#59 Basic Fetal Monitoring: Mastering the Basics

Justine:
Hi, I’m Justine.

Sarah Lavonne:
I’m Sarah Lavonne.

Justine:
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. Going down memory lane, I’m trying to think of …

Sarah Lavonne:
Ooh, I love memory lane.

Justine:
… Memory lane, so it was 2019 when Sarah and I met, and a lot of you know the story. I stalked her on the internet, we got together, spent the night at her house the first time we met, and the rest is history.
After physiologic birth, and when the big C-word shut down the world, we were like, what next? That’s when Mentorship was formed, that’s when I got a job, that’s when I was doing social. I’d always had new nurses and new nursing students on my mind, and Sarah always wanted me to have them on my mind, but I couldn’t … I don’t know. I haven’t done anything with that yet, besides Instagram. I haven’t done anything. Something’s coming, and we want to talk to you a little bit about it, because I’m nervous as heck about it.

Sarah Lavonne:
It is time. It is time, Justine. The time has arrived.

Justine:
I’m not a live teacher, normally, I like to have my notes and I like to teleprompt. I’ve written and taught a class once, and it was in Cancun, so like 325 people, or actually it was like 150 because it was a breakout session. Got to see it, and I got to do it in an N-95, so this one should be a little easier than that, because I [inaudible 00:02:11] …

Sarah Lavonne:
So true.

Justine:
… Cancun. I have been spending my time creating a basic fetal monitoring live class. I’m pretty pumped about it and pretty nervous about it, and I’d love for you to come hang out if this is something that you need. We’re going to do two fetal monitoring episodes this season, the first one being right now, where you’re listening to, so don’t leave. Then, the next one coming is going to be all about Category II. Being friends with Jen and Heidi, who are educators with us here at Bundle Birth Nurses, I am learning more and more and more and more about how it is not taught well across the United States, and babies are getting injured/dying because we are not all speaking the same language.
Jen taught me that there are 157,000 birth injuries a year, and a lot of those are related to Pitocin and mismanagement. It was more on my heart to like, we need a baseline. I don’t think money is spent on basic fetal monitoring. Usually, it’s just whoever is in that position or whoever wants to throw a slideshow together is going to teach the new grads, or you got it in nursing school and just learn on the go, but the person that’s teaching you took one class 30 years ago, and now is just winging it, so I think it has to change.

Sarah Lavonne:
I think a lot of times, we’re doing it as a requirement versus really understanding that any kind of learning is an investment into our ability to keep families safe, hopefully. Again, fetal monitoring, whether it keeps families safe, in some circumstances it doesn’t, and of course there’s that debate, which is another whole world for us to go into later. I think that piece of just shifting our mindset around education, particularly to fetal monitoring, I’m sorry, as much as we’d love to do IA, so many patients don’t rule in for it, and/or they have one D cell and they’re back on continuous. This is our whole lives, the entire shift, you are watching a tracing while doing a million other things.
As a baseline, not only obviously, we preach physiologic birth as a baseline, but fetal monitoring, we’re not going to get away from anytime soon. We have to sort of accept the fact that and take it upon ourselves that, I better know my ish. If I’m going to know anything about labor and birth, fetal monitoring is one of those baseline things, that makes so much sense.
That’s also why we have a whole complex class in our mentorship program as a part of it, but that’s not enough. I also think that we did that for mentorship, and I think that we’ve talked about putting it on sale or getting it out there, but it’s not the same as a live class. Yet, it sort of fits in the world of mentorship for right now, so I think there’s a world in which it all of a sudden is available, but it’s sort of like you need the basics to start, then you take that class, and then, it’s like you pass your field monitoring certification, CEFM, certified EFM person class. Stay tuned on that one.

Justine:
Yeah, you’re so right. I think about, you expect tele nurses to know how to read a cardiac strip.

Sarah Lavonne:
Yeah, you would hope.

Justine:
Right, so we expect you specialized. You chose to specialize. I hope you didn’t choose to specialize just because you hated med-surg. You chose to specialize to better advance obstetric care, better advance our outcomes, then be good at it. Decide you’re going to really do it, and learn it. This one is for the peeps that need basic. If we’re going back to basic, in 2008, a group of people got together, and there’s only one nurse in that group which I have friends that are bitter about, but they got together. It was NICHD and they made terminology for us, so we can all speak the same language.
I guess before 2008, and I wouldn’t know because I was a graduate of high school that year, they did not speak the same language when it came to fetal monitoring. Now, we do, for the most part, speak it. In the United States, we go with our three tiers. Canada also goes by three tiers, but they’re a little different. We go with our normal baseline rate. We know what our D cells are. The goal of this class is that we all understand what the NICHD language is and how to defend it, because there’s a lot of… If I hear, “But it’s only a subtle late,” one more time, I’m just so frustrated. I’m like, “But it’s a late, so it’s telling you that there’s transient hypoxia. What are you going to do about it? What are you going to do about it?”

