Hi, I am Justine.
And I'm Sarah Lavonne. And We are so glad you're here.
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By nurses. For
nurses, this is Happy Hour with bundle birth nurses.
We are back with our fetal monitoring experts,
our bundle birth educators, Justine and Heidi.
I am about to embark on the journey of studying for CEFM.
I have literally no idea where this conversation is going,
but they have been cooking up something
nice and juicy for us.
And we are gonna talk about intrinsic factors.
I don't even really know what that means.
So I get to be the student today
and y'all are gonna teach me all the things that I need
to know for the intrinsic factors
of the fetus.
Yeah. Okay. Good guys. I'll
Say it's not, it's not fun if you know everything right.
We have to leave some surprises for you too.
I mean, I kind of love showing up to podcasts
and being like, what's happening today?
And I will be honest, like the last few podcasts have
Done That's 90% of the podcast.
I know, I know. Where I'm like, yeah,
we're talking about this, right?
And Justine's like, no. I'm like, oh, okay. Okay.
So you're getting the real and raw reactions to like, okay,
that's where we're going with this.
Let's do it. Mm-hmm. I love it. Well
Love it for you. You're
Able to be on flow flex and flow.
Yeah. You know how to flex and flow.
But I will say when we were preparing for this episode too,
I had just filmed the Oxygen Pathway
video, I mean podcast with you Sarah.
And I was like, what did you talk about?
And I was like, I blacked out.
I have no idea what I talked about.
But, so I hope that that episode was helpful.
But I know for sure we did not talk about one
of the more fascinating parts of fetal physiology, which is
how it compensates and the intrinsic parts
and how this like fetus is so incredible in, in
pregnancy and in utero and in labor.
And so we're gonna, we're gonna talk about the fetuses built
in survival gear that it has.
That's the intrinsic factor.
Yeah. So it's all the things like inside the fetus.
So what comes from inside the fetus that allows them
to be able to do what they do
and adapt to changes in their environment.
If there's like decreased oxygen in pregnancy
or during labor, like how are they built for that?
So we're, that's what we're gonna dive in today
and like, like how does it communicate its distress to us,
which you guys already know.
We see that those are the changes we see in the monitor.
So we're gonna dive into like why you see those changes
and then what you need to do about 'em.
I'm here for that. Yes. Okay.
So let's start with pregnancy.
Everything works on a gradient, especially oxygen.
It flows passively from the maternal side,
the pregnant person's side to the fetal side
across the placenta.
So when we're talking about this gradient,
like things in the pregnant person are going
to be more alkali so that the fetus is more acidotic,
meaning that it's like craving that oxygen.
It needs more oxygen.
And so oxygen is one of those things
that just like freely flows across the placenta.
There's like no disruption.
That's something that just easily flows across.
And then CO2 easily flows back across towards the pregnant
person giving us that more alkali
state on the side of the pregnant person.
And then the pregnant person's oxygen consumption
increases up to 40%.
And so it creates this like balanced system
to keep the baby well oxygenated. It's like incredible.
So like the, the patient consumes more mm-hmm Oxygen
to have it available for the fetus.
Yes. Yep. I love being the student. It's so fun.
I can't wait to be in your CEFM class and be the student
'cause I'm gonna study and I'm gonna take the exam
because I don't have that one.
I need more letters too.
Yeah, they all having everybody need letters
Too. Yeah. I love
having all the letters like why wouldn't you
want them so fun.
Yeah. Especially like
this one, you're gonna make it so easy.
Mm-hmm. So it's flowing freely
and they have more oxygen available so
that the fetus can get more free flowing oxygen
to their acidotic state.
Right. And so long
and they're like built that way purposefully like so long
as like there's no disruption really
what they're getting like exceeds their, their needs.
So they're kind of built to like function
with like less oxygen
because everything's like flowing to them.
And if we think about like their structures,
everything like within them is super immature.
So like they couldn't manage that all themselves anyways.
Like we know that with how their circulatory system changes,
their lungs are actually like bypassed their gas exchange is
happening through the cord.
Um, so yeah, they're heavily reliant on the pregnant person
to like supply that to them.
'cause really what they're trying to do is just like grow
and and develop and like mature all their little structures.
So the next little thing we're gonna talk about
is hemoglobin.
Um, so the fetus actually has a special type of hemoglobin
that you only have as a fetus.
And for lack of better words, it's called fetal hemoglobin.
And so it's really cool. So really
what it has is like a higher affinity for oxygen.
Meaning that when it comes in touch with oxygen,
like it just latches onto it.
So as soon as that's like flowing across the placenta,
the little fetal hemoglobin is just like grabbing onto that.
And at birth, the fetal hemoglobin level is actually like
higher than what it is in adulthood.
It's actually averages
to be about like 17 grams per deciliter,
which I think is like so interesting.
Mm-hmm. So all these little things it's doing are just like
working to help it like grab more oxygen.
Its circulatory system has more capillaries.
Like it is just all like feed me, give me all the nutrients.
