4), 60–72.
doi:10.1097/00000446-200604000-00030
Trossman, S. (2007). Issues up close: The science behind
caring. American Nurse Today, 2(12), 40–41.
Tucker, S., Klotzbach, L., Olsen, G., Voss, J., Huus, B.,
& Olsen, R. (2006). Lessons learned in translating
research evidence on early intervention programs
into clinical care. MCN: American Journal
of Maternal Child Nursing, 31(5), 325–331.
doi:10.1097/00005721-200609000-00012
 1. ADVOCACY, COMMUNICATION, CHAIN OF COMMAND, AND EVIDENCE-BASED PRACTICE
Welker-Hood, K. (2006). Does workplace stress lead
to accident or error? American Journal of Nursing,
106(9), 104. doi:10.1097/00000446-200609000-00042
White, A. A., Pichert, J. W., Bledsoe, S. H., Irwin, C.,
& Entman, S. S. (2005). Cause and effect analysis
of closed claims in obstetrics and gynecology.
Obstetrics & Gynecology, 105(5, Pt. 1), 1031–1038.
doi:10.1097.01.AOG.0000158864.09443.77
Whitehead, P. B., Herbertson, R. K., Hamric, A. B.,
Epstein, E. G., & Fisher, J. M. (2015). Moral distress
■ 23
among healthcare professionals: Report of an
institution-wide survey. Journal of Nursing Scholarship,
47(2), 117–125. doi:10.1111/jnu.12115
World Health Organization. (2018). WHO
recommendations: Intrapartum care for a positive
childbirth experience. Geneva, Switzerland: Author.
Zabari, M. L., & Southern, N. L. (2018). Effects of shame
and guilt on error reporting among obstetric clinicians.
Journal of Obstetric, Gynecologic, and Neonatal
Nursing, 47, 468–478. doi:10.1016/j.jogn.2018.03.002

Assessment to Create an
Individualized Plan of Care
and Informed Consent
Constant attention by a good nurse may be just as important as a major
operation by a surgeon.
—Dag Hammarskjöld (former Secretary-General of the United Nations)
INTRODUCTION
Assessment is the gathering of data through the senses,
questioning the childbearing woman and her family
and significant other, and reviewing the medical re-
cords. Triage can be both a place and a process of
brief, thorough, systematic assessment to determine
acuity as emergent, urgent, prompt, or nonurgent, or
for a test or procedure. Getting the assessment and
acuity right impacts patient safety and outcomes.
The timeliness of assessment should occur in less
than 10 minutes (Quaile, 2018). After data are col-
lected, the nursing process includes critical thinking,
clinical decisions, nursing diagnoses, creation of an
individualized plan of care, forethought (planned de-
cisions prior to action), and shared decisions with the
woman. In some cases, there will need to be informed
consent prior to surgery or other procedures. Safety is
diminished when assessments are incomplete and the
plan of care is not individualized. Adverse outcomes
are more likely when actions are not responsive to
the maternal or fetal condition. Adverse outcomes
may include fetal injury resulting in cerebral palsy
or death (Gaffney, Sellers, Flavell, Squier, & Johnson,
1994). This chapter focuses on the assessment pro-
cess in triage and the labor room, determination of
the maternal and fetal risk of an adverse outcome,
creation of an individualized plan of care, and shared
decision-making for comfort and other needs during
labor and how this differs from informed consent.
Interdisciplinary collaboration is critical as an unin-
formed provider cannot provide informed consent.
2
C H A P T E R
■ TRIAGE AS A PLACE
Triage is both a process for rapid assessment of the
childbearing woman and her fetus(es) and it can be
accomplished in a room designated for triage or in the
labor room. Triage may be an area designated for out-
patient services. Occasionally, triage will be a place to
evaluate gynecologic patients or postoperative or post-
partum patients (Ciranni & Essex, 2007). Sometimes
triage units include a separate fetal assessment area
and a holding area where external cephalic versions
and other procedures are performed (Angelini, 2006).
Triage Staff
A triage nurse must be experienced, confident, deci-
sive, an excellent communicator, and a leader. The
triage nurse must be an expert nurse and be able to
promptly assess the patient, identify problems, deter-
mine the acuity and priority status, promptly com-
municate with the right personnel to meet the patient
needs based on the priority status, and act to expedite
care when it is needed (Mahlmeister & Van Mullem,
2000). Triage nurses need a minimum of 2 years of
obstetric experience (Quaile, 2018). They need to
be well educated with clear guidelines on how to re-
spond to the different priority levels for treatment.
Triage may also be staffed with midwives, nurse
practitioners, physician’s assistants, residents, an OB
hospitalist, or other physicians. These providers must
make management decisions based on acuity. They
may decide to admit, deliver, or discharge the woman.
26 ■ LABOR AND DELIVERY NURSING
As a nurse, you must agree with this decision. If you
do not, involve your chain of command (chain of
communication; chain of resolution) so that maternal
and fetal safety are preserved.
Triage Patients
Typical patients in an obstetric triage unit include
women who report decreased fetal movement, women
in term or preterm labor, women who experienced
trauma, women with preterm premature rupture of
the membranes (PPROM), women with pregnancy-
induced hypertension or an infection or deep vein
thrombosis, women who are dehydrated or who com-
plain of shortness of breath, chest pain, and/or gastroin-
testinal disease (American College of Obstetricians and
Gynecologists, 2016; Jenkin-Capiello, 2000). PPROM
increased the risk of a placental abruption within
24 hours of the PPROM. They also had an increased
risk of abruption in the presence of intrauterine infec-
tion or oligohydramnios (Ananth, Oyelese, Srinivas,
Yeo, & Vintzileos, 2004). Assessment of vaginal bleed-
ing and vital signs will provide important data.
A medical emergency would be a large placental
abruption with vaginal bleeding and pain. This would
demand immediate attention and action. When there
is a separate obstetric ED (OB ED) or separate OB
Triage Unit, it is important for the hospital to col-
laborate and communicate with emergency medical
services in the community and with the main ED to
instruct everyone to bring any pregnant woman to
the OB ED and to bypass the main ED (American
College of Obstetricians and Gynecologists, 2016).
This will expedite the triage process.
■ TRIAGE LOG
Federal law in the United States related to the Emer-
gency Medical Treatment and Active Labor Act
(EMTALA), Title 42, Part 489.20, requires that a
log be maintained in the ED for pregnant women,
20 weeks or more gestation, who are sent to the ob-
stetrics department for their screening. This is called
the “central log.” However, if a pregnant woman by-
passes the ED, there should be a registration process
in triage. In some cases a triage log is created and
maintained. All triage nurses should know where this
log is and who is responsible for entering data into it.
■ TRIAGE AS A PROCESS
Triage as a process has been defined as a visual assess-
ment and acuity assignment by a qualified healthcare
provider for the purpose of identifying an obstetrical
emergency or life-threatening problems. It has also
been described as a brief, thorough, systematic mater-
nal and fetal assessment to determine the acuity (pri-
ority) of care prior to a full assessment (Quaile, 2018).
In the United States and in compliance with the
EMTALA, when a woman presents to triage, a timely
(usually <10 minutes) medical screening examina-
tion should be performed to determine if an emer-
gency medical condition exists. If so, and if there is a
plan to transport the woman to another facility, she
must be stabilized and the physician must certify that
there are benefits of transfer that outweigh the risks
(Angelini & Mahlmeister, 2005). Once screened, her
acuity must be determined.
