birth center, birth team, Co-Dependency, Home Birth, hospital birth, Labor, Long hours, Long Labor, Midwife, Midwife's Assistant, Nurse, OB, Patient Safety

Gambling with Safety: Hours Worked and Quality of Care

On April 16th, 2019, Washington Senator Maureen Walsh (R) stated she didn’t support a bill that would give nurses mandatory, uninterrupted rest breaks. Her hesitation was rooted in her belief that in districts like hers, where hospitals are small (fewer than 25 beds), nurses have plenty of down time, and thus are not in need of scheduled breaks. She stated on the Senate floor that she understood that nurses need rest, but that “We need to care for patients first and foremost,” and added that, “Nurses probably play cards for a considerable amount of the day.”

Senator Walsh offered an amendment to the bill which would require 8 hour shifts instead of the more recently customary 12 hour shift, in order to lighten the nurses’ loads. This did not fly; many nurses prefer to work fewer 12 hour shifts rather than more 8 hour shifts in order to spend more time with their families. Juliana Bindas, a nurse in Chicago, pointed out that 12 hour shifts frequently turn into 14 shifts, as nurses will naturally overlap in critical situations to provide good communication and continuity of care. Bindas invited Senator Walsh to shadow a nurse on a 12 hour shift. Senator Walsh accepted.

Regardless of length of shift, uninterrupted breaks are imperative. Even if a critical-care employee has plenty of time to “play cards,” being always on and having to drop your sandwich and run if a patient needs you, can put considerable stress on a worker and cause mental and physical exhaustion that are detrimental to patients.

Overwork and sleep deprivation result in increased dangers to the public, including:

  • Shift workers, particularly night shift, are more likely to lose sleep with regularity, resulting in cumulative sleep loss. After only two weeks of sleeping 6 hours per night, performance levels are observed that are similar to that of a person suffering 24 hours of acute sleep deprivation. After one week of 4 hours of sleep per night, performance levels are similar to that of a 48 hours of acute sleep deprivation.
  • For many workers who are able to steal away for a nap during a shift (if they are lucky), they will suffer from what is called “sleep inertia.” This is the idea that short naps taken when one is already very sleep deprived can cause poor performance and judgment for several hours after the nap.
  • Physicians with recurrent 24 hour shifts make 36% more serious medical errors than those doctors who worked recurrent 16 hour shifts. The 24 hour shift doctors also “suffer decrements in performance commensurate with those induced by a blood alcohol level of 0.05-0.10%.” The same doctors reported making 300% more medical errors that can lead to a patient’s death.
  • Researchers at Washington State monitored the sleep of 80 police officers. Officers who slept less were significantly more likely to associate African American citizens with carrying a weapon.
  • Another police audit found that working only one additional hour of overtime per week increased the odds by 2.7% that those officers would be involved in a use-of-force incident. It increased the likelihood of ethics violations by 3.1%.

In short, when we are too tired, we run the risk of turning into racist drunks, potentially hurting people who don’t have any choice but to trust us. The worst part is, we are so tired we may not be aware of how dangerous we are. If we are aware, who is to say we have support in place to enable us to step back?

Some jobs have regulations around maximum work hours before an employee is simply forced out of rotation. Some of the policies are put in place at the federal level, many are state mandated, and some policies may be put in place by the worker’s company or direct supervisor. Some fields have no policies in place at any level. There are shockingly few rules.

  • Passenger-carrying drivers have a 10-hour driving limit, as long as they have been off-duty for at least 8 hours.
  • Property-carrying drivers have an 11-hour driving limit as long as they have had 10 consecutive hours off-duty. (See Tracy Morgan’s story for an example of a truck driver who had been awake for over 24 hours before a falling asleep at the wheel, causing a collision that killed one and left others severely injured.)
  • Flight attendants have a mandatory rest period following each shift. The length of the rest period corresponds to the length of the shift.
  • There are currently no laws and very few department-mandated policies regarding police work length.
  • Medical residents are allowed to work no more than 80 hours per week. They are permitted to work shifts as long as 24 hours.
  • The length of shifts for EMS workers varies widely in the US. In California, they are required to be reachable during all of their work breaks.

Birth workers (midwives, doulas, monitrices) in the out-of-hospital setting have no state- or federally-mandated policies to reduce fatigue or limit works hours.

Many midwives and their employers take extreme exhaustion for granted. A freestanding birth center I worked at full-time had no limits on work hours for midwives or assistants. If a midwife needed to call in another midwife to take over after many hours at a birth, she was required to relinquish 50% of her birth salary so that the new midwife taking over could be paid. I’m not sure what was more traumatizing for me – hallucinating with sleep deprivation and knowing I was a danger to my patient, or taking a 50% pay cut to get help after working an inhumane number of hours.

