#63 Navigating Cat II FHR Tracings: Tips for Nurses with Heidi Nielsen

Justine:
Hi, I am Justine.

Sarah Lavonne:
And I’m Sarah Lavonne.

Justine:
And we are so glad you’re here.

Sarah Lavonne:
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.

Justine:
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.

Sarah Lavonne:
But 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.

Justine:
By nurses, for nurses. This is Happy Hour with Bundle Birth Nurses. When we plan this podcast, there’s a balance of things. It’s like we want to just have regular conversations. We want to help with education. We want to help inspire. And one of the things for this season that was fun to plan was, what is an issue and what is a fear that so many nurses have that I get so many DMs about, so many questions in mentorship? And that, my friends, is Category Two. And so we have a fun guest for you today, Heidi Nielsen, who you may or may not have heard of, which is fun. This might be your launch, Heidi. Hard launch. I don’t bundle birth.

Heidi Nielsen:
I don’t do anything soft. You just throw me into the deep end.

Justine:
Damn. Because I have been fortunate enough to have so many conversations with you around Category two, and I just think you’re an absolute genius. What, Sarah?

Sarah Lavonne:
I’m so sorry. I’m the most rude podcast person right now. I ran in to this meeting, this is behind the scenes, you’re going to get it, from an entire day of not a breathe, take a breath. And so I grabbed this big thing of cheese from the kitchen and a thing of blueberries, and then I opened the cheese and it was moldy. So I was running and I grabbed a jar of pickles. And I have no idea how old this pizza is, but I’m shoving my face as we were talking about this. So that was the delay. I also want to say that for the hard launch, Heidi has been instrumental in motions research development. So I think we need to pimp you out a little bit because also, we’re going to talk Category Two because you’re a genius. But also, you have an RNC review course coming that you’ve been putting together with Jen Atkinson.
And then you also have helped me with so many random researchy things along the way where I’m like, “Can you vet this? Can you find me something on this? Can we make sure we’re up-to-date on this?” And then, poor thing, talk about throw you in. I think we’d hired you for five seconds for RNC and you told me that you like research. And so I was like, “Oh, I have a project.” And I threw you the whole motion back office, everything, and was like, “Make sure it’s evidence-based.” And the poor thing went to town on it and also added research and basically was like, “Yeah, this thing looks great, but it was vetted through the lens of all of the things out there.” And so I appreciate your research brain and having you as a resource to Bundle Birth. And many don’t know that you have been a resource to Bundle Birth for the last however many months and we’re so excited to hard launch you here and then into the RNC review course that’s coming.
So if you want to get on the list for that and get updates and whatnot, you can sign up for a newsletter. We’ll drop the link down below.

Heidi Nielsen:
Yeah. Oh, thanks guys. Well, I’m really excited to be here and be brought out from behind the curtain and just be able to talk all things that I love and nerd out about, which is fetal monitoring, and research, and all the things. So yeah, this is perfect.

Justine:
You want to tell us a little bit where you’re from?

Heidi Nielsen:
Sure. Where am I from?

Justine:
Yeah.

Heidi Nielsen:
I am born and raised in Portland, Oregon where I currently am right now. I’m not down in sunny California with you guys right now, but it’s actually really sunny and nice here. And then I have been in the L&D realm for… This will be year 11 for me. And actually fun little fact, both my mom and my aunt were labor and delivery nurses.

Justine:
I love that.

Heidi Nielsen:
Yeah. My aunt was a labor and delivery nurse for 45 years, and my mom did it for about 10 and then she switched to the office life when she started having kiddos because she was like, “I need a better work-life balance.” So it’s been embedded in me, even though I tried to deny it for a while and thought I was going to do dental hygiene. I was like, “I’m going to be different. I’m not going to be a nurse.” And then-

Justine:
You do have really nice teeth.

Heidi Nielsen:
I totally was like-

Sarah Lavonne:
I was going to say that too. You have great teeth.

Heidi Nielsen:
Oh. Yeah, I am pretty OCD about my teeth and I am the person that flosses every day.

Sarah Lavonne:
I just started doing that. My dentist told me that it’s the wellspring of life.

Justine:
Oh.

Sarah Lavonne:
Yeah. It’s supposedly, again, whatever. But she said that flossing is essential for your overall health. And I was like, “I don’t know if that’s just motivating to try to get me to floss because I have not been a good flosser.” But it’s worked.

Heidi Nielsen:
No, it’s true. It plays a big role in cardiovascular health. Justine’s cringing right now.

Justine:
Because I’m like, “Great.” But now and you’re like-

Sarah Lavonne:
You’re like, “I’m going to die of heart disease.”

Heidi Nielsen:
Yeah, but that’s what they say-

Justine:
Good morning. Halfway there.

Heidi Nielsen:
Especially pregnant people, you’re supposed to get your teeth cleaned. So this will be a PSA for oral hygiene too.

Sarah Lavonne:
You’re supposed to get them cleaned more than usual or just get them cleaned?

Heidi Nielsen:
Just get them cleaned while you’re pregnant. Yeah.

Justine:
Heidi already knows I haven’t been to a dentist in nine years, so.

Sarah Lavonne:
Wait, what?

Justine:
I know. It’s a whole thing. Anyway, we’re here to talk about Category two, not my teeth.

Sarah Lavonne:
I am very concerned.

Justine:
I know.

Sarah Lavonne:
You need to go to the dentist.

Justine:
I know.

Sarah Lavonne:
That’s going to be my outro. You’re going to be like, “Thanks, everyone, for being here at Happy Hour.” And I’m going to be like, “And now it’s your time to go and get your teeth cleaned, Justine.”

Justine:
No. Okay. Season five, I’ll come back and say that.

Sarah Lavonne:
Give us the review. You’re pregnant too, so it’s especially important for your cardiovascular health.