■ TRIAGE ACUITY LEVELS
One percent to 2% of pregnancies are complicated with
an obstetrical emergency (Clements, Flohr-Rincon,
Bombard, & Catanzarite, 2007). An efficient and sys-
tematic way of determining if a patient is experiencing
an emergency is vital. The Maternal Fetal Triage Index
(MFTI) was designed for childbearing women and it
has five acuity levels: emergent STAT (Priority 1); ur-
gent (Priority 2); Prompt (Priority 3); Nonurgent (Prior-
ity 4); and Scheduled/Requesting/Procedure or Testing
(Priority 5; Quaile, 2018; Ruhl, Scheich, Onokpise, &
Bingham, 2015). Templeman (2018) used the acronym
CURE for a four-category system that included critical,
urgent, routine, and extras. Both are means to prioritize
care, but parameters involving the timing of interven-
tions regarding each category are not defined.
In the MFTI, immediate lifesaving interventions are
required for STAT (Priority 1). These women may have
life-threatening problems, such as diabetic ketoacidosis
(DKA), seizures, or preterm labor, or they may report
decreased fetal movement. The STAT category usually
involves ABCs (airway, breathing, and circulation).
STAT (Priority 1)
A STAT (Priority 1) category requires the triage nurse
to answer the following questions: Does the woman
or fetus have STAT (Priority 1) vital signs? Does the
woman or fetus require immediate lifesaving inter-
vention? Is birth imminent? These women may have
life-threatening problems, as the STAT category usu-
ally involves ABCs. Evidence of a placental abruption,
a uterine rupture, an unresponsive woman, DKA,
seizures, or fetal bradycardia are all STAT/Priority 1
findings (Ruhl et al., 2015).
CLINICAL EXAMPLE: STAT (Priority 1) child-
bearing woman that required immediate life-
saving interventions: A pregnant woman was
 2. ASSESSMENT TO CREATE AN INDIVIDUALIZED PLAN OF CARE AND INFORMED CONSENT ■ 27

driving her car and felt wet. She notices blood
on her pants. Using her mobile telephone, she
notifies paramedics to pick her up at a rela-
tive’s home. She arrives at her relative’s home
5 minutes later. The paramedics are there within a
minute or two later. The fetus is preterm and at 32
weeks of gestation. Vaginal bleeding is occurring
en route to the hospital and vital signs are stable.
Time cannot be sped up or slowed down, but
it can be used as an ally (Templeman, 2018).

Elapsed Time
in Minutes What Transpired
0 Pregnant woman arrives with paramedics in the main ED. Paramedics were not informed to bring pregnant
women to the OB ED.
3 Patient is registered (admitted).
7 OB ED nurse notified Obstetric Emergency Department concerning the pregnant woman who is bleeding.
12 The pregnant woman arrives on the stretcher with the paramedics. The OB ED nurse does an immediate
evaluation or quick look and determines the priority is STAT 1.
13 Woman is taken by paramedics to a separate bay on the stretcher; she moves to the triage bed. A blood-filled
underpad is noted. Paramedics leave.
15 Another triage nurse applies the fetal monitor.
17 The first OB ED nurse leaves the triage bay to find the OB hospitalist, an obstetrician with cesarean section
privileges. She informed the OB hospitalist about vaginal bleeding, pain, and the low fetal heart rate.
17–18 The OB hospitalist comes to the triage bay and does a vaginal examination (in spite of the active vaginal
bleeding) and finds the cervix is dilated 2 cm. No progress note is written. The physician leaves the bay. No
bedside ultrasound is done. At the same time, the first triage nurse leaves the bay and the second triage nurse
stays with the pregnant woman.
19 The first triage nurse calls the on-call obstetrician who agrees to come in STAT. The nurse also calls the charge
nurse on labor and delivery to open the operating room (OR) and to notify the OR team.
19–20 The second triage nurse calls out that there is fetal bradycardia in the 60s.
21 The OB hospitalist returns to the triage bay and declares the need for a “crash C-section” 6 minutes after the
fetal monitor was first applied.
22 The first triage nurse returns to the triage bay.
25 The fetal monitor is removed and the pregnant woman is taken to the “patient-only” elevator and to the labor
and delivery unit.
28 The pregnant woman arrives on the labor and delivery unit and is met by the anesthesiologist who does a quick
pre-anesthesia interview and accompanies the woman and the triage nurse into the OR with the charge nurse.
The OB hospitalist does not want to begin the cesarean section and tells the anesthesiologist to wait for the
on-call obstetrician.
37–39 Preoxygenation, cricoid pressure, IV premedication to prevent or minimize effects of laryngoscopy and other
medications, IV medication of a paralytic, induction by IV infusion of a hypnotic agent, endotracheal intubation
and other measures by the experienced anesthesiologist (general anesthesia) are done.
38 The on-call obstetrician arrived in the OR.
39 Skin incision
42 Delivery by cesarean section under general anesthesia. A 50% abruption was noted. The baby was asphyxiated
and brain damaged.

Did the time to intervene when there was fetal
bradycardia and signs of placental abruption
comply with the urgency of a STAT Priority 1?
What steps could have been eliminated with
system changes, communication, and collabo-
ration to shorten the arrival to delivery time?
As can be seen in the clinical example, triage is
an important process that determines urgency for
treatment. In this example, the priority status for
treatment was STAT (Priority 1). This means the acu-
ity was critical or the highest priority, which required
immediate intervention to prevent decline or damage.
In this example, the priority was correct, but the in-
tervention was too slow and there was fetal injury. A
quality improvement process can improve timeliness
of care. In one study, nurses improved the patient’s
time of arrival to assessment from 19 to 10.4 minutes
28 ■ LABOR AND DELIVERY NURSING
after receiving education (Quaile, 2018). The Asso-
ciation of Women’s Health, Obstetric, and Neonatal
Nurses (2019b) recommended that hospital obstetric
units and EDs need to collaborate as well as emer-
gency response systems outside of the hospital, to es-
tablish guidelines for triage of childbearing women.
Urgent (Priority 2)
In this category, the patient is complaining of urgent,
although not immediately life-threatening issues.
There may be a complaint of decreased fetal move-
ment or the woman may be dehydrated, have a fever,
or be in active labor with a fetus at less than 34 weeks’
of gestation. A fever of 100.4°F or more in women
with a term fetus increases the risk of fetal death and
may or may not be related to an intrauterine infection
(Smulian et al., 2003). Other high-risk medical condi-
tions may exist such as difficulty breathing, an altered
mental status, suicidal or homicidal thoughts or be-
haviors, or a preterm gestation of less than 34 weeks
with or without contractions. The woman may be in
severe pain without contractions or she may require
a higher level of care than the institution can pro-
vide (Association of Women’s Health, Obstetric, &
Neonatal Nurses, 2019b).
CLINICAL EXAMPLE: URGENT (Priority 2)
childbearing woman and an incomplete admis-
sion assessment following suspected trauma:
A nulliparous woman presented to labor and
delivery with a fetus at 29 weeks of gestation.
She had a recent history of a fall down 7 stairs
3-1/2 hours prior to her arrival. She reported
no pain or vaginal bleeding. She had no uter-
ine tenderness and no contractions. She had an
abraded right knee, a tender right shoulder, and
a fetus who was actively moving. She did not
fall on her abdomen.
A brief fetal monitor tracing revealed a fe-
tal heart rate in the 80 to 90 beats per minute
range. Maternal vital signs were not recorded.
No other fetal heart monitoring was done on
admission including the typical 20 to 30 minute
continuous tracing known as an admission test
strip. No pulse oximetry to continuously moni-
tor the maternal heart rate while simultaneously
recording the fetal rate, in order to differentiate
the two and avoid signal ambiguity, was done.