That's an intrinsic factor. Mm-hmm.
Because it's inside the, inside the fe,
inside the fetus. Okay.
So x so extrinsic are gonna be those things like outside.
So that's gonna be that, that the fetus has no control over.
So that's gonna be like the everything within the pregnant
person, the placenta, the cord, all of that.
It doesn't have control over any of that.
Okay. Yeah.
Also there's that like fun fact
of fetal oxygenation saturation in utero, which is one
of those things that you call the little blue babies.
Do you wanna talk about that? Oh yeah. Blue weirdos, right?
You've seen I, yeah I know I need to like trademark that.
Um, I call them blue little weirdos
because in utero they are blue, right?
Because like they're, as we've talked about, like the amount
of oxygen they have is like less,
even though it's like exceeding.
But they have like these little built-in things
with their hemoglobin to um, carry oxygen.
So they're like floating around and they're floating around
'cause they're in amniotic fluid at about like
45% like plus or minus five.
Um, which makes sense
and is kind of like an aha moment at birth.
Like that's why they come out blue.
It takes them a while to like pink up
until their circulatory system goes from that right
to left shunting to left to right.
And they start doing their gas exchange through the lungs.
'cause really they don't get to 85, 90 5%
until they're about 10 minutes old.
So if you're just like thinking about all these things
and like start putting all these pieces together,
you're just like oh, oh, oh.
And I feel like I still have like so many
of those moments when I'm reading
things. It's just, it's fun.
Yeah. I have a question. If they're at 45% mm-hmm.
You're saying saturation mm-hmm.
In utero, that means 45% of their blood cells?
No, their blood cells are saturated with 45% oxygen.
Like if they're not a hundred percent saturated,
Like what's floating around?
Yeah, it's like 45. But all of their like oxygen.
So they're getting like a hundred percent of the oxygen
that they have is going to like their brain, heart
and their adrenals and then all that oxygenated blood.
So it can be like confusing.
It's not that they're lacking oxygen
but just what's like free floating around.
It's like about 45%.
But a hundred percent of
what they're getting getting is going towards their brain.
Heart and their adrenals.
And then they're getting deoxygenated blood too.
And then that's what's suffic to supply their um,
extremities and um, their non-essential organs.
Okay. So I'd never thought of O2 sat
that it's the amount left over in the blood that tells you
how much is saturating the red blood cells.
Right. If the red blood, if there's more red blood cells
that are fully saturated, meaning they have what they need,
there's just extra floating around that makes it okay,
am I onto something or am I,
This is wrong. Yeah. That's how, yeah. And they
have like all these things
built in with them that like they're able to compensate
so they don't need to be at a hundred percent.
They don't need 'cause
Their organs are immature.
Yeah. And it's not like you don't,
their lungs don't need all this oxygen,
their lungs aren't working yet.
So the requirement,
the oxygen requirement is significantly lower, therefore 45%
or 40% is sufficient. 45.
Mm-hmm. But because it's lower
and we are a hundred, the birthing person's a hundred, the,
the gradient of oxygen is going to the baby more freely.
Because if the baby, if the baby is at a hundred,
that means they're not needing anything
from the pregnant person.
Mm-hmm. And all of their structures are so immature
that like they can't handle
that Their metabolism is immature.
They can't, they wouldn't be able to sustain that
and continue to to develop like that would
blow everything out of the water for them.
Like even if you think about, okay,
let's take a little side step, like even like glucose, like
that's another thing that freely flows to the fetus
because with their circulatory system,
with their like ductus osis, it bypasses that fetal liver.
So they have very limited glycogen stores.
So if glucose is like cut off from the fetus
and they're not able to like get that
and they're having to use their own glycogen stores,
they burn that up really quick
and then they start like traveling into hypoxia.
So that's why that like freely flows.
Like same thing with like oxygen.
Like they just don't have the ability
to like manage that all themselves.
So that's why they have like all these additional things.
Like they have extra capillaries,
their hemoglobin carries way more oxygen
than that of an adult.
And then they have all those changes in their circulatory
system to like feed that like check and balance.
So they need to be in a little bit more
of like a starvation mode so that they can like accept it.
And what they're getting is like,
it's just like free flowing.
So even though it's like at 45,
it's not like they're necessarily like running at 45.
That's just kind of like what's like floating around
And isn't that why they can like withstand a,
so say all of a sudden you have a patient setting at 90
or 85, the baby's still gonna be okay
because it only needs about 45%.
Mm-hmm To be able to be okay
and to be regulated so it can like have that interruption
of oxygen and have that reserve
because it doesn't need as much.
Mm-hmm. Where where if it was demanding a hundred
and we were at a hundred and then we go down,
it would have more detri detrimental effects.
That's kind of how I've like said it
in my head 'cause it is confusing.
Like why wouldn't it need a hundred? Why 45? You know?
Mm-hmm.
I think for me it like what it, what it,
what sticks is like that The oxygen demand is not as high
as somebody living on their own.