Justine:
I know. I know. Okay. Okay. Moving on.

Sarah Lavonne:
As labor and delivery nurses, we know that our categories… If you’re in the US, if you’re in Canada, we realize that you don’t have the same categories that we do, but it’s the same concept, right? That we want to keep our families that we’re caring for safe. And so obviously there’s Category One, that’s the normal. There’s Category Three, that’s the terrible. And expedite, expedite. And then there’s this whole huge range of Category Two. And so as we begin to talk about this huge range of Category Two, Heidi, from your perspective also as an expert witness, I would love for you to just give us your take on Category Two. And when you look at our profession, you’ve been doing this for a while, you do have your finger on the pulse of L&D, especially… I think about you teaching all of these nurses all over the country for RNC. You are an expert at this. And so what do you want to tell us related to Category two to get us started?

Heidi Nielsen:
I think it is such hot topic because it covers 80% of tracings, which is so huge. At any point during labor, 80% of those tracings fall into CAT Two. And I think what’s important to know is just take a breath and just look at what it is. Take into account, okay, what stage of labor are they in? What interventions have I done? Are they responding to those interventions? Those are going to be your two key things to help you make the decision and help to better communicate with your provider about what’s going on. And I think at times we get timid about being like, “Oh.” Especially if you’re charting in the colors, which we can talk about, the five tier. I was on the floor working a couple of weeks ago with a nurse who was asking, she’s like, “Can you help me with this tracing? I’m just struggling with it.”
And so I was helping her work through it and she’s like, “If I chart this, means that I have an orange tracing.” And I was like, “Whether you chart that it’s that or not, you still have an orange tracing. And so the important thing is to be able to recognize it, give yourself education, take fetal monitoring classes, advocate for yourself even if your facility doesn’t require it because a lot of facilities don’t or they may just have a one-off during orientation. Take a class and be able to recognize what’s going on so that you can respond quickly and appropriately.” And I think those are the two big things to be able to conquer this weird world of Category Two.

Sarah Lavonne:
I think that brings up such a good point because I do feel like we almost take it on like it’s our fault that the baby’s Category Two, or like, “Oh, they’re having lates, I need to fix it.” And that mindset is a piece of what I’m hearing here of this idea that the late’s not your fault. The late is the late, not a subtle late, it’s a late. And therefore, you need to respond to what your assessment is versus it being your fault and us trying to mask or, “Let me fix it.” If there is an issue going on, first of all, you won’t be able to fix it, but second of all, you want to actually be able to recognize and respond appropriately like you’re saying. So I think we take it on too much rather than just call it a spade a spade. But I also think that there’s culturally a thing of the doctor’s like, “Why are they Category two?” And you’re like, “Well, I don’t know. They’re placenta’s old or something. There’s a cord or I don’t…”
None of us know, but it is. And so it’s not a matter of whose fault it is, it’s more like here’s where we are, now what?

Justine:
Well, I have two things to say. So one thing is I get a little frustrated because sometimes speaking of the providers, why are they CAT Two? I feel like some providers think some nurses are really good at fixing CAT Two or those nurses can always get them delivered or make sure they don’t deliver until 5:00 AM or whatever. We have this magic and why I think we do have magic, it’s not magic, right? It’s not like the individual nurse’s fault. Mind you, there’s definitely education to that and we’re going to go on to that soon with the Category Two. But my second thing is, Heidi, I know you’ve reviewed hundreds of cases in your life and do you see a lot of people, do you see a lot of CAT Twos where you’re like, “What are you even talking about?” When you see the charting, you’re like, “You said they’re moderate variability with no D cells and it’s obviously minimal with late D cells.” Do you see that often?

Heidi Nielsen:
Yeah. There’s a lot of discrepancy in calling things moderate when it’s actually minimal. There’s a wide range of things that you see, but you see common things over, and I would say the most common thing that you see is charting that it’s moderate variability when you actually have minimal variability failing to recognize that there’s been a change in baseline and that… What was their baseline when they got there? Their baseline was 125, and now your baseline’s 155. That also needs to be a clue in. And then also just D cells keep happening and not recognizing them. I’m very pro-nurse and so people want to… They want to do the right thing. We went into nursing because we care about people and we want them to have good outcomes, and I feel like a lot of it is a result of a system failure that these nurses aren’t being provided with the support and education that they should have. It’s hard when they talk to these certain providers because they’re like, “Well, why is it a CAT Two?” Or being intimidating in a way.
And it’s hard for nurses to speak up, especially when you’re new and you feel like you don’t know anything. The best way to advocate for your patient is to advocate for yourself and put that into your education because then you may not have the years of experience to back you up and build on that confidence, but if you have that educational knowledge base you can say, “Well, based off of NICHD terminology or based off the five tier or based off of what I learned in my intermediate AWHONN fetal monitoring class or whatever it may be.” You have these hard facts to back you up and then people are going to stop and they will respond and listen to that.

Justine:
Now they’re going to be like, “Based on what Heidi told me in the podcast.”

Heidi Nielsen:
That’s fine. They can say that. They can come at me.

Sarah Lavonne:
I was thinking too what I hear often and I would be curious to see if you’ve seen it is, well, I can’t chart it’s late because then I can’t keep the Pit on. Do you see that? Because I hear that and I see it.

Heidi Nielsen:
Yeah. Or we’ll see these common things that are put in a note, they’ll be charting that they’re having lights or whatever it may be. And then they’ll have a note in there that says, “Pit left on per provider.”

Justine:
Oh, that’s a battle all the time.

Heidi Nielsen:
That’s such a thing that it’s like you can tell that that nurse knows that she maybe or he maybe should turn it off, but that they aren’t because of the providers telling them to keep it on. Turn it off. Just turn it off. You can always turn it back on.