A second-year resident applied the ultrasound
transducer and scanned the abdomen to locate
the fetal heart but did not evaluate the fundal
placenta for an abruption. The fetal heart was
beating at a rate in the 80 to 90 bpm range. A
second-year resident did not look for fetal move-
ment with the ultrasound and called another
second-year resident to the bedside. That sec-
ond-year resident agreed with the resident who
performed the ultrasound. They both decided to
call for an immediate cesarean section without
consultation by a higher level resident or an at-
tending obstetrician. They did not wait for the
attending obstetrician to arrive. The nurse did
not suggest they get a longer tracing, did not ad-
vocate to wait for the attending physician, and
did not report the assessment of fetal movement
that was present. The two second-year residents
performed the cesarean section.
The 29-week gestation neonate was born
with high Apgar scores and was diagnosed with
an arrhythmia. Second-degree heart block is
the most common fetal bradyarrhythmia. The
most common irregular rhythm (dysrhythmia)
is premature atrial contractions (PACs). The
neonate was diagnosed with premature atrial
contractions with some blocked PACs. Because
the baby was premature, there was an intracra-
nial bleed, and the child now has mild cerebral
palsy.
This scenario illustrates the need to know
the mother, know the baby. Furthermore, it il-
lustrates the need for a complete assessment
and analysis as this was not a STAT (Priority 1)
situation.
Prompt (Priority 3)
This category requires the triage nurse to answer the
following question: Does the patient require prompt
attention? This category encompasses the majority
of patients seen in obstetric triage. Childbearing
women in this category have abnormal vital signs
that are not life-threatening and/or may be in active
labor with a fetus of more than 34 weeks of gesta-
tion. They may have ruptured membranes at 34 to
36 6/7 weeks of gestation or have a plan for a repeat
cesarean section but are contracting. They may be in
labor but not coping with contractions (Association
of Women’s Health, Obstetric, & Neonatal Nurses,
2019b).
Nonurgent (Priority 4)
The question to answer is: Does the woman have
a complaint that is nonurgent? In some hospitals,
women who initially do not appear to be in labor,
based on their uterine activity (UA) pattern and con-
tractions and cervical dilatation, will be sent home.
In other settings, the patient will be asked to walk
for an hour or two and her cervix will be rechecked.
It is a myth that walking will speed up dilation.
Researchers reviewed the findings of the very best
 2. ASSESSMENT TO CREATE AN INDIVIDUALIZED PLAN OF CARE AND INFORMED CONSENT
studies (randomized controlled trials). They pooled
the data from seven of these studies, which included
2,166 women, and could find no evidence that an up-
right position or walking reduced the duration of the
first stage of labor or the number of cesarean sections
(Souza, Miquelutti, Cecatti, & Makuch, 2006).
Another example of a nonurgent (Priority 4) acu-
ity is a nulliparous woman in the latent phase of labor
at more than 37 weeks of gestation with normal vital
signs. If it is decided to admit this nulliparous woman
to the hospital, the risk of cesarean section increases.
In fact, researchers found the risk of cesarean section
for a nulliparous woman admitted in the latent phase
of labor was 14.2%. The also had double the odds
for an arrest of the active phase of labor, oxytocin
use, insertion of an intrauterine pressure catheter and/
or a fetal spiral electrode, and almost a threefold in-
crease in chorioamnionitis (Bailit, Dierker, Blanchard,
& Mercer, 2005). However, if nulliparous women are
in the hospital in early labor and their screening in
triage reveals maternal and fetal well-being, it may be
best to send them home with instructions to return
when they are in active labor.
Scheduled/Requesting (Priority 5)
The questions to ask include: Is the woman request-
ing a service such as a prescription refill? Does she
have a scheduled procedure and no complaint? An
example of a scheduled service is a nonstress test or a
biophysical profile (Ruhl et al., 2015).
■ FULL ASSESSMENT AFTER TRIAGE
Allergies
Patients with allergies must be clearly identified. This
might include application of a wrist band. Usually,
hospitals have a policy for identifying patients with
allergies and generally that includes application of
a band and labels in and on the medical record or
chart. Follow the protocol and place a label on her
chart identifying her allergies. In some cases, a label
should be placed on the patient’s door, especially if
there is a latex type I or IV allergy.
Ask your patient if she has a latex allergy. There
are two classifications for latex allergies, type I, which
can result in asthma or cessation of breathing and
death, and type IV, which causes a rash or blisters.
If she reports she is allergic to latex, determine and
document her reaction when she is exposed to latex
products. A latex allergy will cause heightened anxi-
ety because of fear that the healthcare providers will
forget. Be sure to mention you are aware of her al-
lergy and remove all latex products from her room
■ 29
unless your hospital is already a latex-safe facility.
Also investigate food allergies as many are related to
latex hypersensitivity. You may need to notify the nu-
tritionist or dietary department to avoid those foods
in meal preparation for your patient.
■ PRENATAL CARE
Prenatal care is valued because the woman’s health
may impact her baby’s health (ACOG, 2005a). Pre-
natal care is a preventive health service to improve
outcomes for women and their infants. However,
some women who receive prenatal care reject medi-
cal recommendations, continue to use illegal drugs, or
engage in behaviors that can harm themselves or their
fetus (Maloni, Cheng, Liebl, & Maier, 1996).
The value of prenatal care is to know the passen-
ger (fetus) and passageway (pelvis) over the course
of the pregnancy. During the first prenatal visit, the
pelvis is measured and classified (clinical pelvimetry).
The failure to assess the pelvic measurements and
type prevent the labor and delivery team from cre-
ating an individualized plan of care during labor. A
normal female pelvis is gynecoid. An abnormal pelvic
type (android, anthropoid, or platypelloid) increases
the risk of a fetus (passenger) who will not safely pass
through the pelvis (passageway). There will be an in-
creased risk of a fetal malposition, obstructed labor,
and mechanical dystocia requiring a cesarean deliv-
ery. The pelvis is discussed at length in Chapter 6, The
Passageway, Passenger, Placenta and the Umbilical
Cord.
In spite of value placed on prenatal care, in the
United States 1.5% to 2% of women do not re-
ceive prenatal care. Poverty is a barrier that prevents
women from seeking prenatal care. More than 15%
of women live below the poverty level. Sixty per-
cent of impoverished families have a female head of
household, with children less than 18 years of age
(Luke, 1998). Due to poverty, as many as one in four
pregnant women will not receive prenatal care, even
when it is available. Women who received no pre-
natal care were most likely to be Black or Hispanic,
unmarried, young, less educated, foreign born, mul-
tiparous, and urban dwelling. The largest group was
young Black women with low education and high be-
havioral risks such as smoking and alcohol use. Birth
outcomes for the “no prenatal care” group were two
to four times worse than for the total population. The
preterm birth rate was 9.6% for the total population
and 26.9% for the “no prenatal care” group (Taylor,
Alexander, & Hepworth, 2005).
In addition to poverty, a lack of health literacy
or access may prevent some women from seek-
ing prenatal care. Health literacy includes the skills
30 ■ LABOR AND DELIVERY NURSING
and competencies that people develop to seek out,
understand, evaluate, and use health information and
concepts to make informed choices, reduce health
risks, and increase the quality of life. Limited health
literacy may therefore be a barrier to obtaining ad-
equate prenatal care (Murray, 2018; Wood, Kettinger,
& Lessick, 2007).
Prenatal healthcare serves to detect and moni-
tor health problems and, when health problems are
detected, can ensure appropriate interventions are
implemented to protect the health of the fetus. For
example, during the second trimester women may
have serum screening for alpha-fetoprotein (AFP),
human chorionic gonadotropin, unconjugated estriol,
and inhibin-A (Wax, 2007). Such screening can help
to detect the risk of Down syndrome. Maternal serum
AFP (MSAFP) is a screening test for open neural tube
defects and abnormal values associated with ventral
wall defects, recent fetal demise, imminent miscar-
riage, preterm labor, risk of intrauterine growth re-
striction, and hypertension. Low MSAFP levels are
associated with Down syndrome.