Right. And so you're the,
because the demand isn't as high, they still need oxygen
but it's just, it's like metabolized or it's processed
or it's brought in to the organs in a different way.
And so the gradient allows for there to be like
so much extra oxygen that's just naturally flowing to them
and is available if needed
but there's like leftover in the blood
because they don't need it. Is that, am I wrong?
No, that's like, that's right. Yeah. Okay.
So how they have like the body set up, um,
how you know the oxygen man, the gradient,
the flow of oxygen.
Then how their little blue weirdos
and their hemoglobin, how they hold on tightly to that
and then glucose, they bypass the ductus osis.
But now, so then you have the autonomic nervous system
and that's where I think we see more.
So this is where we're like we know this one
because this is where variability comes in
and this is what we see on fetal monitoring.
And so the autonomic nervous system has two sides.
You have sympathetic fight or flight
or you have parasympathetic which is rest and digest
and those balances how we know
that their autonomic nervous system is in check
and like working is because we see variability,
we see those ups and downs by 32 weeks we start
to see moderate variability and 15 by 15 accelerations.
That's when we kind of require it right. For NST and stuff.
And that's a sign that the nervous
system is functioning well.
That baby is alert and oxygenated
but it is a good sign to see variability and minimal
and absent are definitely could be signs
that your baby is not as oxygenated as we hope
and that is an intrinsic factor that they have
to tell us and communicate with us.
Yeah. Yeah. So it's the tug
and pull between that sympathetic
and parasympathetic nervous system
that creates the variability.
So the fetus, how they
like adjust to any changes in their environment,
they can only increase
or decrease their heart rate in the fetus.
Like their heart rate equals their cardiac output.
So as much
whatever they're getting from the pregnant person is
what they have, they can't adjust that volume.
So to compensate for decreased volume,
decrease oxygen content, they're either going to increase
or decrease their heart rate.
Those are the only things that it's able to do.
So when we're seeing those changes on the monitor,
like we're seeing decelerations like we can kind of like
retrain our brains of thinking like oh that's really bad
to like, oh there's some sort of disruption here
that they're having to compensate.
So I need to figure out where this disruption is
and like fix the problem.
So really like the D cell is like a symptom of them having
to adjust their cardiac output so that they can keep
what they're getting going towards their brain, their heart
and their adrenals.
And so that's why like as the fetus matures more, that's
where we will start seeing moderate variability
and we get those accelerations
and then any disruption in that is
where we're gonna be seeing our decelerations
or tachycardia.
Um, and then eventually like our variability is going
to go away and then we're gonna get like a
prolonged bradycardia.
I really love like thinking about fetal com compensatory
methods and like all the intrinsic factors
because it makes me a little bit less scared.
Like it's not just up to the pregnant person's body.
Like there's also the fetus in there like working
and doing things and like keeping itself as safe as possible
during the stress of labor.
Hi bundle birth nurses.
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and we'll hear from you in season seven
of happy hour with bundle birth nurses.
Let's talk about hormones and the stress response.
'cause like you, like we just said, labor's stressful
and it'll get tacky or it'll change its heart rate.
It'll go up and down in response to what it's sensing.
And so, um, let's talk about how it responds
to acute hypoxia.
So we've kind of talked about like
how I think we mentioned earlier
or you've maybe heard that like babies are built
to like handle the normal stressors of labor
and what that means is not that like oh they're supposed
to have D cells or, or not.
It's really like they are made to adjust
to those intermittent disruptions in their oxygen pathway.
Right? Because that's gonna happen with a contraction.
And if that just happens for a prolonged period of time,
then that's when they start having to compensate.
So that's like where we like move beyond normal.
So these hormonal protectors are built in for
when their pH starts like dropping below normal
and they're having to adjust when their oxygen drops below
their normal threshold.
That's when we start seeing problems
and their oxygen can actually be cut off by about 50%
before they start having to like do something about it.
Which is like pretty significant.
So We're talking about the hormonal changes,
like the first thing we're gonna kind
of talk about is norepinephrine.
And so this is like a big team player on the side
of the sympathetic nervous system.
This is what comes into play.
Um, when we get to a point of hypoxia, which means
that there's decreased oxygen in the tissues.
So you may hear the terms hypoxia, which
that's I just explained what that is.
Decreased oxygen in the tissues
and then hypoxemia is
where there's decreased oxygen in the blood.
Okay. Um, so that's kind of like the first thing
that is going to like respond when we have
that decrease amount of oxygen.
So Justine, do you wanna talk about what it does?
Yeah, I do. Uh,
because I like, I feel like this is
honestly I've only really learned this part
and kind of realized this part in the last year.
Mm-hmm So, and I said this wrong on the last episode
and so I wanna clarify this
because I was talking about,
we were talking about cardiac output a little bit
and I was just saying I don't know much
about cardiac output.
I think I remember the, um, the
equation was like stroke volume equals cardiac
output times heart rate.
But I think I mixed it up. What is it actually? Okay.