Justine:
And this again is why physiologic birth is so important because we can have other tools to get our patients delivered and you don’t have to rely just on Pit. Just throw that in there. [inaudible 00:13:40].

Heidi Nielsen:
Yes, take physiologic birth. Take a physiologic birth class every year. It makes such a difference. And then you just have all these things to pull together to make sense of everything and really understand why you’re doing what you’re doing.

Justine:
I keep telling people because I started working at a new hospital and they’re going to physiologic birth next week or this week, it’s in… Well, when this comes out, it was in May. But I’m like, “Yeah, I think this is my 15th class and I’m still learning every single time I go.” I’m like, “Oh, wow, taking a note.”

Heidi Nielsen:
Yeah. Oh. I learn something every time I go.

Sarah Lavonne:
I feel like I learn something from myself every single time I teach it. And there’ll be certain aha moments where I’m like, “Oh, that makes sense.” Or someone in the class will make a comment. Remember the parking space?

Justine:
Mm-hmm (affirmative).

Sarah Lavonne:
I use that every class now. It’s like a park. You’re backing up a parking space. Physiologic birth being the foundation of our practice, I think that’s one of the things that people don’t understand that it actually trickles into every single area of what we do because if you’re feeling like you need to turn off the Pit and you’re looking at the tracing going, “There’s no…” It’s totally contraindicated and your provider is pushing that on you, how do you stand up for yourself? One, if you stand up with the facts, you know the knowledge, you know the definitions, you can say, “Well, based on NICHD, it’s blah, blah, blah, blah, blah.” And you can give an actual thoughtful response and then you add on and based on where the baby’s at, I’ve performed Leopold’s and I know and I’m using my Motion app, by the way, to make it really easy for you, and this will help rotate the baby. And so you can buy time or the baby’s more well applied on the cervix or whatever, whatever. It all plays in together.

Justine:
Back to Category Two. We went on a little tangent. Do you have any tips? Do you have any major hard hitters that you’re like, “For Category Two in general, this is what I wish everyone knew.”?

Heidi Nielsen:
Oh, there’s so many things. I think we talked about this a little bit, but just really being able to not be afraid to call it what it is. If it’s a late, it’s a late. A subtle late doesn’t make it sound better. And just whatever tool that your facility has, use it. Whether you have Clark’s CAT Two algorithm or Shield’s or you have five tier, they’re so helpful. Okay. So with the five tier, it takes away all the options that you have to weed through with Category Two because it’s so many. I think it’s 134 different options of types of tracing that you can have in Category Two, which is so many. So if you have an algorithm that you can look at, use it. It really does help because we get hung up on… Well, but they have moderate variability and they have accelerations. But if you’re in a CAT Two, what is your acid based status? It’s indeterminate, right? So you need to pay attention to that.
And if you look at that and follow the algorithms, even with moderate variability and accelerations, you can still end up with a C-section. And so I think it’s important to just really pay attention to what’s happening with the tracing. What’s the evolution of the tracing? What interventions have you done? Is it responding to it? And if you’ve done all your interventions and things are still not responding to it, then that’s your tell that, okay, we need to reevaluate our plan here.

Justine:
Okay. So Heidi, I’m new and I feel like every patient I get handed is a hot mess and I can never fix them. And they always end up in the OR and I just feel like all my interventions, I’m just throwing the kitchen sink of them and I don’t really know why they’re working.

Heidi Nielsen:
Okay. Well, first of all, I would ask you if you’ve… Have you had a fetal monitoring class?

Justine:
Yeah, I took one that the hospital gave when I first started.

Heidi Nielsen:
Okay. So I would really push for taking the intermediate AWHONN fetal monitoring class where you can actually learn the physiologic intervention. So that will teach you about why you’re having a late, what is actually happening in the baby when that’s happening, what’s happening on the maternal side and why you need to do certain interventions to fix that, versus just throwing all the things at them. While it may help some of the time, there’s a good chance that you’re not doing the correct interventions to fix your problem. So why we do all these interventions is to improve cardiac output, right? So when a contraction happens, there is no gas exchange that is happening. The blood remains in the intervillous space. So think about when that uterus contracts, whatever is there, is what the baby has to use up. And sometimes that’s totally fine, right? They’re made to deal with what we call transient hypoxemia. But when it gets to a point where their fetal PO2 drops below normal, that’s when you start having the compensatory mechanisms, which what are those?
Those are D-cells, and we always think of D-cells as being bad, but really it’s just… These babies are super smart. They know how to help themselves. And so everything that they do feeds to improve their cardiac output so that they can get blood to their vital organs, which in a baby is their heart, their brain and their adrenals. Circling back to when I was talking about when a contraction happens. So let’s say that the contraction happens, they aren’t having that gas exchange happen, their fetal PO2 does drop below normal. So this is when we have chemoreceptors that enter the chat. And what those are is those are specialized nerve cells that are activated when they notice that change in the fetal PO2 dropping down, and it sends a specific message to the vasomotor center in the brainstem of the baby, and that’s when we get a sympathetic response. Okay?
It activates their sympathetic nervous system which causes vasoconstriction because it’s working to improve their cardiac output. So if it constricts their blood flow, they’re having more blood going to their heart and their brain, and their adrenals. So when that vasoconstriction happens, their blood pressure increases. And when their blood pressure increases, then the baroreceptors notice that there’s change in pressure. And then that will then circles back and elicits activation of the parasympathetic nervous system which causes a decrease in the baby’s heart rate, which is the deceleration that you’re going to see on the tracing. When that contraction then lets up, then that is all restored because the oxygen exchange is restored, and then you’re going to see the heart rate then return to baseline.

Justine:
I feel like it was in the last couple of years that if you would’ve said all that to me a few years ago, I’d be like, “What in the world is she talking about?” And I happen to know on dinners for a little while. You know what? I’m like, “I just have no idea. There’s a veal chop and when there’s a variable, I move them because there’s obviously a cord.”

