Justine: Hi, I'm Justine.
Sarah: I'm Sarah Lavonne.
Justine: We are so glad you're here. We believe that your life has the potential to make a deep, meaningful impact on the world around you. You, as a nurse, have the ability to add value to every single person and patient you touch.
Sarah: We want to inspire you with resources, education, and stories to support you to live your absolute best life, both in and outside of work.
Justine: Don't expect perfection over here. We're just here to have some conversations about anything, birth, work, and life, trying to add some happy to your hour as we all grow together.
Sarah: By nurses, for nurses, this is Happy Hour with Bundle Birth Nurses. Since we are a real podcast, growing into our sixth season.
Justine: A real one.
Sarah: A real one. We actually had a meeting. We actually had an end-of-season five, starting season six planning meeting, which I feel like is our most official thing we've ever done.
Justine: For the whole team.
Sarah: For the podcast. I'm like, "We do a lot of official things." All day. Oh my God.
Justine: For this thing that you're listening to right now. One of the things that were super insightful that the marketing team and Ashley brought to us was our most popular episodes, what's doing well, because Sarah and I don't really track that. I especially don't now that I don't edit. One of the things we definitely learned was that people love fetal monitoring and they love those episodes. Then the beginner's fetal monitoring podcast did really well. We were trying to brainstorm what else could we talk about?
This episode, we are going to talk about the oxygen pathway. The oxygen pathway being how does oxygen get from the birthing person to the fetus, especially during the intrapartum period. Why I like it is I feel like so often there's a group of people that have no clue, have never thought about it, are on the unit, and just know how to read fetal strips. Read the strip. I don't know what I just said. There's the opposite of people like you and I, Sarah, who were studying the intricacies of things to really understand it, especially you.
There's a lot of people out there that are like, "Yes, I never thought about the interventions we do or why we do them. I just throw the kitchen sink at them and hope it gets better. We're just going to take it back a little bit and go over the oxygen pathway.
Sarah: This is critical thinking, by the way, like when we learn in nursing school that use critical thinking to assess my patient, my intervention is critically think my way. What that means to me is always pathophysiology, what's actually going on, why am I doing what I'm doing, and you will become a better critical thinker when you ask why.
Justine: Yes, it's good. What happens? Big picture. When you're pregnant, and even when you're pregnant or a birthing person is pregnant, they have to breathe in oxygen ultimately. This oxygen goes into our lungs and into our bloodstream, where it hitches a ride on the red blood cells. That's why we need red blood cells with hemoglobin, oxygen, and that's where you're getting your oxygen saturation of how much oxygen was allowed to attach to those red blood cells.
Then it gets pumped through their body with their heart and through their vasculature system and sent to the uterus and then into the placenta. What I found was interesting, and I don't think I really knew this before I was prepping for this episode a few months ago, because some things I just get glossy eyes over when they tell me. If you tell me, uterine spiral arteries, I'm like, oh, glossy eyes. I don't know. I did find out that the uterine spiral arteries are the terminal arteries of the large artery vein.
Sarah: It's an artery, not a vein.
Justine: [unintelligible 00:04:06] that makes sense. It's the terminal arteries of the uterine artery, and it gets remodeled in pregnancy specifically for the placenta. That's one of the leading causes or the leading theories of preeclampsia is that when you have preeclampsia, that remodeling doesn't work 100%, and so it doesn't allow as low resistance as it's supposed to. The way it remodels itself is it becomes very low resistant so that all of the oxygen could go in very passively.
Sarah: When you think low resistance, it's just like an open door. I'm just flowing through, and I'm not going to force you to do any work.
Justine: It's going to run in smoothly and easily, and that's done in early pregnancy, which is so neat. You actually can look up spiral arteries, and there's different things that it does during our menstruation and during pregnancy, and I just thought that was really interesting. Our uterus [crosstalk]
Sarah: The uterine artery spirals itself into, I think of a spiral FSC. They're swirling in to the uterus to oxygenate the uterus.
Justine: Then during pregnancy, in the beginning of the pregnancy, they transform themselves, little transformers, to be low resistant so that there's all these doors open to oxygen. I think that's super cool.