Women may also have ultrasounds to determine
fetal anatomy or fetal size. For example, the ultra-
sound may reveal cleft lip and/or palate, which are
more frequent in women who smoke during preg-
nancy (Shi, Wehby, & Murray, 2008). Antenatal test
results will assist care providers in determining ma-
ternal risks and problems so that diseases can be rec-
ognized and treated to decrease maternal and infant
mortality (Maloni et al., 1996). In addition, an action
plan can be determined to reduce the impact of these
diseases and risk factors to improve maternal and in-
fant outcomes.
■ KNOW THE MOTHER, KNOW THE BABY
Review the prenatal record and your patient. Note the
presence of fetal movement and the FHR, especially
at the last prenatal visit. If the childbearing woman
reports decreased fetal movement, work to obtain a
complete copy of the prenatal record. Review the re-
sults of the last ultrasound. Note the size of the head
circumference (HC) and the abdominal circumfer-
ence (AC). Consider your patient’s nutritional status
and what impact it may have on the baby.
Overweight women who consumed omega-3
foods such as flaxseeds, walnuts, canola oil, and ol-
ive oil during the pregnancy had babies with greater
birth weights and HCs than the babies of overweight
pregnant women who consumed a placebo. Omega-3
fatty acids are also found in fish oil. Omega-3 fatty
acids impact fetal and infant health including visual,
cognitive, and central nervous system development
(Gaitán et al., 2018).
If the ultrasound was done within 1 week of her
presentation for labor and delivery, an HC of 35 cm
significantly increases the risk of a cesarean section
(Lipschuetz et al., 2018). This will be important to
communicate to the nurse(s) and physician(s) who
manage the second stage of labor because the pres-
ence of excessive fetal head molding can result in
developmental delay and cerebral palsy (Jensen &
Holmer, 2018). If there was no ultrasound, review
the last fundal height. It may be helpful to measure
the fundal height if it was not assessed in the week
prior to labor and delivery. Feel for fetal movement
when you perform Leopold maneuvers. Estimate the
fetal weight and record your findings in the medi-
cal record. From admission until delivery, all of the
healthcare providers must always analyze all of the
available data to determine if labor is normal, dilata-
tion is not protracted or arrested, the fetal head is
normally positioned during the second stage of labor
(neither occiput posterior, occiput transverse, or any
other malposition), and the baby fits the pelvis and
is normally descending (no protraction or arrest of
descent).
To “know the baby” from admission to delivery,
you need to know the fetal heart rate (FHR) during
the pregnancy (see the prenatal record for the baby’s
norm prior to the onset of labor). You need to know
the baby’s current FHR pattern. You need to know the
maternal pulse if you plan to auscultate the FHR and
while you are auscultating the FHR if you use a Dop-
pler device. Notice after you apply the fetal monitor or
auscultate the rate if the rate you assessed is similar to
those recorded in the prenatal record. Can you access
any nonstress tests to review the FHR pattern? This his-
torical information can provide additional data about
the baby’s normal heart rate and help you decide if the
current assessment is normal for the baby or abnormal.
For example, if the FHR was near 130 or 140 bpm
during the pregnancy, yet on admission the FHR is
in the 160s without accelerations, that’s an abnormal
finding for that baby. Explore the possible reason for
fetal tachycardia. Could there be fetal hypoxia and a
compensatory response? Any abnormalities should be
promptly reported to the midwife or physician. In this
example, assessment of maternal vital signs may pro-
vide clues as to the cause of the tachycardia.
■ WHO IS LOW RISK FOR ADVERSE
OUTCOMES?
Risk means there is a chance that loss or harm will
occur (Cragin & Kennedy, 2006). For example, a his-
tory of preterm birth is a risk that increases the like-
lihood of another preterm birth. In fact, there may
be a gene related to preterm labor and birth (Ward,
Another random document with
no related content on Scribd:
“I’ll take that box!”
The coins jingled. Happy laughter responded to happy smiles. Wine
flowed. At the river laundry the surface of the stream was billowy
white with the suds from well-washed clothing. With a drum for a
chair, the barber was busy with his razor. At another place shower-
baths completed the work of renovation. New faces emerged, fresh-
skinned and wide-eyed. The exuberant joy of youth burst forth into
gay cries and bodily freedom. Visits were exchanged. The smoking
kitchens were sending out delicious odors. The non-coms were kept
busy hunting for their men who had disappeared, flown away.
By noon, however, the troop was again in order. In the square the
soldiers were in line, with arms polished and garments clean. The
roll was called. Their appearance was noted, their losses of
equipment were made good. The report was read. We learned that
such an one was cited for bravery, that the general was pleased, that
we would remain eight days without molestation.
Then the gayety increased. We organized to make the most of our
vacation. Some men with a bright idea arranged a theatre and
prepared a concert. Two sawhorses supported the stage, which we
trimmed with leaves. We draped the flag of the mairie overhead. The
programme was quickly arranged, as we had a considerable talent in
the regiment.
On the day appointed for the performance chairs were placed for the
higher officers, the chief of the battalion, and the captains. The
privates noisily disposed of themselves as chance permitted. There
were spectators roosting on the wheels of carts, others perched on
straw-stacks; wherever a body could hold its equilibrium, there was a
body. An improvised orchestra opened the entertainment. Then
several singers followed with comic songs. The applause was
tumultuous, as high spirits mounted higher. We forgot the war, at that
moment, and its suffering and privation. A ballad touched our deeper
sentiment. A monologue was punctuated with laughter. The hilarious
faces of the spectators told of their pleasure—the joy of living, with
youth and health. We relaxed our tense nerves, and became human
beings again. There were no more shells, no more mud, no more
guard duty, no more fatigue. The tragedy had paused; and, if one
had not heard the growling rage of the cannon bent upon its work of
death and destruction, one would have believed that there could be
no more pleasant existence.
On other days there were games in the open air. Like children freed
from school the men ran in the meadows, tussled in a game of
prisoner’s base, or played leap-frog. The suppleness of body, the
litheness of movement, were such as to inspire admiration. These
were no longer soldiers, but graceful athletes, with agile muscles and
solid torso. Under the trees gently waving in the breeze, with the
clear sky of France above a charming countryside, the scene evoked
the picture of the athletic games of antiquity. Not even the group of
philosophers was lacking, walking up and down and arguing.
Thus the hours ran on, peaceful and all too short. The troop took a
fresh breath, renewed its spirit, calmed excited nerves, found new
courage and a magnificent enthusiasm. The cruel remembrance of
dark hours, of horrible spectacles, of losses, became dim. We found
again a vibrant love of life. The soul-sickness which had grown upon
us at the parapets, under the shells, melted away in the new
environment, in the joy of a recreation dearly won.
The week of vacation was completed. They were new men,
refreshed and invigorated, who fell into line when the hour arrived. In
the darkness we retraced the road by which we had come. We were
returning to the battle, we were re-entering the tunnels, the dugouts,
the redans, the trenches, the parallels. Now we were the relief, in our
turn. We took our place. We brought back with us arms, food,
replenished cartridge-boxes, new men to fill the vacancies in our
ranks. More than that, we brought back valor, patience, faith, and a
spirit reborn.
We entered again the domain of death, again we began the agony.
 IX
THE BATTLE OF CHAMPAGNE

A YEAR had passed. The Marne and the Yser had gone into history.
We knew that enormous preparations were in progress behind our
lines. They are always known. The symptoms are perfectly visible.
The artillery is massed, the various operations are pushed more
vigorously, new precautions are taken.
Vague rumors are afloat. Every one wishes to appear informed, and
the strangest forecasts, the most absurd reports are passed from
mouth to mouth, originating no one knows where.