Sarah Lavonne:
I think that goes to show too that somewhere in there, we have separated our brains from the tracing as this paper thing. “I must read, I must chart on, I must look at and identify what’s going on, and go up the chain.” It’s this robotic sort of to-do check off versus actually asking, “What’s going on and what does it mean?” I think quickly, you’re like, “A variable, cord compression, a late.” I would say, “Interruption in the blood flow likely at the placental level,” or whatever. You think chord or placenta or perfusion piece.
It’s sort of like, wait a second. Let’s think big picture, and let’s actually consider the whole patient or a patient assessment and all of those things. I think we have to somehow merge the two. I know that there’s many of you that are doing that, but also I literally see it at the bedside of… We see this all the time. We’re ignoring things, like the subtle late of like, “Oh, it’s just a this.” Mind you, some of them are just a random variable, and that’s not terminologies, but there is a random variable …

Justine:
Periodic variables.

Sarah Lavonne:
… But like a rando that’s there, and you’re like, “Oh, okay, cool but the rest of it overall, can I rule out metabolic acidemia? Yes, I can.” But when I say that, am I actually thinking, “I can rule out metabolic acidemia, and I know exactly what that means for the two, mom and baby, working together in their oxygenation of likely their brains?”

Justine:
[inaudible 00:08:12] you will not learn any of that in this basic class.

Sarah Lavonne:
That’s fine, but I also think that there’s a lot of experienced nurses that maybe basic isn’t appropriate for them, but they’re like, “I am ready for that other way of looking at fetal monitoring,” right?

Justine:
For sure.

Sarah Lavonne:
As we’re looking at the big picture of fetal monitoring, too, can we start thinking about what’s actually going on? The only way to do that is if you have the basics, there’s not one single way that you’re questioning it, that this …

Justine:
Right, you know your definitions.

Sarah Lavonne:
… has to be memorized, and there needs to be a reference tool, which by the way, a badge buddy is coming for it so that you can have that on your badge with all of these little quick tips and definitions and all of that. In the meantime, if you don’t have that and you couldn’t be quizzed on the spot, ready to go, then start with a basics class, and then build your way up into the next levels. I’m excited to take your class.

Justine:
I’m not excited for you to take the class. You always make me so nervous.

Sarah Lavonne:
Whatever. You know I’m going to take the class even before you actually teach the class, so-

Justine:
Well, still nervous.

Sarah Lavonne:
… By the time I’m there, I’ll just be cheering you on and be that friendly face because I will say, to teach online to a bunch of dead faces, no offense to everyone in the audience, but everybody kind of looks dead at one point, where you’re like, are you okay?

Justine:
Or black screens.

Sarah Lavonne:
Oh my gosh, black screens is the worst. Usually, when I teach physiologic birth, there’s usually somewhere around 300 in that room, but maybe two pages worth of screens, and I always lock in, where I have my people by the end. Watch your face when you’re on her class and just give the soft, like, “Oh, wow, I’m so interested.”

Justine:
Yeah, [inaudible 00:09:46].

Sarah Lavonne:
Even if you’re not just…

Justine:
Even if you’re not…

Sarah Lavonne:
… Kind face.

Justine:
… Pretend you are.

Sarah Lavonne:
To be totally candid and real, and if anyone I work with is listening to this, this will be the first they hear it, I did a little CEFM series for us ’cause now, HCA is requiring CEFM for all their nurses. If you didn’t know that and you work for HCA, it’s coming. I canceled all of them because the first one was so bad, there was no screens. I would ask a question and no response. I told my manager, I was like, “I cannot do that again. I can’t. I cannot do it.” Luckily, I have a manager that’s like, “Yeah, don’t do that. That’s dumb. Don’t waste your time.” I just canceled. I was like, “I can’t do the rest of the series.” It wasn’t worth the energy that I felt coming out. I was like, “I feel awful. I don’t want to do that again.” No pressure. No, but I think the audience just having an awareness of what it’s like on the other side. I mean, remember my first physiologic birth?

Justine:
Oh, she was comatose. No, I can’t that’s not the right word, but-

Sarah Lavonne:
I dissociated.

Justine:
Yeah.

Sarah Lavonne:
I had a trauma response. Everyone around me was like, “She’s not okay. Oh my gosh, what can we do?” I cried. Up until that point, I’d only taught live and then I’d taught mostly childbirth classes and then nurses on the floor, a nurse’s day, or I’d done a little bit of conferencing stuff, but not really. Holy moly, it is a different beast to teach online and for eight hours.