Sarah Lavonne:
Oh, it’s veal chop.

Justine:
But I think there’s a lot of nurses out there like me. And so if you’re listening to Heidi right now and you’re like, “I had no idea, any of that.”

Heidi Nielsen:
And I think when you understand that, I feel like when I learned that, and had this turning point because when you start L&D, it’s so overwhelming, right? You’re learning so much all the time. I remember my first year just almost panicking like, “What kind of assignment am I going to get?” And you’re so scared of what the tracing is going to be, right?

Justine:
Right.

Heidi Nielsen:
Because you just have it locked in your head that decelerations are bad, and it’s like, okay, this is a sign that the baby is having to compensate. And they’re having to compensate because there is a disruption in the oxygen pathway. And so I think when you understand the cause of it and you understand, okay, I’m treating this problem, it makes things simpler and I think less intimidating. Because then you’re like, “Okay, my baby’s having to work harder, so how can I take their workload off so that we can maintain their cardiac output?” Right? Because their brain tissues are super fragile. And yeah, I think that that just caused a huge shift in practice for me.

Justine:
Well, and it builds, right? That even with physiologic birth or anything else that you have to start somewhere. When you’re new, it’s like, “What am I looking at? Okay, where do I put the Togo? How do I say hello?” There’s very basics. And then as you build, the expectation for our profession is to be lifelong learners. It’s like at some point you need to continue to level up and we need to be asking these questions. The good news is the moment you understand pathophysiology, that’s why I love it so much, or even that explanation you just gave us. It’s like, “Oh, now I get it. And now I can start critically thinking my way through what’s actually happening. Oh, there’s this contraction.” And, “Oh, that’s causing blah, blah, blah.” Well, when I look at my contraction, my contraction’s almost three minutes. So no wonder the heart rate’s dropping, right?
That now you can start to figure out what’s actually going on and your interventions all of a sudden become so much more meaningful and so much more intentional when you’re choosing that if I’m looking at it and I’m saying there’s a three-minute-long contraction, I know what to do. And while that might be common sense, but it’s like if you understand the pathophysiology, you’re even more motivated to act.

Sarah Lavonne:
How do we as nurses become less scared of Category Two? I feel like there’s a spectrum and there’s… And this stereotypically the new nurse that’s like, “[inaudible 00:23:35].” Anything, or I’d be sitting there with my piece of paper, I’d line up with the baseline and be like, “Oh, it dropped.” And I’m like, “Okay.” And that’s not even a subtle late, quote, unquote. It’s nothing. Calm down. So there’s that extreme. And then there’s the extreme that you’ve done it so much and I would say that even when I’m at the bedside, I’m like, “[inaudible 00:23:54]. Okay.” Very nonchalanty. A D cell here and there. Okay. I just am like, “Whatever. Yeah, sure. How do you feel about getting in bed and laying on your side?” There’s very nonchalant and then there’s other nurses who are like, “It’s fine. Everything’s fine.” There’s doctors, they’re like, “It’s fine.” You’re like, “This is minimal. It’s been minimal now for four hours and I’m seeing D cells. And hello, everyone. Raise the alarms.” Right?
And so for those that are across the spectrum, I think the one that’s really, really jumpy, and then I think there’s also this in-between of I’m nervous about it, but should I be nervous about it? And somebody else is nervous about it, so then should I be more nervous about it? And so again, there’s the wide spectrum of how we feel, but how do we become more comfortable with it overall, but without sacrificing patient care or safety?

Heidi Nielsen:
I think one thing is just to, first of all, take a deep breath. You have to regulate your own nervous system before you can help somebody else’s. And then I think at first, like I said, it’s so overwhelming. And also do this at times too. You can just pull up the definitions of things and then just take a minute and actually look at the whole picture. Like, okay, maybe I do have minimal variability, but how long have I had it for? If I’ve had it for four hours, okay, we can cross out that it’s a sleep cycle, right? Have they had any medications that have caused it? No, they haven’t. Okay, then I am going to start being concerned that this baby is compromised in some way. And I think just taking it piece by piece and breaking it down so that you can take it in these little tidbits instead of just trying to swallow it as a whole, it makes it less overwhelming.
And then also look at, okay, where are they at in their labor? Are they having all these D cells and minimal variability, or whatever, and they just got here? Or have they been here for three days? Are they a multip and they’re complete and plus three, and we’re about to have a delivery? So I think also looking at that as where are they are in their labor and knowing what your resources are, being comfortable with talking with your charge nurse, knowing how to use the chain of command and using it and not being afraid to do so. I think we got to let go of being afraid of talking to providers and just doing it, even if it’s scary.

Justine:
When you said, “Use your chain of command correctly.” I’m thinking, so one of my jobs, I’m a charge nurse and I have new nurses every night, lots of them. And I think that I tend to do what Sarah was saying, “It’s fine, it’s fine, it’s fine. You’re fine.” I’m barely glanced at it. I’m like, “You’re fine.” And mind you, I know the nurses that I’m working with and I know that they are the people looking at them. It’s not even anything, what they’re seeing. They’re just very concerned, which I do love too. But if they were to come to me like, “Hey, so I have minimal variability. I checked back to when she got here, it’s changed definitely in the last 12 hours. It’s been minimal for four hours. She didn’t get any meds. I can rule out a sleep cycle, blah, blah, blah, blah, blah.” They kept going through all these things. I’d be like, “Wow. Yeah, okay, let’s dive in.” And then the same thing with the doctor. If you call and you have all of those facts, I think that’s really a great move for them to start doing.
Even now, I’m like, “Yeah, I need to look back at my strips more.” You get so bird’s eye view, tunnel vision, on this is what it’s looked like on my shift. And we start looking back once it looks bad, quotation, right? It leads more into Category Two. Why not look back all the time? Like, “Oh, they look great now. Baselines normal, moderate variability.” But then, yeah, you look back and you’re like, “Oh, last night, they had this weird minimal variability for a few hours, et cetera and then the next night they have it again.” Sarah?