“We are going clear to the Rhine, this time!”
“What! do you think? As far as the Meuse, and already——”
“The cavalry is massed at the rear; and if the cavalry passes, the line
is already smashed. Then, mon vieux, how far do you think we’ll
go?”
The war was changing its aspect. Germany, checked at the Marne,
seemed to have an unsuspected force. Her regiments were renewed
continuously. They seemed to spring from the ground, an uncounted
host, capable of breaking over any barrier. Unprepared France, in
accepting the combat, profited by the period of “digging in,” to cast
big guns and manufacture shells. A colossal effort galvanized her
hope. People repeated the famous words of Joffre: “Je les
grignote.”[F]
We were confident: Germany could not win. She would be beaten as
soon as we could collect guns and ammunition in sufficient
quantities. Some words of the generals came down to the ranks.
Gallieni had said: “They are in the trenches—they are lost!”
We believed it, we were sure of it. The humblest cook, in his smoky
abri, spattered with his sauces, his blackened face beaming with
smiles, had no more doubt of it than the major-general in his
automobile.
Many furloughs had been granted. Each man had been allowed to
visit his family, and had spread assurance of success in return for
the festivities his friends had prepared for him. No doubts found
lodgment in the minds of the people. On tenter-hooks the country
awaited victory. Trembling old mothers believed it, tearful wives put
faith in it, fathers felt convinced of it. At last we would be avenged,
we would punish the enemy’s infamous arrogance, we would
chastise him, we would crush him. We were going to crunch him by
an enormous pressure, overthrow his system of trenches, advance,
break his line; and then, with one burst of valor, we would hurl him
back whence he came—into his deep forests, as far as the Rhine;
perhaps still farther, to his lair. Every one knew the good news,
counted on it, awaited it with impatience.
People liked the bearing of the soldiers. All were delighted to see
them so robust, so hardened; more alert than at the beginning, more
viril, more manly. The warrior’s helmet graced his forehead like an
aureole. The men were fêted and showered with tokens of affection.
Long trains brought them home—so ardent, and young, and
splendid; shouting their joy in the stations, passing through towns
with the air of a victor. How the women admired them! They were
treated (in advance) as liberators. Those sober people who still were
apprehensive of the outcome, who reckoned up the future and
calculated the chances, were looked upon with a reproachful eye.
This time it was certain: we would pass!
The opening came the 20th of September. A furious storm of artillery
saluted the dawn, and set the thunder rolling. It was a prodigious
simoon. The sky cracked with the terrible, hot breath; the earth itself
bubbled. A deluge of red-hot iron fell. It was more than a noise: it
was a tempest, a gigantic roaring, the forge of Vulcan in full action;
an entire sector of the front bursting into flame. What a fantastic
tornado! All calibers of shells shrieked together. No single voice of
cannon could be distinguished in the concert. They were blended in
one roll, as if a god had sounded the charge on a gigantic drum. The
avalanche of steel fell on the enemy’s breastworks, spattered over
the intervening space, let loose billows of smoke, dust, and flames.
The very earth seemed to cry out to heaven, as it was pounded to
powder and scorched by the fire. Entire sections of trench walls
leaped into the air; a giant plough turned over the tunnels. A heavy
cloud formed, grew thicker, rolled over the battle-field. The passing
hours augmented the uproar. No sooner did the climax appear to be
reached than the tumult increased afresh.
Massed near the field of carnage, the bivouacked troops were in
readiness. Each company had its rôle, and each was ready. Each
knew at what hour to join the dance. They were going to pierce
through, they would pass! Comrades exchanged encouragement
and last promises. All hoped to survive, and pursue the routed foe in
a sweeping victory.
Our regiment, like others, awaited the call. It had no active part in the
festivity, but was present. This was for us a poignant grief. In our
sector, not a sound. The cannon were as silent as if every living thing
had become a mere spectator of the drama. As the roaring
increased in volume from minute to minute, we listened. We divined
the scene. We could follow it in the clouds, and in the sounds carried
by the breeze. We were like curious, listening neighbors who hear
the people next door quarrel and fight. The Germans opposite us
remained silent also, and listened, like ourselves.
Battle of Champagne! It had not yet a name. It held all the hope of
France, a single, united, colossal Will. For five days France could
only listen to the panting of an army in travail, and held her breath.
The 25th of September, at 9.15 in the morning, the first line left the
trenches; bounded forward, hurled themselves on the enemy.
Another line followed, and another, and another. Less than an hour
later, everywhere, even well back at the rear, messages of victory
came. The telephone passed on the joyful news, distributed it to the
end of its lines. In our ranks, where we awaited our turn with arms at
rest, we breathed with high-swelling hope. We defied the enemy, that
day. We looked at his lines, marked his location. To-morrow,
perhaps, we would be where he was to-day. We would command his
crushed-in shelter, his hiding-places opened by the shells; we would
be the victors, and he would be driven before us. Oh, yes, we were
quite sure. Already, with pricked-up ears, we could perceive the
advance. Our cannon pierced his lines. It roared elsewhere than was
usual; already, opposite us, the German had turned.
And yet—no! The accursed race has the tricks of a cowardly beast.
To the chivalrous courage which offers itself for an open test of
prowess, the Boche opposes stealthy ambush, burrowing in the
ground. For the noble élan of our men, for their impetuous passion,
for their valor, the Teutonic sneak sets a snare: close to the ground,
about a foot high or less, a fine copper-wire was concealed in the
grass, and electrified. Our heroes were ensnared in that web. In vain
their assaults were renewed. In vain they accomplished a hundred
exploits. Close to the earth the traitorous wire caught their ankles,
sent the electric shock through their legs, threw them down and
burned them.
But we—we were still ignorant of all this, and we awaited our turn. In
the falling night we saw the neighboring sky light up. The enemy’s
fear was read in the number of his rockets. He was afraid of our
sortie, of our onslaught and the outcome.
Ah! Those hours! Those days, those four days of superhuman effort!
In what a fever we passed them! At any moment we could become
participants, and yet we remained there, inert, champing our bits. We
talked, that we might shake off our impatience; that we might hear
words, though their import went unnoticed. We talked without
knowing what we said, merely to hear ourselves say something. We
waited for our cue: nothing came! Near us our comrades were
fighting in a veritable furnace; they were living the apotheosis of
supreme minutes, living the glory of combat, amidst an uproar of
shells: in suffering of the flesh and in the beauty of sublime
Adventure. We envied them. We mounted to the extreme edge of the
embankments, to the parapets of the trenches, that we might see
farther and follow more closely the movement of the drama; that we
might breathe the odor of battle and grasp its splendor. We looked at
the fire-reddened sky, where a hundred lightnings flashed and a
hundred thunders rolled. We desired, with all our souls, to enter the
strife, and at last force back the intrenched enemy—intrenched in
our land, in our soil.
Since then many a battle has been fought. We have had Verdun, we
have had the Somme, we have had the Aisne, we have had almost
each day a unique page of history. Most certainly; but it was at this
time that we learned our lesson. We learned that patience is the
weapon par excellence in a war such as this; whereas, at that time
we still conserved intact the old faith in French ardor. It was the first
shock following the Marne, after the defense of the Yser. It was the
first hope of breaking through. We were near it, so near we could
almost touch it, but we did not attain it. We were ready for death
itself, but the sacrifice was unavailing. The sacks loaded for the
forward march, the filled cartridge-cases, weighed heavily and more
heavily when we knew that the line remained where it had been, that
the breach was not sufficient, that an insignificant wire had stopped
our onslaught and protected the German.
Nevertheless, the results were worth the effort. We counted our
prisoners by hundreds, we gathered from them much information.