Sarah: Is that a hormonal thing that causes that to happen?
Justine: I would assume. That's a good question. I don't know. We can find that out.
Sarah: This is my brain. This is like the cord gas episode all over again. Oh God.
Justine: Failure of this remodeling is associated with complications like preeclampsia or IUGR. I thought that was really interesting and just a little fun fact. That's where the placenta and through that uterus is where all the oxygen happens, and that's where all the blood can go into then, the umbilical vein, which goes to the baby. When you're thinking about big picture of you're seeing something on the fetal monitor that you know is a category two or you're concerned about, you're seeing decelerations, you're seeing minimal variability, you're going to start thinking through the body system. The most obvious one being, in my opinion, they just got an epidural and now their blood pressure is 75/40.
What's the issue there? The issue is, oh, low perfusion of blood, so low perfusion of oxygen to baby. You need to increase that, increase their blood pressure, and you will get more oxygen to the baby.
Sarah: Which if you have a low resistance system, but you have enough blood pressure to push the blood through the placenta to the baby, and then all of a sudden there's less pressure, regardless that it's a low pressure system, you still have less pressure to the placenta. It's at the placental level.
Justine: Good. Then there's issues like if your patient starts hyperventilating and all of a sudden can't breathe and they're satting low, you're going to have low oxygen to the baby. Maybe in that case, your patient needs oxygen. They're satting 89. Their patient doesn't always need oxygen. Your patient's satting 100, why do they need oxygen? Obviously, that's not their issue. We think cord compressions, if you're having variable decelerations and you think you have a cord, then obviously it's positional changes or it's an amnio infusion.
You're having tachycystole. You're like, "Oh, why do I keep having leads?" Look at your contraction pattern. If you've noticed the past two hours, you've been contracting and giving zero to no resting time in between, at some point, there's going to be not enough oxygen that has replenished in the intervillous space of the placenta. Then baby obviously needs oxygen. We breathe for the babies, the fetus. They cannot breathe yet until they are born, and they can't control their stroke volume.
I never really understood that either. What does that mean? What is it? Heart rate times cardiac output equals stroke volume. I feel like that was an equation in nursing school.
Sarah: For sure.
Justine: I glossed over it.
Sarah: NCLEX, definitely.
Justine: Why can't they control their stroke volume? Their hearts are just too small and too weak. They can't pump stronger. They can't make the pumps more aggressive. When they sense that they don't have enough blood flow coming in, they can't make it stronger. What they can do is they can pump out faster beats, either tachycystole or they can slow their heart rate down to then protect their vital organs.
That is what a deceleration is. I think it's so fascinating. I'm always fascinated with the fetus, and the coping mechanisms it has is that it wants to protect its heart, its brain, and its adrenal glands. How it's going to do that, it's going to slow its heart rate down. That's why they come out with acrocyanosis and why we say, "Oh, that's normal." Because during labor, they were just pushing their blood flow to their body. Their little hands and feet may have gotten blue because they got less blood flow. That's just so fascinating to me. Sometimes you can even reassure yourself, if they're having lates, they're having variables, they're still able to compensate then. In theory, you can think in your head, they still can compensate. Their CNS is probably still intact, especially if you still have moderate variability. For the most part, it's once they lose that ability that scares me. When I see an absent to minimal tachy "subtle lates", and I'm putting subtle lates in quotation because I hate that term, because it's late is late.
Sarah: It's not something to chart. It's not something clinical. Subtle late is not a thing.
Justine: I don't know why someone died on that hill and is really putting that [crosstalk]
Sarah: It goes to show the cultural thing. We just like, "Oh yes, that's true." You don't ask questions.
Justine: Anyway, subtle late is not a late. A subtle late is late. A subtle late is not a thing. It's the same idea and it's the same mechanism. If you want to know more about that, we have not only basic fetal monitoring, but we have our new CEFM class coming. It's very exciting. It's been fun to read up all in this, even more so, and for a reason. Because you can read things just for fun, which people are probably like, "What are you reading for fun?" Doing it for purpose is really nice. It really activates a different part of your brain, which is cool. Which is why it's really good to get certified even if your hospital doesn't pay for it or you get extra or whatever. I don't know. I would bet there's a--
Sarah: What part of the brain does it activate? Oh, that? A part of the brain that's important.