Sarah Lavonne:
This just reminds me what it would look like, and I’m so guilty of this as well, of this is actually being a nurse. In other units, imagine they come and they look at their meds, they look at their labs, they look at their orders, they look at their HMP, they look at the notes of their hospitalization and what other consults they have, and they really orient themselves to the patient. Because our unit moves so quickly, I think that the patient’s progressing and there’s a million things to do and you got to get yourself settled. I don’t know how realistic that is. In the ED, I’m sure they don’t sit down and sit with the HMP for a while. But in general, for us to think big picture about our patient and whole person, about our patients, plural, including the baby, I like that call to action that we’re being a nurse, listen to the lungs, palpated contraction and get a big picture.
But also, I think my next question for you was I’d love to hear how you talk to doctors and how you’ve built courage in talking to doctors, and any tips you have for us on what helps with that because I think it’s such a huge barrier and such a huge concern for all of us. But even just hearing you talk, Justine, or you, Heidi, that the more knowledge we have, the better. Because how are they going to argue with that? And you were giving that example and I’m like, “Yeah, oh my gosh, I care.” Versus, “I’m so scared about this tracing. There’s something going on.” I’m like, “Oh, okay.” I just don’t care as much. It doesn’t pique my interest. And so I do think that’s a little nugget of a strategy for us when we’re talking to providers and really leveling ourself up. Imagine, we’ve maybe said this a few times on this podcast, but it always comes back there.
So Heidi, do you have any tips for us for talking to doctors? Things that may be mistakes you’ve made or even if you have a little phrase or something for advocating for our patient.

Justine:
And I’d love if you can spin it to… Particularly, the nurse on your mind is someone that wants to turn off Pit because I feel like we have that a lot.

Sarah Lavonne:
Yeah. Totally.

Heidi Nielsen:
Yeah. Yeah, we do see that a lot. So I think it just depends what facility you’re at. First of all, do you have a provider there or is your provider not there? Where I’ve done my practice, we don’t always have somebody in-house. And so I think it’s really helpful for the new people. When I was charged on night shift, I was with all my new girls and we were just running the shift together, and so we go to call a provider. And I think one of the first things that’s helpful, especially if you’re calling in the middle of the night, when they answer the phone, they’re half asleep too, right? Call him and say, “I need you to come in.” So then that wakes them up and they go, “Okay, I need to come in.” Or, “I don’t need you at the bedside right now, but this is what I need to talk through with you.” And I think just setting that clarification first because then it tells them what they need to do so-

Justine:
I love that.

Heidi Nielsen:
They can fully listen to you. Because I think we get nervous-

Justine:
Yes, I love that.

Heidi Nielsen:
And just start rambling off what’s been going on. Like, “Oh, I had this D cell and we turned them, and then I gave them a bolus and then now…” And they’re like, “Whoa, whoa, whoa. What is actually going on?” Versus saying, “I don’t need you to come in, but I wanted you to know, over the last 45 minutes, patient has had minimal variability and they’re now having recurrent lates that are dropping down to 90 lasting X number of seconds.” And then just giving them more details about what’s actually happening on the tracing. And so because of these things, I have a CAT Two tracing and these are the things that I’ve done. And so when you’re talking about turning off Pitocin, give the examples of why you need to turn off the Pitocin. Per our policy, it says if tachysystoly occurs with fetal heart rate changes, meaning minimal variability or D cells, we’re supposed to turn off the Pitocin. And they’re now having recurrent variables and I’ve done all these things, I’m turning off the Pitocin.
And just say that you’re turning it off and turn it off because if it’s to the point where you need to turn off the Pitocin and you’re sitting there and you’re concerned about it, then they need to come in and they need to figure something else out too, right? It’s a team effort. Yeah, it’s just it is hard to get to that point, especially when you maybe don’t have the years of experience. But there are so many other things that you can do to still give you that knowledge base without having the years of experience behind you that can give you that autonomy, which I think there’s so much autonomy in labor and delivery and our specialty to be able to turn off your Pitocin.

Justine:
I think too, if you work on a unit where some providers will be like, “Let me talk to your charge.” They’ll just want to get off the phone with you. It would be good to have that conversation with your charge first to be like, “Hey, this is why I’m calling them. This is why I’m going to turn it off.” And they most likely will be like, “Yeah, definitely.” And then if they get on the phone with the charge, the charge is like, “No, for sure, it needs to come off.” Just to add that little bit.

Sarah Lavonne:
So to put my side, I feel really dumb for saying this, but I’ve never really thought through and put myself in the shoes of a physician who’s asleep at night, and I work mostly night shift, and I wake them up. And they’re not watching the tracing. To actually give them and paint the picture, I love the level setting. I don’t need you coming in. But then you paint the picture. The patient for the last, like you said, 45 minutes, this, this, this. And now they can see the tracing. So they’re making a judgment call before you tell them what you’ve done and you tell them that the Pit’s off even. I had to turn off the Pit because… The moment you say that first it’s like, “Oh, well, why?” Versus, paint the picture, give them the reason where they’re like, “Oh, okay, I’m paying attention now.” And so, I turned off the Pit. I love that strategy. And starting your calls with exactly what you need is so good.

Heidi Nielsen:
I think it’s helpful. When I started, before I would call the provider, I would sit down and make all my high points on a little piece of paper or a paper towel. Honestly, a lot of times it was a paper towel. And you just write out exactly what you want to say and here’s what I need from you, here’s what I’ve done, and this is what this means. So that it’s just very clear cut and to the point, so that they don’t get lost in the sauce of what you’re saying and they’re like, “It’s 3:00 AM. What do you need from me?” And you’re on this high of [inaudible 00:35:01], trying to get out what you need and then you’re like, “I don’t even honestly know what I just said to you.”