I believe that this kind of horse shit starts in student-hood and continues as a vicious circle. Midwifery students are frequently exploited and pushed to the edge and, honestly, at first it’s exciting – in the way that holidays or traveling are exciting. It feels like special occasion – who needs sleep? It’s temporary! You get to feel like a hero but have a fraction of the responsibility of the primary midwife in the room, and none of the legal accountability.

By the time your clinical training is over, burnout is inevitable but the long hours and sleep deprivation have been normalized.

It doesn’t help that clients hire midwives specifically for continuity of care. Continuity of care is expected to last as long as the labor does, and then usually 3-6 hours after. Most of us keep our phones on after the birth in case the family needs to call for any questions or concerns.

It doesn’t help that we function in a capitalist healthcare system and that midwives are the cheapest delivery providers around. The global fee only goes so far for paying other providers to step in.

How do we avoid fatigue? So far the balance I’ve struck as a solo midwife is to have some really great individual licensed midwives around for support. We are in frequent contact with each other and have set rates for payment depending on duties and level of responsibility. We all assist each other and trust that the other person isn’t going to call us to a poorly managed, high-risk labor.

  • I always have an assistant in the wings. The assistant doesn’t by law have to a be a licensed midwife, but that’s ideal. I may call my assistant just as the client begins to transition. If labor is running long, I will call in the assistant when I start to fade. When the assistant is licensed, I can take a walk, nap in my car, or stare at a wall and know that a provider with my equivalent skills who does not need my supervision is taking great care of my client. If the assistant is unlicensed, she will still possess the same skills but I will not be able to leave the site.
  • If I am sick or injured, there are a number of back-up midwives I can call, with an agreed-upon back-up fee that comes out of the client’s global fee. In other words, the client doesn’t have to arrange at the last minute for a new midwife and will not be paying extra for her fee.
  • In my practice agreement, I state in plain English (not Legalese) that for better or worse, I am a human being with limits. I talk about how much I value continuity of care, but that safety comes first. Because of the risks associated with fatigue and sleep deprivation, clients can expect a small possibility that a licensed midwife who is not me may be at their birth. I also stress that I enjoy my job and that my clients should expect a cheerful midwife who is happy to be at their birth. If I am severely sleep deprived, I can have all the love in the world for the client and it simply will not seem like it.
  • Also in my agreement, I state that I am free to call in a back-up midwife to the birth after 18 consecutive hours of work, and that I am also free to leave the home at this time (the client will still have an assistant and a fresh primary midwife). I have never actually taken advantage of this paragraph, but knowing that I could if I needed to is such as enormous relief I swear it helps me rest better and maintain a more cheerful attitude.
  • I explain to clients that they will not know who their assistant will be. The fee that assistants are paid is adequate for the work that they do, but nowhere near adequate to ask an assistant to be exclusively on call for a particular family for the entire birth window (5 weeks). In addition, all of my assistants are primary birth workers in their own rights. Thus, when my client is in labor, my favorite assistant may be at another birth or may be still exhausted from her previous birth. Accepting that you won’t necessarily know your assistant allows me to hire the freshest, most competent person available.
  • I tell my clients to expect to see me take a cat-nap on the sofa at some point. Some clients are so thoughtful as to arrange an air mattress or whatnot for the midwives. This is never my expectation but it makes me feel very safe and happy to be serving these clients, who clearly understand my human-ness.
  • While I occasionally do brief labor check-ins during a long latent phase, I do not settle in and stay at the home until a client is well into active labor. If they anticipate needing support during a long labor, they are encouraged to hire a doula or find a volunteer doula.
  • I ask that my clients only use my cell phone for emergencies or urgent matters. All non-emergent matters can be emailed or saved for the next routine visit. This way I don’t have a dad calling me at 3 AM asking me about a billing matter. Or a couple calling me at 8 AM on a Sunday to resolve a pregnancy-related marital dispute. Or a young mom, still lacking in confidence, calling me just as my head hits the pillow because she’s in a fight with her mother-in-law about whether the baby can start solids yet. (All these are true events.)
  • I’m not opposed to screening clients out before they hire. Once I had a consultation with a woman who had had a long, difficult first labor which required a Cesarean birth. She was interviewing me for her second pregnancy, hoping for a home VBAC, and spent a good deal of our visit processing what was obviously a very traumatic first birth. I asked her what she wanted to do differently this time. She expressed how upset she was with her doula during her first birth, saying, “SHE TOOK A NAP!!!” Her husband cut in – “Honey, she was with us for 36 hours!” “I don’t care!” The prospective client yelled, “Doulas aren’t allowed to sleep!” While she may have had different expectations of her midwife for her home birth, I was so afraid I’d never be able to make her happy that I referred her to other midwives.

When you are researching and interviewing care providers, ask them questions about their own self-care and how that relates to your care. Know also that in some communities and practices, all care providers are overwhelmed and doing the best they can by their patients. Be open to alternate plans. Consider that while you may be very fond of your midwife or OB, under some circumstances, a well-rested, less familiar provider may be more ideal than a more familiar, exhausted provider.

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