Is it cardiac output equals stroke volume times heart rate?
Mm-hmm. Is that what it's okay. Well yeah.
So just so you know, I know that I was wrong
but so a baby doesn't have,
these babies have these like weak hearts that can't,
they can't like push their heart harder.
They can't like their contractility
sucks for lack of better words.
And so the only thing that they can do
to increase their cardiac output
is increase their heart rate.
And when they do that, they shunt blood
to their vital organs knowing that we say this consistently.
Their vital organs is their brain,
their heart and their adrenals.
Obviously brain and heart, you understand,
but their adrenals are how they get these stress hormones
to keep working and to keep compensating during labor.
So we want their blood flow to go there. Right.
So I have always wondered. Yeah, yeah. Right.
Um, so what's, that's what helps maintain perfusion
during the D cells. Mm-hmm.
Yeah. So like we said, like
so norepinephrine is like a piece
of the sympathetic nervous system.
So if we think about back to
what Justin was saying about sympathetic being fight
or flight, like that's what's gonna,
it's gonna like increase the heart rate so
that it's just like well okay we gotta just like
tick things up here so that we can just like shoot this to
where it needs to go so that I can maintain homeostasis.
Um, a second hormone that kind of plays into things.
Sorry, I was just thinking like about Axel. Mm-hmm.
And is that why then like the stress of the,
like they have an axel with a contraction
'cause they're like woo little squeezy on
my, my nervous system.
This is new and they kind of like norepinephrine
to cause an cel.
Yeah, they can um, they don't
Or like scalp stem.
Yeah, that's exactly what scalp stem is. So Okay.
Accelerations from scalp stem were kind
of like a secondary finding.
So when talking about scalp stem, how they figured out that
that like elicits an acceleration is back in the sixties,
which we did a bunch of wild things back there.
So they would actually check a baby's pH level
during labor with its scalp.
They pinch it with alice clamps which ouch. Yeah.
And so that was painful to the baby.
And so they started noticing, oh when we do that,
sometimes we get this like increase in the baby's heart rate
and other times we don't.
So then when they would check those levels, they found
that consistently when they got this acceleration
that the pH was about 7.2
and if they didn't then it was like less blan.
And so then that was kind of like an incidental finding
that they were like, oh, okay, well then I wonder
what happens if we just,
and scalp stem isn't like
where you're just like rubbing their head like it's,
it's like in a aggressive rub on the head that you're trying
to like elicit that same response.
And so then that was kind of like a secondary finding.
So I just think that's like so interesting like how we get
to where where we are.
Yep. And I think like a key takeaway for that is
that when the baby sees that oxygen is dropping, it will
launch its hormones at it.
Mm-hmm. One of those intrinsic factors
and norepinephrine is one of the, the major ones for that.
Yeah. And so then kind of like a tag team of that
is cortisol, which we're familiar with cortisol,
it's like a stress hormone.
Right. We hear it described as a stress hormone.
I feel like everyone is familiar with cortisol.
Yeah, same thing I think. Yeah.
Mm-hmm If you're stressed,
like your cortisol levels are high, so like same sort
of thing in the fetus, but cortisol is not like an
acute response in the fetus.
It's kind of like a secondary response for this like
long-term hypoxia that's going on.
So that kind of helps with like maturing the lungs
help uh, mobilizing glucose levels in the fetus
and kind of su supporting some of the catecholamine effects
that that are going on as well.
So you'll see more elevated cortisol levels in things
where there's like fetal growth restriction
or there's like chronic placental insufficiency.
So it's really like trying to like come through
and be like, okay, we've really gotta like help out here
because I can't, I can't grow properly
'cause I'm not getting like all the nutrients that I have.
So that's like one of its other little things that has
and it's bag of tricks to, to accommodate to living
with less oxygen. It's
Like a chronic stress response.
Yeah. I didn't know that part. It's
Like the cortisol part.
Like do they test for that you think in like the NICU
or like if there's like a baby that needs cooling
but like do cortisol testing
and be like, oh this baby's been
stressed for a while. Like do we know?
Hmm. I don't know that they necessarily
test that for cooling.
I haven't heard that but
and then I don't, I don't do NICU so I don't,
I don't know that piece of it.
That would be interesting. Yeah.
Yeah. Well it reminds me of the physiologic coping class
that's available online where we talk about the um,
like the stress response
and particularly the maternal stress response.
Mm-hmm Beyond the physiologic birth hormones
and cortisol is one of those that like helps
activate glucose to be available
for like metabolism and stress.
Stress and all that. So interesting. Makes sense.
Cortisol is villainized but it is. Yeah,
No it's like a helpful thing.
You just don't want chronic cortisol like it's like a backup
mechanism for stress response
but not that it's like your body, the goal is
that it actually helps regulate your stress response
to a place of eustress slash like you're,
you're all down regulated then
and then it doesn't, it's not necessary
but it's like more made available when needed
versus continuously.