Yes; but the gain was as nothing, so great had been our hopes. We
were bound to accept another hibernation, dig in the earth again, dig
oftener and longer; look forward to a war of greater duration, more
murderous; recommence the effort, accept not months, but years.
The war ceased to be a human struggle. The mass of material
became appalling. It was no longer a shock of arms, but an industrial
clash: the machine substituted for the valor of a man, the contrivance
become demoniac. Cannon were made in enormous calibers. Old
pieces were replaced by huge-throated monsters, and one guessed
that the wily German, girt for supreme effort, was preparing
something more, which would make the early part of the war seem
like child’s play.
This is why the present war is impossible of narration. It is no longer
a battle of a certain date. It is not, as in former times, a moment in
history, the clash of two wills, the shock of two armed bodies of men.
It is a period in a century. It involves, not two peoples, but the world.
It is not a turning-point, but a transformation. It is almost a state of
society: “C’est la guerre.”
Later, in an unforeseen epoch, in the year ——, it will be taught the
children as two dates: the war began August 2, 1914; it ended ——.
All the tragedy, all our cries, our furies, our agonies, our suffering and
death—all this, without name, blurred and indistinct, will be
contained between two numbers, and will mark two eons: that before
the War, that after the War. We will have fought and we will have
wept; our bodies will have been broken and our hearts will have
bled, without our being able to say, “It happened as I have told it,” for
we will not know just how it happened. We will be obliged to call to
mind the first day when grenades were used; the day torpedoes
came to light; the advent of the four-hundreds. Facts will be mixed in
our troubled memories. We will no longer recall all that happened to
us. To be more explicit, to create a truer picture, we will say:
“At the Marne, we used rifles.”
“In Champagne, we threw bombs.”
“At Verdun—such cannon!”
“On the Somme the shells flew so thick they met in mid-air.”
“And then—and then, America came!”
 X
VERDUN

THOSE who have not been actively engaged in the war cannot form
any conception of it. When they hear a combatant speak of it, they
say:
“Then you fight all the time?” “No.” Whereupon they think: “Then in
the firing-line one is not really in much danger.”
Ah, not so fast, good people! In this war, this new, present-day war,
the vigilance is continuous, the hand-to-hand struggle is not. Shells
fall unceasingly, but the open battle, the assault, is not without
interruption. Fortunately.
Thus it was that after the German check, after the Crown of Nancy
had withstood the foe’s attack, since the Marne in fact, the sector at
Verdun remained quiet.
It was a particularly good point. Here and there a sprinkle of shells,
then nothing more. There was fighting everywhere else, in Flanders,
in Artois, in Champagne, even in the Woëvre district, but not at
Verdun. The sector was so calm, that the only guard left there
consisted of Territorials, mostly older men. They worked without too
much effort, these fathers of families; without much disturbance,
doing general work of repairs about the fortifications, pipe in mouth,
almost at peace in the midst of war. In the winter of 1915 they
shivered a little with the cold; but the forest was near by, wood was
abundant, and the cold caused no great suffering. In the evening,
down in the deep trenches, in the well-heated huts, or in the powerful
forts, such as Douaumont, Vaux, Vachereauville, they basked in the
heat as on a sunny day. They looked at the falling snow and the
landscape sleeping under its white blanket. They swept the snow
with branches of trees, blew on their fingers a little, accepted their
slight discomfort in patience.
December passed, unusually cold; then January came, bringing the
new year. One more year gone, one less to come! Soon the beautiful
days would come, the spring, and—who knows?—perhaps peace.
Germany was tired of it all, near the end of her resources, and would
give in. Every one had his own definite idea on the subject.
According to one, peace would come before the end of June.
Another thought the war would last well toward the end of July. No
one imagined that the following winter——
February entered. At the listening-posts one received a surprise: one
noticed signs of life and activity among the enemy.
“They are unloading iron.”
“They are doing a lot of talking.”
Bah! The Boches were putting their affairs in order. For more than a
year the opposing lines had been looking at each other without any
great exchange of blows. They felt quite well acquainted. The fellows
opposite were taking good care of their own bones. Some said they
were only the Landsturm, who were hibernating over there.
In the town of Verdun the usual life continued. The cafés were so
crowded they turned people away; concerts and theatres were in full
swing; everywhere there was great animation, on account of the
presence of troops in increased numbers. One could not find a
vacant room to rent, and the price of provisions soared. All the towns
and even villages, where so many troops were spending their
money, were infected with this fever of success, of easy money, of
the riches which rolled in. Verdun was no exception to the rule. The
citadel was choked with troops: officers and privates, drinking and
laughing. To be sure, when the war goes well, there is no need to be
austere.
February reserved its own surprise. The short month, which amounts
to nothing at all, so short that it seems crippled, this one-armed
month, displayed in this particular year the malice of a dwarf.
Suddenly the German line burst into flame. It was like a spark on a
train of powder. Twelve hundred cannon, perhaps more, crashed in
chorus.
“Alerte! To arms!”
Ah! Yes! Ground, hacked, mutilated, overrun, those easy-going
papas, the Territorials, fought the best they could; but the Argonne
was the accomplice of the Boche. The drive became irresistible. With
the shell-power of this massed artillery, the lines were broken and
obliterated. Under the storm of shells the trenches were levelled. It
was not an artillery battle, nor merely a violent attack. It was rather
an avalanche of explosives. The molten torrent, crackling with
sparks, fantastic, inhuman, swept all before it. All the massed Krupp
guns in diabolic fury spat their clots of flaming blood. The torn,
disembowelled earth leaped into the air and fell in dust. A bitter
smoke filled the air, dense on the plain and dense on the mountain
summit. Douaumont became a forge, Vaux was a fiery cyclone.
Thavannes was a scarlet glow, le Mort Homme was a continuous
roar, and Verdun heard the approaching thunder in apprehensive
dread.
At the call for reinforcements the regiments came in all haste, to bare
their breasts to the cannon. Fiercely the units clung to their ground,
placed their batteries, intrenched themselves, and offered stubborn
resistance. The enemy still advanced. The adversary was not an
army division but all Germany, with the dynasty, the Crown Prince,
the old Haseleer at their head. The defenders were again faced by
the terrible order, “Conquer or die,” as on the Marne and the Yser.
Once more that game was played. Once more it had the upper hand.
Destiny, impassive, looked on.
Three kilometres of retreat brought the French to the Côte de Poivre.
The Boche had orders to take, at all costs, the “strongest citadel of
France.” That success would mean the death of our country. It meant
all France exposed to the foe, Paris captured, Defeat. It meant Crime
triumphant, history violated, supremacy of brutal might, humanity’s
bonds reforged. It meant the flower of the Revolution crushed and
Liberty in chains. It meant the Kaiser’s boot on the neck of the world.
“Do you wish aid?” came the message from England, already
preparing to send succor. France responded proudly: “No! I can hold
my ground.”
And she held it. The world knows it.
An innumerable host, coated in dirty gray like a repulsive animal,
rushed on in its heavy, obstinate bravery; as an infuriated bull with
lowered head madly charges his foe, so the German brute in his
blind rage hurled himself toward us. In the path of the Hunnish Horde
stood French valor. They Shall Not Pass! Nor did they. But—what
a struggle!
All the slopes which form the heights of the Meuse and are the
ramparts of Gaul, resounded as a monster forge. There Vulcan had
set up his furnaces. Such a battle is too great to be recounted. It is
the story of Thavannes, whose immense tunnel of approach
sheltered a whole battalion at a time. It is the story of the fall of
Douaumont; then the siege of indomitable Vaux, dauntless, resisting,
panting, quivering like a drum. There the shells fall at the rate of ten
per minute. Raynal is commanding there: that is enough. Ten times
the German hurled his force against the fortifications, and ten times
he fell back, baffled. The garrison stood its ground in a furnace of the
damned. New men entered by a breach, followed a narrow path,
found the postern gate, and leaped in. For every man who came,
came a shell. Overhead twenty airplanes circled about, directing the
fire, like vultures above the eagle’s nest; while the cannon on the
surrounding heights converged their fire.
