Who's in charge?

November 29, 2007 11:41 AM

Can someone spell out for me the hierarchy of doctor(s), certified nurse midwives, nurses and others in the setting of the labor and delivery room?

Imagine a labor that eventually progresses to a “routine” c-section, where the maximum number of types of doctors and nurses show up. Who are all the players and what is the chain of command? And is that hierarchy explicit or implicit among them? Basically, who can tell who what to do and they have to do it? (For example, if it’s early in labor and there’s no need for an OB yet, would a L&D nurse and midwife ever be either confused about who’s in charge as they work together, or even aggressive about staking out their control in the absence of the next higher “level of command”?) I guess I’m interested in perception as well as fact, so if you have some experiential sense of this hierarchy and want to weigh in, be my guest, but if you know the facts of how this works, please let me know how you know it (med school, work, research, the law, as the spouse of a health professional, etc.)

By the way, this is not a veiled request for reassurance about care during the childbirth experience. I’m nerdily creating a literal diagram of decision-making power within the hospital setting.

posted by cocoagirl to work & money (12 comments total)

As a former OB nurse, I can answer this.

An OB doctor, is the lead for the pregnant mother.
A midwife is next in line, just behind the doctor.
A RN (there are many levels of RN as a midwife is also one), is next after the midwife in most cases.
Then comes a LPN.
Then a CNA.

A routine C-section is never routine. Each hospital or facility act in their own way. A small hospital might only have a few in attendance, while others will have more. You need the surgical OB doctor, an anesthesiologist (a CRNA might be able to do that, but I can't remember now if they can), a pediatrician or neonatologist, and one or two staff members like scrub nurses or surgitechs.

Either a RN or LPN is in attendance for a normal non-emergency OB admission. Small remote hospitals will not necessarily have a RN available right away, but one on call. The RN who comes in, is in charge. As the woman progresses, the RN will call the OB doctor or midwife depending on who is the selected primary provider to update them and to obtain orders. Whenever a doctor is present, the doctor is in charge.

Hope this answers your question.
posted by magnoliasouth at 12:06 PM on November 29, 2007

Also, it depends in which country as well. My experience of the medical hierarchy was different in the UK than the US.
posted by jadepearl at 12:10 PM on November 29, 2007

To add a little to magnoliasouth's answer a CRNA can most certainly do the anesthesia for a c-section; an anesthesilogist, however, will be more of a co-equal with the obstetrician in terms of leadership.
posted by TedW at 12:10 PM on November 29, 2007

Speaking from Ontario, the woman is in charge and must be given all options to make an informed choice. If her primary care was with a midwife the midwives will keep her continually updated on her options. For example during my second labour/birth I was unhappy with the on-call M.D. at the hospital I was at and I was told by my midwife that I was fully within my rights to leave and continue care at another hospital (I did not have the option of home birth due to probable fetus distress). The L&D nurses were under the direction of the midwives, including when an M.D was in the room, because I had chosen them as my primary caregivers. After my care was transferred to the M.D. (which I was advised on and had the option to refuse) the nurses and midwives were under the direction of the M.D. but the nurses obeyed all orders of the midwives unless they conflicted with one of the M.D.'s orders. When my care was transferred to the chief obstetrician, he was in charge of everyone in the room, M.D., residents, L&D nurses, ultrasound technicians and midwives but he treated the midwives as equals and took their advisement seriously. Even under the care of the chief of obstetrics it was understood that any medical care to me and my fetus was under my control and he and the midwives explained all options to me very thoroughly. This is all my personal experience but I was kept informed of my rights by the midwives and the chief obstetrician. I've been at a few hospital births and I have never seen L&D nurses and midwives undermine or conflict with each other. The nurses are under the midwives control as directed by the woman giving birth. I have an appointment in a couple of weeks with a registered nurse at the hospital I will most likely use as a back-up during my upcoming home-birth in which all of this will again be explained to me and I have a lot of legal forms from the hospital explicitly stating that I am in charge of my own labour and delievery and has my back-up birth plan itemised. If I was unconcious my next of kin (that I have written on the form) has the power to make these decisions for me, as advised by my midwives.
posted by saucysault at 12:10 PM on November 29, 2007

You should add the anethesiologist in there somewhere, right? I don't know where, I'm just a dad who was in there for a couple of c-sections.
posted by poppo at 12:11 PM on November 29, 2007

magnoliasouth nailed the answer, this is how I've seen it. If you're at an academic medical center there will likely be residents under the main OB (attending) but before the nurses. (Under everyone else are med students, PA students, and nursing students.)

If, for some reason, the OB attending hasn't arrived in the room yet, the Anesthesiologist is in charge. Often the Anes attending and OB attending coordinate their care during a C-section, but from what I've seen the OB attending almost always gets it their way in the end.
posted by ruwan at 12:15 PM on November 29, 2007

Anecdotes: "the hospital" vetoed a drug my OB and I wanted to use, and that when I ran into the bullshit of being told I couldn't take a bath (our cue to get out of there...) by the nurses, my doctor couldn't do anything to change that. "I can't medically order a bath."
posted by kmennie at 2:22 PM on November 29, 2007

I'm a labor and delivery nurse at a big urban teaching hospital. I've never worked at a non-teaching/community hospital, so someone else will have to weigh in about that environment.

My first response to the question is confusion about the need to assign a hierarchy to all the members of the team; it's not nearly as simple as "the attending tells everyone else what to do and then they do it."