Justine: Yes, but what were you going to say? In the sense of, yes, it just makes you feel-- You're nurses, for the most part, that are listening to this, so you're smart. You got here, and you went to school, and you went to school long enough. I don't believe that everyone's so burnt out that they don't ever want to pick up a book again. There's something to it when you're like, "Oh, this is--
Sarah: The expectation would be that you're still learning. That's why you have to get CEs for your license and not just click, click, click. The point is they're trying to keep you relevant.
Justine: What's crazy is Oregon doesn't need CEs. It is fascinating. The state [crosstalk].
Sarah: That is so interesting.
Justine: If I was a state, I would make-- The problem is-
Sarah: If I was a state.
Justine: If I was a state, and also, the [unintelligible 00:11:24] people can't just-
Sarah: The State of Justine.
Justine: -click, click, click, click, and be like, "I got them done." I cannot imagine. Maybe in 30 years that'll be me, but I don't think it will be.
Sarah: No. Same. I'm going to take the exam after your class.
Justine: I know. Which you could take it now.
Sarah: I know, but I'm going to learn-
Justine: Appreciate [crossstalk].
Sarah: -and then I'll feel better about myself because I definitely don't feel like I would pass.
Justine: You would pass. There's no doubt in my mind. I would bet you money you would pass.
Sarah: I did do the advanced test without paying attention in the class because I was moderating, and I passed 98%.
Justine: You can critically think through questions. You know the oxygen pathway, you know NICHD like the back of your hand, and you know how it relates to what.
Sarah: Let's get certified together.
Justine: Yes. Back to the oxygen pathway, when it gets tricky is when we start going into fetal hypoxia and shut down mode. The body can't compensate anymore, like I was saying, and the oxygen deprivation continues. I had this happen to me at the gym three days ago.
Sarah: You had a decel?
Justine: Yes, I had a decel. My heart decelerated. No, I've been doing, which I'm sure you know Whitney Simmons. She's a really fun fitness influencer. I've been using her app Alive at the gym, and I love it. I'm lifting really heavy, and it's been fun. My sister and I have been doing it.
Sarah: Cute.
Justine: We're doing it for six weeks now. I went to do a lunge and I immediately fell down. My entire leg gave out, where my sister looked at me, and she had her headphones in. She looked at me and she takes it off and she's like, "Did I push you?" She was so confused. [laughs]
Sarah: You fully collapsed.
Justine: I fully collapsed very gracefully, she said. I had so much lactic acid buildup, and I went completely anaerobic that my leg was just like, boom,
Sarah: You're such a nerd. That is so good. "I went fully anaerobic." I'm going to start using that in Pilates. I am in an anaerobic state.
Justine: I just thought about that, and when we think about fetuses of we want everything aerobic.
Sarah: They just give it out. Maybe don't make them do so many reps. Try normal workout, y'all. Stop with the tachysystole. You're like, "Too many lunges."
Justine: They're doing too many lunges in labor. Oh, my favorite quote from Jen Atkinson in one of her classes was that we have made five contractions in 10 minutes normal when really it's the line in the sand. That's high yields. No other practice that I know of does that. No one is pushing the most of a med and like, "Okay, good. We got there." We want [crosstalk].
Sarah: No. Let's just give them a little more. Give it to distress, then we'll back off on the fentanyl.
Justine: Everyone that says--
Sarah: The mag.
Justine: -pit them to [unintelligible 00:14:27].
Sarah: Just give them a little more mag.
Justine: Give them more mag. They're doing fine. Let's just give them--
Sarah: Then, if we see signs that they're decompensating, we'll back off, but don't turn it off. Just give them half and turn it back on in a second.
Justine: It's been so normalized. Pitocin has been, and that's what we're talking about in case.