Vaux! Heroic name, name never to be forgotten! Vaux, a rock burned
by acids, by powder, by the fires of hell. Vaux held out five days, six
days—eight days! The sky at night was a hot glow. The earth was
one continuous roar of explosions, enveloped in billows of smoke. In
that inferno men fought unto death. Trenches, shelters, stone, and
earthworks were wiped away by the shells; the battle left the
protection of the ground and swung into free space.
The regiments were brought from the rear. They were supplied with
food and ammunition by a whole army of camions, which looked like
an immense serpent twisting along the road. Beyond Verdun the
men entered directly into the furnace. Their units melted in the very
act of going to the relief of their comrades at the firing-line. No
matter! They advanced, leaping from one shell-hole to another, up to
the lines where the survivors of the preceding regiments still held the
assailant at a distance. They were one man against ten. Of a
hundred who set out, only fifty arrived. They felt the reassurance
given by the strength of Vaux. Vaux hammered by blows—but Vaux
still living, still French, withstanding the tempest and defying the
German. One felt there the heart of steel in the fortress of rock. In
addition to the battle all about was the spectacle of a mass of
masonry holding an army in check.
Vaux fell. Only thirst ended its resistance. The enemy, stupefied to
count the handful of heroes who had thus held them at bay, rendered
the captives the highest honors. The Commandant Raynal kept his
sword; the Crown Prince, in humility before such glory, was glad to
pay him homage, and asked to be presented.
Vaux fell, but Verdun was not taken. There huge shells fell
unceasingly. The German loves the easy targets: a cluster of
houses, a town, is an object hard to miss. In the town, then, the
storm swept the streets. Entire quarters went down in dust. Like
Rheims, like Soissons, like Ypres, like Liége, Verdun was the victim
of the Huns. People took refuge in the citadel, in its enormous
subterranean chambers of massive masonry. There, where the stone
corridors were damp as cellars, night and day both soldiers and
civilians found shelter. There young mothers nursed their babes,
there people of all conditions lived as best they could; there,
underground, helter-skelter, all piled together. They could hear the
shells of the Hun falling on the city, the houses crumbling, the
wounded shrieking.
All France and all the world had their eyes on Verdun the inviolable;
on Verdun surrounded by flames, in the vortex of action; on Verdun,
which did not weaken. Without respite, the Teutonic masses were
hurled to the assault. Like a sea of mud they poured upon the
outposts of the city. They were beaten down by grenades, shells,
machine-guns, fire, shot, and powder; and They did not pass!
All about were scenes most thrilling. It would be impossible to
recount them all. We must choose only one or two.
One day, then, of date unrecorded (Verdun held out eight months!), a
troop going up to the fortress of Thavannes found the railway below
and followed it. They came to the tunnel and entered, although it was
already much encumbered. In vain did the gendarme on guard try to
oppose their passage: the newcomers were too many. They
numbered about six hundred. Above them the battle raged. They
were intending to stop for breath, then go on up the slope and take
their posts, where Death awaited them.
No! They will never go so far. They seek a reprieve for an instant in
the tunnel, but Death comes to meet them. In the long black cavern
are piles of ammunition in transit. There are soldiers, and wounded
men, and mules, and general confusion. Some one, man or beast
(no one knows which), hits a case of explosives. In the dark tube
there is a flash, an uproar, a cloud of smoke: four hundred bodies lie
mangled and scorched, as when the fire-damp explodes in the depth
of a mine. The living make their way out as best they can, leaving
the dead and wounded. The two hundred who escape reform their
line, mount the hill, enter the real furnace: this other episode did not
count. It was an extra, for good measure. The accident could not
prevent the fulfilment of the task before them. What were left of the
battalion went where their order sent them. Four hundred fell on the
way. Too bad. Orders are orders: they are carried out by the
remnant....
This is only one instance in a thousand.

We all had a great curiosity to see the famous precincts where the
strife raged so violently. It was almost with joy, therefore, that we
received our call. The day the order arrived the news ran quickly
through the ranks: “We are going over there, boys!” “Over there”
meant Verdun. That was understood. We hastened to get ready; we
arranged knapsacks; put our affairs in order. The vans were loaded,
the horses hitched. In the canteens we drank to Victory, to the
Return, to Good Luck. Eyes glistened behind the smoke of pipes,
and we jostled and laughed. Even those who feared the terrible
adventure and dreaded death concealed their uneasiness and
cloaked it with smiles. On the other hand, many danced for joy,
happy to have a part in the fight, to be in full action.
All together, pell-mell, happy and unhappy, we were punctually on
the spot appointed for the automobiles to receive us when evening
arrived. The entire convoy waited behind a hill. The drivers, muffled
up in pelts, chatted while waiting for us. They looked fantastic in the
dim light. Only two or three lanterns winked and blinked in the night.
One was dimly aware of a file of conveyances lined up along the
edge of the road, like great beasts asleep; the going to and fro of the
officers of the convoy, and their colloquy with the colonel. It was all
more felt than seen. One could distinguish only shadows; one heard
the tramp of men, the dull murmur of low-voiced talking, sometimes
an exclamation or a stifled oath.
Then orders were transmitted by cyclists. The first battalion set out.
Hurriedly each section climbed into the autos. These ought to have
carried twenty men each, but twenty-five and even thirty were piled
in, somehow, with their arms, their luggage, their knapsacks, their
side-bags, their canteens. As soon as a company was loaded in the
captain gave the order to go. One by one the cars fell into line. The
motors coughed and plunged forward like a dog unleashed. Then ten
more machines received a new company, and departed in their turn.
They also were swallowed up by the night.
When my turn came, by some chance I was assigned to an auto with
the officers, where we were much less crowded than in the large
vehicles of the privates. I therefore expected to gain some further
information concerning our destination. In this I was disappointed, as
the officers knew very little about it; besides, from the time the motor
started and the auto was on its way no further conversation was
possible. We could not hear each other, even when nearly shouting,
and we had enough to do in resisting the bumps which threw us
against each other. We inhaled the dust: a thick, heavy dust, raised
by the wheels. It soon covered us completely. One could feel it
coating his face, and small grains of sand rolled between one’s
fingers. We could not see, for the curtains were drawn down tightly,
and it was very dark. We travelled as in an interminable tunnel, with
no light whatever, with no knowledge of what we were passing or of
the country we were traversing. Sometimes there were sudden
stops. The quickly set brakes brought us to a standstill with a jerk.
We asked the driver: “What is the matter? Where are we?” He
scarcely answered, for he knew no more than we. His order was to
follow the auto in front of him, and to keep his machine twenty
metres behind, that he might avoid a collision in case of a too-
sudden stop. He followed his orders, and knew nothing more. He did
not even know the road we were travelling. The car which led the
procession carried the chief officer of the convoy. Probably he was
the only man besides our colonel who knew our destination.
Thus we journeyed four hours before dawn. As the pale light invaded
our rolling apartment little by little, we saw how completely we were
covered with dust. We were white from head to feet, like a miller
dredged in his flour. Our clothing was white, our hair, our faces, our
arms. We appeared grotesquely like veritable old men. We looked
each other over and laughed. Then, as there was nothing more to
fear from the dust, a lieutenant raised a curtain. We found ourselves
on a winding road in a charming, gently-rolling country. Small trees
formed tiny groves on the hillsides, and the whole landscape was
quite different from that we had just left.