Yeah. So I think that just like circles back to
what we were talking about before of like
diesels are not necessarily like a good or bad thing.
It's like a sign that like we're having to compensate.
Like same thing with cortisol.
It's like okay, what's going on that we're like having
to really like cash in on this right now.
Mm-hmm.
Yeah. Fetal hormones are cool
and that's another intrinsic factor.
Mm-hmm Another intrinsic factor that we are all more common
with than you think more
or we're more familiar
with than you might think is if you hear baro
receptors and chemo receptors.
Now if you've done any CFM
or EFM education, this is like normal.
If you were like me the first time you opened a book
and like read this,
you were like I will never be able to pass this test.
This is absolutely insane. I am not a scientist.
I feel like when I first read it I was like absolutely not.
But it is, the more you're,
the more you familiarize yourself with it, the easier it is.
And again it just helps you like feel more at ease
because you know that these intrinsic factors are
for a reason and those variables
and D cells you're seeing are happening for a reason.
So baroreceptors, chemoreceptors,
baroreceptors live in the aortic branch in carotid sinuses,
which for me I like have to look at a picture to understand
that and like that's less important to me.
But what is more important to me is
that they detect pressure changes.
So when they detect,
if there's baro receptors really come into key play, play
with variables, variable decelerations.
So when there's a variable, there's cord compression, that's
what we know and there's buildup of the blood,
like they sense of blood pressure increase
because that pressure is building up
where the blood flow can't go through.
And so the baro to detect it,
they sometimes most likely shoot out oxygen
and that's where you'll see like a little acceleration
before a variable deceleration.
And then they will drop their heart rate
to protect their vital organs again to compensate
during the lack of oxygen that they're
receiving and the pressure.
And they don't wanna, like Jen has always said,
Jen says in one of her classes, Jen Atkinson,
like they don't wanna like blow their little BA brains out.
Right? I think I've heard her say that. Which is true.
They wanna like keep their blood pressure low
and um, I've always remembered that.
And so another com compensatory method
and they will drop their blood pressure
and so that is where the baro receptors come into play.
So they feel the pressure rise, it activates,
slows their heart rate, you get a deceleration.
Mm-hmm. Yeah.
And I think that one's easy to remember if we think about
like what baro means, that it's like pressure.
So you can kind of like lock that away.
Like okay, baro means pressure.
That's gonna be like there's some like a barometer
like pressure change.
So we see it a lot with variables, right.
'cause of that cord compression.
But okay Sarah, here's the funnel
pop quiz for you and everyone else.
Oh God, what's another thing
that we would see on the fetal heart rate monitor that has
to do with like a pressure change
where there's like early sort of squeeze Yeah.
With early, so it's that same sort of thing, right?
Where in their heads like getting squeezed
and if you think about where those barrow receptors are
and that carotid like along the neck there
and that head's getting squeezed,
that's gonna activate the vagus nerve
and like see a slowing in the heart rate.
So I think that is another thing that like plays back
to like, okay, de cells are not necessarily bad
or good, they're a compensatory
'cause everyone's like, oh early are fine.
But it's like that same sort of like compensatory mechanism,
but you gotta think about like what's causing it.
Like why, why is my, why is the head being squeezed
or why is the cord being squeezed?
And then try and like fix that problem. Right.
Um, okay. Are we gonna talk about like the other partner
of baroreceptors?
I want you to, you want
Me to? Okay.
Okay. So the next thing
that they have are chemoreceptors.
So this is like specialized nerve cells
that are going to
have this like red light alert when there is any change in
oxygen, carbon dioxide
or like pH, any of those levels drop below normal,
they're gonna send out a sympathetic response
and shunt that blood to vital organs.
And then that's what's gonna start like the cascade
of the rest of the, the system.
So that vasoconstriction, that's kind of that first part.
So when there's vasoconstriction that's gonna do what
to the pressure It's gonna change it,
it's gonna increase it, right.
And then the vagus nerve is gonna go, oh okay, my job now
to like slow down the heart rate.
So it's like they kind of go hand in hand,
but they like do separate things.
They have like separate mechanisms in them.
But those are kind of like the two main things
that are gonna like help um, the fetus adjust
to maintain their cardiac output when they have
that disruption in their oxygen pathway.
And the chemo receptors have a delayed response, right?
A slightly delayed and that's where you'll see the lead
deceleration, whereas the barrel mm-hmm Like instant
pressure change variables quickly
and that's why it's like that abrupt boom down
to the Nader contraction.
Um, I mean yeah, deceleration
And if we think about, okay,
and if we think about like late decelerations,
like if you think about the mechanism that's happening with
that so late, we're always like,
well it comes from like placental insufficiency
or utero placental insufficiency.
So if we think about like what is in the intervillous space,
so that's where like that oxygen is going like uh,
to the fetus and then we have waste products
coming back out.