Justine:
Relatable.

Sarah Lavonne:
Totally. I think about your legal background and I’m picturing the nurse who’s like, “I called the physician, they hung up on me.” This has happened to me all the time where like, “Call me when the ears are out.” And I’d be like, “No, I need you now. And we’re not anywhere near pushing, sir. You just missed it.” And so you’re up against that. The easy answer is chain of command, right? You loan a fire charge nurse and they go up, blah, blah, blah, blah. And I need more help and whatever. You’re not necessarily getting the response. I think easily and very quickly we throw out this whole legal thing of like, well, I don’t want to risk my license. And yet you’re faced with the fact that the doctor’s now yelling at you and you’re not wanting to risk your license by turning it on. You’re also not wanting to risk your job by turning it off.
Legally, from your background of reviewing cases, what is the legal risk in a scenario like you call the doctor, they don’t respond? At what point is the nurse liable? What do nurses need to know legally about that scenario?

Heidi Nielsen:
I mean, really, it’s so rare for nurses to actually get their license revoked or to get reprimanded, in that sense. It’s that really getting deposed is just gathering information about what happened and is your chance to speak up about things. And so when I’m reviewing a chart and I can see that the nurse says, “Oh, charge nurse is now at bedside.” Or those sort of things. That is showing that they’re using the chain of command, right? That’s showing that they have clinical judgment, that they’re like, “Okay, this is beyond me.” And so then that’s where it shows that it’s put beyond them that it’s like this is a result of a system failure. There’s other things that are going on. Maybe the provider, like you said, is super rude and hung up on them. And they may not be able to fix that provider, but doing those things of saying, “I talked to the charge nurse.” Or showing that you turned off the Pitocin are huge things that are…
There are times where I review things and I’m like, “The nurses actually did incredible job. They did all of these things here and it goes beyond that.” And so I think just being able to know what you’re supposed to do in those situations and knowing what your resources are make a big difference.

Sarah Lavonne:
And it sounds like also knowing what’s your problem and what’s not your problem. And I think we overstep a lot where it’s like, oh, well, but something bad happened and you’re like, “If all I’ve done is advocate the whole time, I turned off the Pit that is within your control, I went up my chain, I got another physician involved, I did all my interventions and still there was neglect.” It sounds like, and correct me if I’m wrong, in that case, legally, it’s like you can say that you did what you could and it’s outside of your hands, right?

Heidi Nielsen:
Yeah, I totally agree with that. And I think that, circling back to us being nurses and caring about people, we don’t want anything bad to happen, we don’t want anyone to get hurt. And unfortunately, people do get hurt. And so I think it’s great learning opportunities too when nurses are reviewing back on these things and we don’t forget horrible things that have happened, right? We’ve all had trauma that’s happened in this job at one point or another. And I think knowing that you did all that you could, we need to give ourselves a little bit more credit in that area too. And also, you can’t punish yourself for what you don’t know. And so that’s why I think it’s so important, you have to advocate for yourself. When I started out, I had to majorly advocate for myself. My manager, when I was hired, did not want me to take intermediate fetal monitoring until I had at least two years of experience. And I had to fight tooth and nail to get into the class, and I just showed up to the class anyways.
And funny story, Jen Atkinson was actually the first fetal monitoring instructor that I ever had, and that’s when we first met. Anyways. And so I told her, I was like, “My management is not supportive of me being here. I need this because I don’t know what I’m doing and I want to know what I’m doing. I want to do better.” And so sometimes the best thing you can do, I’ve said this a million times, I feel like, already today, but just knowing how to advocate for yourself and building that education for yourself when maybe you don’t have the support of your facility. We’re hoping that things will change in the bigger picture and that more facilities will be on board with providing appropriate education to their staff that they should have. We shouldn’t have to fight for these really basic things that we need to be able to adequately care for our patients.

Sarah Lavonne:
This is a hard one. What would you say about the one that’s like, “Well, the evidence on continuous fetal monitoring isn’t that great and IA is better.”

Heidi Nielsen:
I think you have to look at the big picture. I love IA, but it has a place for it, right? So in those people that are low risk, that is the better option. Research has shown that. But when we have these high risk situations, which we have a lot more high risk patients now than we used to, is EFM perfect? No, but it’s the next best thing that we have, right? And I think that just circles back to, you got to know what that’s like telling you and what to do with that information.

Sarah Lavonne:
How do we balance the idea of fetal monitoring causing over intervention? I’m thinking now I’m going to pay attention, I’m going to call it late to late, and that’s the reason for a C-section all of a sudden because there’s been a few lates with minimal variability. Where do we find that balance and how would you describe that balance, between being overly jumpy to overly medically intervene when… We also know that you could have a terrible tracing and boop, Apgar’s nine and nine and no issues, and cord gas is normal. Sort of. I don’t know that they’re drawing cord gases on those nine and nines, but you know what I mean. I think I also hear so much of it’s such a crap shoot that… Then you have a Category One that comes out needing full-blown resuscitation. So how do you navigate those inconsistencies in practice and what would you say to all that?

Heidi Nielsen:
Yeah, I think that there is variants that obviously happens, and you are going to have those outliers, like you said, where you have that CAT One tracing that’s great. But 50% of CAT Three tracings, those babies will come out okay, not needing resuscitation. And I think that’s a hard pill to swallow, but you got to look at the bigger picture. Okay, yeah, they have been having lates, but how long have they been in labor? Did they just start this? Okay, Have I done any interventions and are they responding to the interventions? And then just taking it one piece at a time and not jumping to conclusions. I think that’s the way that you got to navigate through it.