Sarah: By the way, we have a whole class on this, and so we invite you to shifting the Pitocin paradigm. If you haven't been, it's like the perfect little hit of information. It's two hours. It's all on everything heavy hitter that we deal with, like Pitocin, obviously. We al-- we meaning you, give Pitocin constantly. If you're like, "I just want to learn and be stimulated and critically think and stimulate my brain to grow," that's the class I'd go for. If you haven't been to physiologic birth, the other one would be that because they go hand in hand. Anyway.
Justine: I know. I have another new hospital job, and we didn't have a patient from 7:00 PM to 2:00 AM, no one on the ward, which is so different for me. There was a new grad there who had her advanced fetal monitoring book out. She had just taken the class and was writing all these notes and has three little notebooks in her scrub pockets of all of these things.
Sarah: Oh my God. Cute.
Justine: Don't have social media.
Sarah: That was neat.
Justine: She was talking about something, and I was like, "Oh, you need to take this Pitocin class." I sent it to her and I was like, "Oh. There's these podcasts you need to listen to." Which is always a teeny bit awkward because once I share it, she's going to see my photo.
Sarah: She's like, "This is the girl. You are her."
Justine: What was funny is I sent her one of the Pitocin podcasts we did with Jen. She was like, "Oh my God, I was just listening to this yesterday while I was doing my dishes." I was like, "Great."
Sarah: Cute.
Justine: Even then she listened to that podcast, fell in love with Jen, and then want to do the Pitocin class because [unintelligible 00:16:18].
Sarah: You will.
Justine: Yes. It's so helpful.
Sarah: I learn something every time I go, and I've been four or five times now.
Justine: Yes, I agree. It's so good. Again, we like Pitocin. It can be very effective-
Sarah: It's fine.
Justine: -if needed. It's fine, but there are are other things you can do to stimulate contractions, like take physiologic birth to really--
Sarah: Take physiologic birth or use motion because remember, we do have an app that does it all for you. Doesn't do it. You have to do the work.
Justine: Your anniversary is coming up here soon.
Sarah: I know.
Justine: Two days.
Sarah: When we're recording this. Yes. Two days. It's been a year.
Justine: Basically, when it gets really upsetting for the baby is when they have to go into anaerobic because we have depleted their oxygen enough, usually from how many contractions we're forcing them to have. Which I know is such a hard thing because we want them to get delivered. We don't want to sit on them. We don't want to be the nurses that feel like they're sitting on them. You have providers breathing down your neck to up the pit, residents breathing down your neck. Again, educate yourself, take the class, know the lingo, know what's going on, know what's normal so you can advocate. It's the biggest thing.
Sarah: Also helps stimulate contractions without it, so that you know that you are not the one causing harm.
Justine: When they do go into anaerobic, they have a harder time compensating. Maybe they can't regulate their heartbeat as much. They might go into a bradycardic episode and not come back up, and that's when we're crashing them.
Sarah: Prolonged decels is an example of that. Are there any other things people should be looking for anaerobic that that's like, "I'm an anaerobic metabolism. Too many lunges."
Justine: Too many burps.
Sarah: Not to give out.
Justine: That's the biggest one that I can think of. That paired especially, your cat 3s is what I'm thinking of. That's why they're category three. Your absence with lates or tachy. Tachy is not in cat 3, but it should be, and according to--
Sarah: I bet it's coming.
Justine: I know, but who knows when they're going to meet again, and that's what I've been wanting--
Sarah: I know.
Justine: [crosstalk] is 2008, hashtag too late and [unintelligible 00:18:31] but there's all these algorithms now, or the five-tier color that I really like that you can go deeper into category two because tachysystole with minimal or absent variability is very concerning and you need to intervene. Again, come take CEFM.
Sarah: Let's recap. That if you have an interruption anywhere on the pathway, it will affect the fetus. Obviously, it potentially affects the parent, like the birthing person, but not always, and that's where, especially related to our fetal monitoring, it would behoove you. I've been using that word a lot. It makes me feel very proper and smart. It would behoove you to think through each step of the pathway, so did they fall on their face, and their face is being covered so they cannot get oxygen into their lungs? Unlikely but like, "Hey, is the airway clear? Did they choke on something?"