So if there's that disruption there with a contraction,
so if our contractions are either too frequent,
meaning we don't have enough time in between for that
to replenish or there's some sort of holdup,
maybe we have an old placenta, we have a placenta
that's not working well because of hypertension
or GDM something, something is causing this like disruption,
then when that contraction happens,
whatever's in the intervillous space at that time, that's
what the fetus has to work with.
So as that contraction's happening, the fetus is like, okay,
like I made to deal with transient hypoxemia,
but then if it's decreased going into it, then it runs out
of it and by the time the contraction gets
to the strongest point and nothing else is coming through,
then that's when it's like, oh okay, I've gotta adjust.
I can't maintain where I'm at
and I gotta slow my heart rate.
So that's why you're seeing that
after the peak of the contraction.
And so I think that's like a helpful little tidbit hopefully
to kind of describe why we're seeing
that at the point that we're seeing it.
Whereas like early as it's gonna line up
because that head like it's just, you know, saying there,
it's like right there, it's right by those carotid arteries
where it's like that change is gonna happen quick
or that cord is getting compressed
and it's like a garden hose that gets pinched off.
The change you see is like quick right away. Yeah.
Mm-hmm. They get frustrated when people are seeing
or variables and not really too concerned or maybe minimal
and the patient's two or three centimeters
and like in their prime, I'm like, we have a long way to go,
like what are we doing to make sure
we're protecting that reserve?
Because yes, they can compensate
and when they're, when the system is stressed from a
contraction or a cord issue
or a placental problem, they're gonna,
we're gonna see it on the strip, right?
We'll see D cells decreased variability, tachycardia,
bradycardia, worst case.
But um, these are messages from the fetus
and they're trying to compensate
and like, how can we best support them in this compensation?
And so let's talk about how, what do we do about it?
Yeah. So we kind of talked about this earlier,
like we don't wanna just treat the symptom, right?
We don't wanna just be like, oh
they're having d we gotta flip them.
Like yes of course you want to
use your intrauterine resuscitative measure measures,
but you wanna pay attention to like what's causing it.
So if you're, if they're having lates in your flip
and you're just like changing position, yeah
that's gonna help maximize cardiac output.
But you also gotta look at other things like did they just
get an epidural and they're blood pressures in the toilet
or are they on pitocin?
Like, so those would be your two problems.
So like, okay, I need to turn off my pitocin
or I need to address their, their blood pressure
and like that's what's gonna fix your problem.
And then you turning them, which you still add.
I'm not saying don't turn them, you obviously still should,
that's gonna help, but it's not gonna fix it.
So you gotta do like, it's like a twofold thing.
You gotta treat the problem and you gotta like
address the symptoms then.
And so if you address that problem, then that's,
that's ultimately what's gonna fix it.
And then turning them is just gonna help
that fix that you're doing.
They did a study on cardiac output for positions, right?
Mm-hmm. And we've seen that, we've talked about it
and now I can't really remember.
What I do remember is standing's the worst,
which obviously we're not gonna,
like they're having a late stand
them up, like it's not gonna happen, right?
Mm-hmm. But I want, is it hands and knees?
That's the need. Chest is the best.
It's knee, it's knee chest.
So really what the study was looking at is like, like
because cardiac output increases so much during pregnancy,
then they're like, okay, where do we get like the best
like cardiac output?
So yes, it's best when it's like knee, chest
or like standing's the worst.
But this is like in terms of um,
when you're doing intrauterine resuscitative measures,
like if you're having decelerations
or decreased variability,
it's like sand's not gonna be the best thing just
because of all that pressure.
You're more likely to be impinging on those greater vessels
and that um, inferior vena cava.
So putting them knee, chest, I'm, I'm trying
to pull this study up.
I have, I mean I have it in like a hundred different places
but of course the second that I wanna pull it up
mm-hmm. Um,
And left and right are about the
same for a long time. Left
And right. Left and right are
pretty much about the same. Yeah. Yeah.
Mm-hmm. Yeah. So you just wanna put them in one
of those three positions, um, either left or right.
Yeah. I think it's like they're off by like 0.1
between like left and right. So
I love how like in a de cell, like,
or you can have a unit that is like anti hands
and knees during labor and then in a de cell they're like
getting all hands and knees and you're like,
why can't we be like this always, it's actually the best
for their cardiac output.
Hello? Right.
Well I just a little side note there.
That's what I kind of tell nurses when we do sims
for shoulder and everyone's so like
they can't even think about doing hands and knees
or gas skin 'cause like they're having an epidural
and I'm like, but during a D cell we would,
and then I always like, I've been telling providers like,
ask your nurse, like your nurse will know
and I tell the nurses like, tell
your provider we can do gaskin.
Like, you know how mobile they are with their epidural
because you've been doing it most likely
for intra resuscitation or just position changes in general.
But anyways, side note.
Yeah, no I think that's such a good call out.
Like, especially like thinking about it.
'cause I think for like shoulder two you get just like
so focused on, oh we are in a
position to like get the baby out.
Which like obviously duh.
But also like yeah that's a great option also
because it's gonna help with that cardiac output on the side
of the pregnant person
and have more willing to the fetus while you're trying
to quickly yard 'em out of there.