Sarah Lavonne:
Well, and they don’t become acidotic in one second, unless there’s a cord. Oh, sorry, a cord meaning a knot in the cord or something. My first crash was a knot in the cord and we’re Category One to prolong with nothing. And then we’re like, “What the heck?” Comes full on, not got pulled. And so there are those outliers as well, but I think remembering that typically, right? They’re not going to go from to Category One to Category Three unless there’s some sort of legitimate reason.

Heidi Nielsen:
Right. Metabolic acidemia takes a while to develop. That’s why it takes a while for it to be corrected, right? Once the baby’s born. And so just being able to piece between the two of, okay, has this been going on for a while? And like you said, unless there’s a knot in the cord, it’s not like all of a sudden this kiddo’s going to be horrible and you’re going to be so shocked. If you actually look back at things, there’s a systematic response that happens. Okay, and moderate variability, but oh, I’m not having accelerations anymore. Now I’m having decelerations. Okay, now my variability is going away. Now my baseline’s increasing. So it’s not necessarily always predictive of what outcome you may have, but the tracing as follows is predictable.

Sarah Lavonne:
What would you say is the most ominous, like cytocidal or CAT Three? Okay, those are givens. But of the Category Two, what types of combo deals are the most… Where you’re like, “The research shows, if this, this, this.”?

Justine:
I bet, I know. I’m not going to say it, but I’m going to say if I’m right.

Heidi Nielsen:
Okay. I would say minimal variability, tachycardia and D cells.

Justine:
I was going to say that. I was going to add the D cells. I was just going to say minimal and tachy even.

Heidi Nielsen:
Minimal and tachy. Tachycardia is actually one thing that the research is showing that that’s actually something that we need to pay a lot more attention to.

Sarah Lavonne:
Tell me more about that. What do we know about it?

Heidi Nielsen:
What we do know about it, right? So when we’re talking about tracings, right? If we’re seeing D cells or just if we’re seeing tachycardia, what is the baby trying to do? They are trying to increase their cardiac output. And so there is some major disruption in their oxygen pathway that they are now increasing their heart rate because they’re like, “Okay, if I put my heart a lot faster, then I can get a lot more oxygen to my brain, my heart and adrenals.” But that is not something that they’re able to sustain for very long. And so that’s one of the end things that we’ll see. You’ll see that their variability goes away, they’re tachycardic, and then that’s when all of a sudden you’ll see big old D cell and the bradycardia.

Sarah Lavonne:
What about though, my patient has chorio, they spiked a fever?

Heidi Nielsen:
So if it’s in the presence of chorio, that’s more them reacting to the infection that’s happening. And so you would want to respond to treating the infection, giving them Tylenol, bringing down the temperature, right? And then okay, those things aren’t working. So this tachycardia then is resistant to the interventions that I’ve done. And then now I’m calling the provider and we’re like, “Okay, I’ve done these things and I’m still having tachycardia. You need to come in.”

Sarah Lavonne:
And if the patient is cooled, they shouldn’t have tachycardia?

Heidi Nielsen:
Potentially.

Sarah Lavonne:
Yeah, in theory. But I’m thinking, oh, they had chorio, we gave Tylenol, we did cooling measures and now their temp is 98.9. They’re still tachycardic. And all of a sudden it’s, well, but they have chorio.

Heidi Nielsen:
Yeah. If it’s still happening, then there’s something else going on. I don’t know. Just in on it.

Justine:
Yeah, I feel like we’ll see. Once we identify and we give the antibiotics and we do the cooling measures and we give Tylenol, that baby will perk back up. If it’s chorio, from my experience. Almost to the point where you’re like, “Dang it.” Because you’ve already called it, kind of thing. And so they know they’re going to get lab draws, which is good. I love that where screening, but yeah, it’s good that we find it.

Heidi Nielsen:
That’s why it’s important to treat the cause of what’s going on and not just pay attention to the symptoms.

Justine:
And you know what’s funny? So my husband is in the ER, I think I’ve said that multiple times, and he was talking to my sister about ACLS because my sister’s in nursing school, and he was like, “Well, yeah.” And we’re going through the steps. And he’s like, “Yeah, and then you have to do the tease.” The teases of the causes, right? In my mind, I was like, “I just thought that was on the side of the big poster, the ACLS poster. Do they actually do that?” And he was like, “You have to do that. You have to think of the causes.” It’s absolutely the number one thing that these ER nurses and probably ICU nurses and critical care nurses are thinking of. And I don’t think we have that on our mindset. We’re not like, “Cause.” We’re just reactionary to what’s happening, but we don’t look at the cause as much as we should. And so it’s just something we need to start doing.

Sarah Lavonne:
This is going to be controversial to say, but what if we all acted like ED nurses in that way as far as they just know so much. I very much look up to the ED. I look up to other specialties just because there’s all other specialties. I’m like, “I have no idea.” I don’t have a geriatric issue because I can tell you the very minimal basics about it. Or cancer, that’s a whole oncology or all the things. And mind you, I hear these stories of Eric and I hear other stories of other friends that I know that have either been in the ED or whatever but, well, did you listen to their lungs? I’m sorry, that’s very basic.

Justine:
No, I didn’t.

Sarah Lavonne:
Right. Right. That’s what I mean. How embarrassing for me as a nurse, but also it’s so culturally not it. And there’s somewhere in there that we’ve gotten really lackadaisical on actually being a nurse because I think it’s the nature of the specialty that the specialty in general, there’s health… You hear, “Well, you’re not sick. You’re having a baby.” And until they’re sick and then when they’re sick, you better know how to pull out your stethoscope and identify what’s going on.

Justine:
And have it. Because I’ve got to say, bring mine all the time and now I feel really guilty about it. And I’m using those yellow ones because I’m like, “Oh, I got to get the stethoscope.”