Justine: They have pneumonia.
Sarah: It's actually more likely. Then that would be lower in the lungs. Then you go down, do they have some sort of lung infection, virus, COVID, embolus, something else going on at the level of the lung? Your interventions are very different, like a position change when you have a pulmonary embolism. Those are different. Your position change is not what you're doing. When the patient's gone unconscious and there's a lung issue. If you correct the lung issue, it will ideally correct the baby. How is the oxygenation? What is their O2 sat? I would be thinking lugs and then blood.
Justine: Said lugs.
Sarah: Lungs, and then blood. Then you're checking an O2 sat because if they're satting 75, no duh, this baby's going to look pretty bad. Then you need to fix the oxygenation of the red blood cells. Are there enough red blood cells? What's their labs? If there aren't enough red blood cells, how do they carry that oxygen to the uterus? Now, if all of that's fine, then we start looking at the uterine level, and that's where that placental insufficiency that we see everywhere it's placental insufficiency. What does that mean?
That at the level of the placenta, the cord is good. The cord is juicy. There's lots of space. There's no knot in the cord. There's no nuchal, but instead there's some sort of spiral artery. Now I'm going to start saying that to make me feel really smart, but there's a spiral artery, a perfusion issue, a calcification, something.
Justine: Abruption?
Sarah: Yes. There's no connection totally, or yes, at the level of the placenta, there's something going on. You ideally want to eliminate everything else because if you fix anything higher than that, it's going to likely fix the lower levels of the issue, meaning lower placenta cord. Then placenta good. There's a cord that's getting smushed. That's where your position changes, or your amnio infusion might actually help you. Giving oxygen to fully saturated cells, obviously, follow your policies and procedures, but if we're looking patho, does it make sense?
Now, if we're looking at the placental level also, that's where our blood pressure comes in because you need pressure in the blood to push to baby, and if the parent is lowered, obviously that also goes to blood volume. It could be a blood pressure by volume because they're hemorrhaging, or it could be a blood pressure because of an epidural drop or some other hypotensive episode for some other reason. It doesn't matter.
Hypotension then, you have your IV fluids, you have your other interventions, potentially meds, and then you get to cord. Is the cord okay? Now, can you fix a knot in the cord? No. Can you fix a nuchal? No. You want to be aware of it because as the nuchal or the knot gets pulled, you're going to see those terminal bradies that then go into the baby. Now, what if the baby has some sort of issue?
We're probably not going to know other than seeing arrhythmias on the monitor, and in general, that's not even necessarily going unless it's incompatible with life or there's some sort of cardiac issue along the way. You can assume that it's placental or cord. When you're following your interventions, going forward, ask yourself, "What's actually going on here to cause this?"
At the level of the uterus, we talked a lot about tachycystole, multiple contractions, how often are your contractions, but also what's your resting tone? All of that we talk about in all our classes, but basically, you're trying to find the cause to fix it, rather than just like you said, throwing the kitchen sink at them. It's like, let's use our brilliant brains and try to figure out what's going on instead of throwing them 16 liters through their labor when their blood pressure and O2 sats and volume and all of that is good.
Justine: Please don't give them 16 liters. That would be--
Sarah: Six is too many, and then you cause an issue and try to kill them.
Justine: If you want more fetal monitoring, we have a few episodes we can link on that on cat two on beginner fetal monitoring. Then like we talked about, we have those classes that I think you would like. The basic fetal monitoring is about two hours long, and then CEFM will be about four hours long, and we're really excited about the CEFM one. You get a printed workbook. It's mostly case studies with deep dives. I hope to see you there. Thanks for spending your time with us during this episode of Happy Hour with Bundle Birth Nurses. If you like what you heard, it helps us both. If you subscribe, rate, leave a raving review, or share this episode with a friend. If you want more from us, head to bundlebirthnurses.com or follow us on Instagram.
Sarah: Now it's your turn to go and follow the oxygen pathway. We'll see you soon.