Yeah. So we kind of talked a little bit about just
that we wanna focus on our interventions leading
with like what's the problem
and then doing our supplemental things like giving them
fluid, turning them
and then are we gonna talk about,
do you wanna talk about oxygen administration or
Whose side are you on? Are
you on ACOG side or a one side?
So like the past decade it's been a big thing.
It's been a big argument.
You'll have nurses that will die on those hills of mm-hmm.
You'll have, you'll be going through a D cell
and you're either with a team
of like oxygen's immediately on
or you're going with a team where you have charge
nurses taking oxygen off.
Like when they go in to help you with intruder or sation.
I feel like I've been on both sides,
but I think the consensus now is like,
if you need it, use it.
Don't mm-hmm. Use it for too long
because it is a medication, it can cause
what they say is free radicals.
Not that I fully understand what that means.
I won't lie to you, but if you think about, what I like
to think about is like with, with neonates in the nicu,
like oxygen is not safe for everybody.
And not that this has anything to do
with a utero giving oxygen,
but like even when a baby is on oxygen,
it can cause like blindness in the nicu.
Like oxygen is, can be, and I don't know like dangerous,
but we leave it on, like I have seen patients have it on
for like seven, eight hours.
Like it's crazy. Like don't forget about it.
It's, um, use it if you need to,
but use everything else first and it could help.
Like it, they have done studies right where they did the,
the p the what they tested the cord, the oxygen
and the cord, the pH and the cord Right.
With people with oxygen and it was higher I believe.
Yeah. Well, okay. Yeah.
Kay Rice, of course that's Kathleen or Simpson,
but has done, was involved with like a big study
where they like evaluated what fetal SP O2
levels were like based off
of intrauterine resuscitative measures.
So one of the things that they looked at,
like I'll mention oxygen first
'cause that's what we were talking about.
Like we want, if we're giving them oxygen, like
as Justine said it, it needs
to be short term about like 30 minutes last measure that's
in alignment with what Aon says.
And we wanna give it like via a non-rebreather mask at
um, 10 liters a minute.
And because this delivers like between 80
and a hundred percent oxygen.
And so if we place oxygen on
and the fetal SP O2 is less than 40, it can
increase their fetal SP O2 by as much as 11.4%.
And if it's greater than 40, it increases it on average
around 7.6%.
Um, and then there was like a mean fetal SP O2 increase of
around 8.3% that persisted for 30 minutes
after the oxygen stops, like the oxygen, um,
administration stops.
So I think that's like an important takeaway too, that like,
you don't have to like keep it on.
There are gonna be some factors like as you take it away
and um, yeah, you don't wanna keep it on there
because it, you do have to kind
of treat it like a medication
and um, if you're needing, if you're still,
I guess like the way I think about it too is like, okay,
30 minutes, like we have like between like 30 minutes
I would say like around 30 minutes
to like do our interventions
and if things are, are not improving, that's kind
of like our tell mm-hmm.
Right. That we need to maybe reevaluate our plan. Mm-hmm.
And uh, maybe like change our mode of delivery, right?
That like, okay, we've done all the things like this isn't,
this isn't improving.
Um, rather than just like keeping oxygen on them for hours
and no oxygen with pitocin on.
'cause like that goes back to like,
you gotta treat the problem and not the symptom.
So a symptom is that they have decreased oxygen.
The problem is that they're not getting enough
because they're pitocin on that they're,
their contractions are too frequent or too long.
Um, so just yeah,
Don't, yeah. And don't
forget to look at the contractions.
I work with a lot of nurses where like they're trying
to fix the details but
they're not looking at the contraction.
Like they're looking at that top half of the screen. Mm.
Wait, look at the, what are we
look at their contraction pattern.
Like we just kind of forget, we
kind of be looking there first.
It's like one of the things we
potentially have more control over.
True. Very true. Especially if we're
augmenting or inducing them.
For sure. And like if you think about it like
that bottom half of the tracing, like that's reflective
of like where the oxygen's coming from,
like headed to the fetus, right? Yeah.
Like That's where it's coming from.
And then the top line is the fetus being like,
yep, I'm getting enough.
Or like, no, I'm not like, here's here's what I'm having
to do now because X, Y, and Z.
Mm-hmm.
All of these things, this is like such a big important
part of our job and what we do.
Right? We'll say like, I tell my patients like,
how did you know like that you, she came off the monitor
and I was like, oh, like 90%
of my job is watching your baby.
You know, I'm just looking at your baby. And so we do do
this all the time and I,
and especially if you're new, I want to encourage you
to keep learning
and like how you're gonna feel better about this
and how you're gonna feel about fetal monitoring
and the stress of not being able to, we always say like,
we have two patients and we can't touch one of them.
You know? And yes, that is true,
but there's so much you can do to help
that patient that you can't touch.
And one of those things is education.
And so if any of this was like, I had no idea, um, Heidi
and I would love to help you learn more.