Every morning at rounds, the nurses present our patients to the team, summarize their current status (which includes their requests, desires, and plans), and make recommendations based on that information. These recommendations are then discussed among the team and decisions are made as a group. These can be long and tiring conversations, and decision-making frequently requires compromise from all sides, but it means that everyone's put aside their egos and hammered out a plan that's best for the patient. The doctors-give-orders-and-the-nurses-follow-them-without-question model of caregiving is long gone, thank God.

In the labor room itself, things are egalitarian during an uncomplicated delivery, I think because every person in the room is capable of doing the same things--cervical exams, assessments of fetal well-being, giving medications, and delivering the baby itself. (Sometimes babies come very quickly, and whoever happens to be at the end of the bed at the time had better be able to do the delivery.) There's almost no one saying "do this" or "do that" because everyone knows what needs to be done, and we all just do it.

During more complicated deliveries, docs/midwives with the skills to perform a forceps/vacuum delivery or manage a shoulder dystocia are "in charge" and call the shots. In those situations, everyone still knows what needs to be done, but not everyone's got the technical skill to do it. Still, if a doc or midwife asked me to do something during a complicated delivery that I thought would further complicate the situation, I'd protest and suggest a different plan.

In the OR, the delineation of who does what is even sharper, because not everyone knows what to do in every situation. I can't be an anesthesiologist or CRNA because I don't have the necessary skills or training, and I don't have the foggiest idea how to place an epidural catheter or intubate someone. Nor am I a surgeon, and I'd screw it all up if I tried to sew someone up. The residents are inexperienced and need the support and teaching of their attending during the operation.

So everyone has their role--the anesthesiology resident and attending do their thing on one side of the drape, keeping the patient comfortable and giving general anesthesia/meds/fluid/blood if necessary. The OB attending is the surgeon in charge, and the resident surgeons follow that lead. The scrub tech or scrub nurse passes instruments and maintains the sterility of the operative field. The circulating nurse keeps track of everything else that's going on in the room. The "baby nurse" will be in the room for the delivery itself and will care for the baby as soon as it's born, resuscitating the baby if necessary. If fetal distress is suspected or expected, the pediatric team (attending, residents, and NICU nurses) will be there too.

I hope that helps answer the question, though I'm afraid it'll make drawing that chart a bit more difficult! I'm a huge nerd about my job because I love it so much, so I'd be happy to expound on anything you want to hear more about.
posted by jesourie at 3:05 PM on November 29, 2007 [2 favorites]

Thanks for the replies everyone.
Magnoliasouth gets at the simplest hierarchy I was looking for.
saucysault, I debated adding 'patient' to my scenario but didn't since 1) I'm dissecting the hospital culture which has its own momentum whether or not a patient is there, and 2) here in the US it's almost unquestioned that everyone but the patient has decision-making power. (There's even another 'invisible' player I wondered about including: insurance companies or hospital management.)

My first response to the question is confusion about the need to assign a hierarchy to all the members of the team
jesourie, thanks for the amazing detail! Part of the reason I worded the question that way is because I've been in, seen and heard of situations where it seems like whoever is in the room with the woman makes decisions about care, whether or not that person is the primary caregiver. For instance, I know of OBs rupturing membranes to speed things along while the midwife is out of the room, even if the MW is the primary caregiver and they don't see any need; and of L&D nurses starting monitoring even if no one's requested it; and of various levels of nurses arguing over, more or less, who has to do an enema. So it seems like there's a grey area in practice if not on paper. Your version, that the hierarchy is there (but less necessary) in uncomplicated cases and that it gets more sharply defined as a case increases in complexity, makes a lot of sense.
posted by cocoagirl at 6:30 PM on November 29, 2007

Wow, I'd hate to be a patient at a hospital like that, and I'd never be able to work in that kind of environment. And I'd hate to see what would happen to the docs at my place of employment if they examined, let alone ruptured, one of the midwives' patients without asking. Heads would roll.
posted by jesourie at 7:43 PM on November 29, 2007

Does your scenario necessarily involve a c-section? If not, and if a certified nurse midwife is attending the birth, there should be no OB in the scenario at all. My wife had two routine, vaginal deliveries attended by certified nurse midwives in the "birth centers" located within two urban teaching hospitals. In these instances, the midwife was the only caregiver during active labor and delivery (there were nurses around only when we first checked in, and afterwards, of course). Once the midwife showed up, no doctors entered the room, b/c my wife was not the patient of any doctor. Had some random doctor entered during delivery and done a non-emergency procedure on my wife without her informed consent, that would constitute a crime (common law battery, at least, although this is not legal advice).

In fact, the midwife attending the first birth got stuck in traffic and showed up late. Before she arrived, two OB residents called in by a nurse told my wife they would take over the birth if the midwife didn't arrive within the next five minutes. She arrived in time, and we never saw those OBs again.

In our case, we would have called an OB back into the room only if we had needed the OB, in his role as a surgeon, to perform emergency surgery -- i.e., a c-section.

If a woman has chosen in advance to have a planned c-section (is this what you mean by "routine c-section"?), wouldn't it be unlikely (or at least redudant) for her to have hired a midwife in addition to the OB-surgeon she has selected to perform the surgery.
posted by hhc5 at 9:14 PM on November 29, 2007

hhc5, a midwife could still provide all woman's prenatal care until the day she went to the hospital for her planned surgery. After that, the docs would take over.

At my hospital, midwives aren't hired by the patient--they're credentialed and given privileges by the hospital, and they get paid by the hospital as staff members. They care for most of the low-risk women, freeing up the docs to take care of the really complicated cases.
posted by jesourie at 12:56 PM on November 30, 2007