Suddenly the captain made a gesture. He had perceived an airplane,
soaring directly over us in a most disquieting manner. It was flying
too high for us to distinguish, even with glasses, whether it was
French or German; but its manœuvres were suspicious. It had
command of the road, and seemed to be preparing to fire on the
convoy. In fact, that was exactly what happened, a few minutes later,
when the flyer suddenly came lower and opened fire with his
mitrailleuse. The automobiles increased their speed and lengthened
the distance from one to another. Nevertheless, the aviator could
move much faster than could we, and he circled above us like a
vulture over his prey. Fortunately, he had no bombs, and his aim was
too uncertain to inflict much damage. As it was, he wounded several
men, and would have wounded many more if the special guns for the
purpose had not opened fire on him, or if three French planes had
not appeared on the horizon. At sight of them he made a hasty
escape, amid our shouts and jeers. Our wounded were rapidly cared
for by a surgeon, and shortly after were placed in the first field-
hospital encountered on the road, amid the ruins of a village. This
village gave us the first knowledge of our whereabouts. We were
entering the valley of the Woëvre, and Verdun lay beyond the hills.
The roll of the cannon had become audible.
After a short halt we set out again. This time we entered the field of
action. It was evidenced by the constantly increasing number of
convoys encountered. Long lines of camions were climbing toward
the battle, loaded with munitions or food; or, like our own, with men.
The road became very wide, encroaching some distance into the
fields. Some soldiers, in the stream of conveyances, threw pebbles
under our wheels without as much as lifting their eyes to look at us:
they had seen so much already that the spectacle of troops going
under fire interested them not at all.
With our advance the scene changed rapidly. We saw some autos
overturned in a ditch and burning. Some dead horses stretched their
rigid legs in the air. Under some tents men bustled about with
stretchers, instruments, and boxes. These were the temporary
dressing-stations, where the men wounded on the route were cared
for: any who had met with accidents from vehicles, as well as those
who had been hit by shell-splinters—for we had entered the zone of
projectiles, and stray splinters reached even that far. The scene
became indescribable. It was a mob, where one felt nevertheless a
discipline, a sense of regulated, methodical order. We were in the
side-wings of the battle, in the midst of its movable stage-settings,
among the stage-hands, machinists, electricians, and
supernumeraries, whose activities are unseen by the public, but who
make it possible for the performance to go on and be brilliant. Long
trains of horse-drawn caissons followed each other at full speed.
Field-ambulances, marked with large red crosses, slipped into the
moving stream. Vehicles of every sort, gray with dust or mud-
bespattered, rumbled, creaked, rolled along, stopped, started, stuck
in the ruts, freed themselves. The moving line looked like the folds of
a fabulous serpent.
The voice of the cannon increased in power and volume. It was like
hearing an orchestra of inferno. The ear received only a tremendous,
continuous roar, like the rolling of thunder which never ceases.
We could see the earth tossed high like a geyser when a shell
struck. We breathed the pungent odor of the battle. We were getting
into it now. Most of the houses were demolished. The buildings still
standing all bore the marks of war, with great ragged holes in walls
and roof, with stains of powder and fire. Enough of them remained in
close rows to indicate the streets leading into the town. We crossed
the Meuse and found ourselves in the city. It appeared deserted. We
looked curiously up and down the streets, without finding any sign of
life whatever, except an occasional hurrying soldier, a cyclist, or an
automobile racing at full speed between the silent houses. We made
some détours, crossed squares, and skirted gardens. The whole city
lay open to our view; and above the roofs the massive silhouette of
the citadel spread its protecting wings.
The locking of wheels gave us a jolt: we had arrived. Glad to tread
the ground once more, we leaped down and entered an abandoned
factory, where we were to camp. The windows had long since lost
their glass, but the roof remained. It was a fragile protection against
shells, but quite adequate against wind and rain. Along the walls was
stacked dirty straw, broken to crumbs by the many sleeping troops.
That was our bed. It would be for many their last sleep before the
sleep of death, for the orders came immediately: we would mount to
the first lines at nightfall.
The march into the battle was at first simple. We advanced in the
descending shadows, we left the town behind. Before us the
heavens were streaked with the light of explosives. We marched by
sections, in silence. We marched straight ahead, with heart beating
quickly, mouth dry, brain a blank. In spite of myself, I set my teeth
and gripped my hands. We could not distinguish the road we trod,
but were dimly aware sometimes of trees stripped bare, of low ruins,
of puddles of water, of general débris. We simply followed the man in
front, scarcely turning the head when a flock of shells fell at the right,
or left, or ahead. We only knew we were in the zone where they fell.
We heard the hoarse shriek of the projectiles high in the air, and the
chorus of cannon re-echoed in each breast. We no longer felt the
chill of the night air. We knew not if we breathed. The farther we
went, the more difficult did the walking become. We stumbled over
the uneven ground, ploughed up by the shells; but we were not yet in
the place of torment, and the missiles spared us. We passed many
moving shadows: couriers, orderlies, estafettes, officers, wounded,
we knew not what. They were only dark objects moving about in the
night, outlined by the glow of the projectiles; instantly swallowed
again by the shadows and giving place to others. We knew nothing
about them. We knew only one great fact: that we were always
advancing toward the fire; we were approaching the first lines, where
the conflagration raged at white heat.
Then—we were in the midst of the shells. The frenzy was on. The
wounded cried out. We held together the best we could. We entered
chaos. Whirlwinds of explosives enveloped us. They were above,
around, beneath. The very earth leaped up and lashed our faces and
hands. Violent gusts of hot wind shook us. We ran. We joined some
other comrades. We could not proceed in lines, but moved in groups.
There were no longer any usable trenches. They were torn open,
crushed in, filled up, making any advance in them impossible.
Therefore we marched in the open, and we advanced. We would
leap into a shell-crater, catch our breath for a second, look out for
another hole, and hurl ourselves into it as quickly as possible. The
rain of steel enveloped everything, in a tumult unbelievable. We
scarcely knew if we lived; we certainly thought no more about death.
The fixed, absolute, imperious idea, the only surviving thing in our
consciousness, was to arrive at our destination, where we could give
our service. We felt that we were near the spot and must attain it.
We often lost our way. The officers looked for the road, asked the
direction, shouted orders. We understood as best we could. We ran
at full speed, threw ourselves flat on the ground, sprang up and ran
again. We knew only one thing: we must succeed in reaching our
appointed post, we must reach the firing-line: we could not stop, we
could not rest, until we found the location of the regiment we were
sent to relieve.
For three hours we plunged across the jagged fields. The ground
rose and fell and rose again. Sometimes, behind a pile of earth, we
found some men. We shouted some questions. They knew nothing
to tell us, as they were not of the regiment which we sought. They
were out of breath, like ourselves; or they were wounded, or they
had just been relieved, or they had just arrived and were themselves
seeking their post, or they were hopelessly lost and joined in with us.
If they were officers, they questioned us:
“What regiment?” “Where are you going?” “What division?” “What
army?” “Have you seen such and such a regiment?” “No.” “Yes, at
the right.” “Over at the left.” “Make room there!”
Some ambulances charged past. We saw some first-aid stations in
full operation, with wounded shrieking all about. Some couriers, out
of breath, shouted instructions: “Go straight on. Your regiment is two
hundred metres from here, near the canal.”
Finally we arrived, under such a hail of bullets, machine fire, and
shrapnel that we were not even conscious of danger. We found
some men, half buried in holes, who went away and left us. They
melted into the night.
We had reached our post on the firing-line, in an unknown plain,
which seemed to be flooded with dead bodies, as a fallow field is a
riot of corn-flowers and nettles. We had no idea how we had
succeeded in reaching the spot.
There was nothing more to do but fight and in our turn, wait for the
Relief, or for Death.