Sarah Lavonne:
It suck, right?

Justine:
And they do suck and you’re so right. Poor Heidi’s like, “You guys don’t have your stethoscope all the time?”

Sarah Lavonne:
I know. You guys are not even nurses.

Heidi Nielsen:
No, I just use the unit ones now. I had a super nice one after nursing school-

Sarah Lavonne:
They go missing.

Heidi Nielsen:
And I was so excited. And then I was like, “Why do I have this? I’m never using it or I leave it in my locker, and then I just end up using the unit ones anyways.” But I think we need to give ourselves more credit because I think we’ve conditioned ourselves, or at least I have to. It’s like, “Oh, I don’t know anything. I’m an L&D nurse.” But we know so much and if you-

Sarah Lavonne:
So much.

Heidi Nielsen:
The card, anybody else, they don’t want to have to come to our unit just as much as we don’t have to.

Sarah Lavonne:
Totally

Heidi Nielsen:
Have to go to theirs.

Sarah Lavonne:
Totally. Totally. I think I just would love to see us increase our assessment capabilities. And that always comes up for me, anytime I teach a class, I’m like, “Yeah, because our job is to assess and so we need to know all of our organs, we need to know what’s normal and abnormal, and be able to recognize abnormal. That’s being a nurse.” I think a lot of times we’ve gotten a little slacky in some areas like palpating a contraction. I hope that’s changed, but that’ll forever be my go-to, because Lord knows. Or the station being high. So it’s minus three.

Justine:
You know what’s great about all this? If we get better at this, we’ll have even more respect in the eyes of our colleagues to be like, “Yeah, they’re crunchy, but they’re safe. They know they’re ish. They dot their I’s and they cross their T’s. But yeah, they’re going to advocate for them to be on the monitor or off the monitor or in this crazy position or whatever, because they know what they’re doing.”

Sarah Lavonne:
Well, and I think the stereotype is crunchy equals bad nursing. Whereas crunchy could be just as bomb ass nurse that in an emergency is like, “[inaudible 00:50:40]. I got this.” And you see a whole new side of that nurse. It’s like the secret super skills to whip out when needed, but otherwise you’re like, “Oh, you knew that?” Yeah, I know everything. I want to be the person that knows everything. Of course, they’re going to grab the yanker on the wall and have that ish ready because I’ve done my emergency checks and you don’t even know it. To me, when you say it like that, I’m like, “That’s the picture of an ideal nurse.” Cute.

[Mentorship ad]
Sarah Lavonne:
So Heidi, to wrap it all up, what words of wisdom do you have for this nursing audience related to category Two.

Heidi Nielsen:
I think everybody to know is if you have a CAT Two, it’s just your call to action that you need to get off your hiney and do something. And it doesn’t always have to be a big something, it can be a little something. But that’s your alert to tell you that, okay, I need to do something to try and get this back to a CAT One tracing, right? That’s what your goal is. And just not to be afraid to call it what it is and learn that pathophysiology. Sign yourself up for classes, if you aren’t already. Bundle Birth has so many wonderful resources and many more things that are coming. And like I said, the best way to advocate for your patient is to advocate for yourself.

Sarah Lavonne:
With that being said, I’d love to recommend some things for you as next steps because once again, one of the themes is very much take control of your own learning, be better for yourself and for your patients, et cetera, et cetera. And so if you want more from us, we do have a basic fetal monitoring class. It probably will have passed by the time that you listen to this, but stay tuned on the Bundle Birth Nurses website where you can go to and look up live classes. That class will be live. It’s taught by Justine to get you going on your basic fetal monitoring. The other fun one is we have a new product in the store, and that is a fetal monitoring badge buddy that does have your categories. It has interventions and it has your definitions to keep right on your person while you’re at the bedside and while you’re at the nurse’s station to be able to cross-reference that information to make sure that you’re safe.
We have a 12-month mentorship program. And like I said, that we have a whole entire fetal monitoring section in there with IA and fetal monitoring, and all of the patho is all in there and whatnot. Join our 12-month mentorship program. Our next one is in July, and then we don’t open up again until two weeks before the October cohort begins, and you can join a whole community of nurses from all over the place and learn from them, learn from us, and really level up your practice. That, to me, is the best investment that you could give yourself in the efforts of investing in yourself and your career.

If you’re not in Motion, please get into Motion. That will be one way to help provide evidence-based recommendations to keep labor progressing, especially in those cases when you need turn off your Pitocin. And if you haven’t taken a physiologic birth class, that, to me, is a great intro into everything that we offer. It’s live. It’s online. I teach it. It gives you the foundation of your practice. That’s the class everyone was referencing earlier where Justine’s like, “I’ve been 15 times and still learning.” It is such a fun day. If you haven’t been, it’s one of those things that is a no-brainer for your practice. So there are lots of ways to get involved. We have products, tools, resources. Everything’s over at bundlebirthnurses.com. Thank you so much for all of your support in keeping this business going, keeping this podcast going, keeping all of us being able to continually offer more resources to you. All of your money is being reinvested into these ladies in the work that they’re doing and in being able to provide you with more resources and tools.
If you have other ideas, feel free to email us at nurses@bundlebirth. Always looking for other ways that we can serve you and provide any kind of education or support so that you can live your best lives and keep this profession moving forward and keep us bettering our worlds through birth.

Justine:
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 bundlebirthnurses.com or follow us on Instagram.

Sarah Lavonne:
Now it’s your turn to go and quiz yourself on your basic terms and definitions of fetal monitoring. It’s okay if you don’t know everything all right now, but the goal would be that you would have the basics down, pat, like the back of your hand. And if you don’t, study it and know it. So that you can be prepared to advocate for your patients, go up the chain of command, talk to your providers, and ultimately, walk away from your shift knowing that you did everything possible to keep your patients safe. We’ll see you next time.