We have a new C class coming and our first one's in July
and we've been developing it and it's been fun
and I have been learning a lot myself.
I learned a ton from Heidi.
And so I think that one way to encourage you, well there's,
there's also like, it's like a rabbit hole,
but you could also do like beginner fetal
monitoring first if you want to.
And then come to CEFM if you feel like you're not ready.
But I do think you are ready for CEFM, just so you know,
for just the test in general.
You don't have to have any experience to take it. Yeah.
We kind of want you to like,
if we were gonna put a disclaimer on the class
because we're doing a lot of case study
like heavy stuff in the class,
we would love if you had some experience to do it,
but you still can come.
Um, what, like, Heidi for you, like what made you,
what like first sparked your interest
to like really wanna become an expert in fetal monitoring
and all of this?
Oh, I think just
'cause like, it's like kind of like the centerfold of like
a lot, a big, big part of our job is always looking at this,
the number one thing
that people are getting into discussions
or disagreements with out at the desk is this,
it's fetal monitoring.
Mm-hmm. And um, when I started out, like I, I,
I think all of us can like relate to this.
Like people saying things at the desk
or like saying little terms
and you're like, is that a thing?
I don't know. And I like had my little notebook,
I'm like scribbling stuff down, like going home,
like looking it up, like reading studies
and like wanting to know the things.
And then, you know, I had like the, like some,
some knowledge when I started
but like didn't know a lot had to like do a lot of learning.
And so for me, like I was like, I wanna know about this so
that I can say no, this is what's going on
and like this is why and have things to like back it up.
So that's what I think is cool about CEFM. Yes.
You do not have to have your two years like you do
for inpatient obstetrics.
And so I think that this is something
that while you can't do anything about adding to your years
of experience, other than just like waiting out the clock,
like this is something that you can be proactive about
and go go in, like get those letters
and so then that kind of gives you like another piece
to be like, yeah, you know
what I I am certified in fetal monitoring
and I think it's kind of like a badge of honor
and like patients think that that that is important too.
Like they want some someone that is skilled
and like certified in in what they're doing, right?
Like, I don't know, it's like that in,
in pretty much every other specialty.
And so I think it's like so important for nursing
and um, yeah.
But fetal monitoring is just always something
that I've been really passionate about.
'cause it's like a big part of our job
and something that people disagree on so much that I'm like,
okay, I gotta figure out what this is so that I know
how to respond
and like, you wanna feel like you know what you're doing and
and feel confident in it.
And so I think adding your CEFM is like a huge part of that.
And um, I didn't get my CEFM for for a while.
Like until, like I actually didn't get mine until what,
like last year?
Last year. Um,
because like Justine was like, why don't
what you don't have that?
And I was like, oh, I know.
It's just like one more test to take.
And I was like, I know I probably should.
And I mean I'm a a one fetal monitoring instructor
and I have my R-N-C-O-B
and so I was like, well do I need it?
And I was like, yeah, I do. I do want it.
But I just kind of had kept backburning it
'cause I just was like, oh, I don't have the time
and just, and I was like,
I like threatened our friendship.
I was like, I can't talk to you anymore until you your
Seat. Yeah, I know.
Well,
and I was saying to her, I was like, I need to study.
And she's like, oh my gosh,
no you do not. At least. So that's
What I'm saying, right. And
I tell you, you also don't either, but I, I
Know and I, but I did. But
anyways, I finally took it so we're still friends
And now we're writing a class together, so Yeah.
And so we're so excited
and we wanted, like, we get excited about this
stuff and we care about it.
We know you guys do too.
And so we want you to like share in this.
Sarah's gonna be taking the class. I'll
Be right there with you. We
Won't be friends with her anymore unless she gets it.
All right. No pressure.
No pressure. But yeah,
our class is meant, it's meant to be.
We want you guys to learn a lot.
Um, but yeah, what Justine said about,
you may wanna like take something else first just
because we don't want you to feel overwhelmed,
but the test is very physiology heavy
and so our class is also very physiology heavy.
Like this was kind of like just dipping the,
dipping your toes in the water of kind of like what is going
to be on the exam.
Just like a little piece of it.
Yeah. Because you know how to read strips, you know how,
you know, at this point
you should know what a variable it is.
You know what a late is. You know what it really is.
You can tell us a baseline like,
and there will be some of that stuff on the test,
but where I feel like people's stress is the physiology
part breaking up. Yeah.
Mm-hmm. Yeah. So we're gonna,
we're gonna talk all of that in the class.
We're gonna talk, um, interventions
and really like why you do what you do.
Justine has created two amazing case studies to apply it
and then we have like some other really fun interactive
things for you guys and a killer workbook.
And so come learn with us. We wanna learn with y'all.
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
and share this episode with a friend.
If you want more from us, head to bundle birth nurses.com
or follow us on Instagram.
Now it's your time to go
and consider the cause
when you're resuscitating those babies
and take the CEFM class.
We'll see you soon.
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