Justine:
Yeah, it’s not as good.

Sarah Lavonne:
It’s going to be so good. It’s so good.

Justine:
I’m like, “Nevermind. Rewind.”

Sarah Lavonne:
No. What I’m saying is what a beautiful challenge as you up level yourself in your profession as an educator, as an influencer, and imparting all of your knowledge and your just down regulating personality on the world through the class. The good news is the class is 90 minutes, right?

Justine:
Yes. Quick and easy, and a lot of that’s going to be interactive. We’ll spend the first time learning basics. You will have a workbook to follow along with. Then, I want you guys to be able to practice not only charting strips, but giving an SBAR to providers/charge nurses/whoever you to talk to if you’re feeling concerned about something. That is the goal there.
I want you to walk away feeling less like you don’t belong. I think imposter syndrome feeds on not admitting what we don’t know. With fetal monitoring, that’s a scary part. When you’re new or coming into it is a new language. We get zero of it in school. You might’ve learned HUFF or VEAL CHOP. There’s so many little acronyms now, my new grads tell me. I’m like, “What is that?” But there’s little things that you learn in your little bit of OB training that you have, which is getting less and less by the way, because the NCLEX is asking less and less OB questions. They’re kind of cutting out a lot of it, so that’s unfortunate too. Also, just side note, we know that as people on the floor. We know you’re not getting much, and we know you don’t know anything when you come. Just bring your heart and your desire to do well, and we’ll get there.
You got to know the basics to stand up to things and then you can build on it, like Sarah said, and then come back and listen to Heidi’s episode, which is coming out in a few weeks, on Category II and why we’re doing the puff interventions. POOFF interventions, I think it is, like pit off, oxygen, flip them, fluids, or something. Did you know that?

Sarah Lavonne:
No, no. I only know that.

Justine:
It’s fixed. It’s fixed, right? Anyways, why we’re doing those interventions and then you can talk the way you heard Sarah talk earlier about bigger picture and you’re like, “What is she even talking about?” That all starts to build and make sense when you start inputting the information. It’s not going to all make sense day one.

Sarah Lavonne:
If I was a new nurse and I was going to my first day, but I also had some time to prep, which all of us did… I know I read an entire perinatal nursing book before I started my first day. That is my personality in a nutshell. So I’m going to the floor for the first day, Justine, from your perspective, what are the nurses expecting of new nurses that don’t have experience in OB, strictly related to fetal monitoring? What should they know going in and how do they prep them? Obviously this class is the filler for that, so no, we’ll do all of that work for you, but to give a frame of reference for our new people, what would you expect them to know?

Justine:
I think that’s really nuanced based on where you work. I think there’s people that walk in and they’re like, not you at all. They’re like, “We monitor the heart rate?” Versus you read the whole textbook. I think maybe by end of shift one even, I think you should know that we do monitor the heart rate, and that’s a lot of our job is chasing baby and charting on the baby. When we say chasing baby, you’re adjusting heart rate all the time. It would be great if you come in, look at the strips and you know baby’s on the top and contractions are on the bottom. It would be great if you knew usually, and I think in most, and correct me if I’m wrong you’ve been in more hospitals than I have, but is there that line to show the baseline? Is there a darkening in most… You know what I’m talking about? The baseline 110 to 160, there’s a shooting…

Sarah Lavonne:
Like a shade, “This is within normal range.”

Justine:
This isn’t normal. I feel like that’s normal, but that shade is like, “Okay, baby’s heart rate within normal.” I think that you could know…

Sarah Lavonne:
I mean at least you could know what the normal is. What is a normal fetal heart rate baseline?

Justine:
Put it in your brain. 110 to 160 is normal no matter the gestational age. That’s a trick question sometimes on these tests. You know that the contraction pattern happens during a contraction. There’s no oxygen going to baby during too many contractions, but we need contractions to labor. Because you know that contractions affect oxygen, you can gather that the heart rate could be changed if there’s no oxygen.
If you just have a general realization of that, and that’s even a little bit more deep, but really think about the only language baby can speak to us is their heart rate. The only thing that they can do to regulate their blood pressure and to make sure their vital organs stay safe is going up or down in their heart rate. They’re very smart and they compensate well, but we are just there to respond to the cues and clues that they’re giving us, but it’s not always accurate. What is it? 33% of Category III actually come out with bad outcomes. That’s 67% are okay, and Cat III is bad. You barely see Cat III.

Sarah Lavonne:
You better move.

Justine:
Yeah, so there are categories. There are things that we’re looking for in the heart rate, and also you have so many knowledgeable people around you that you can ask and go to. They want an expectation on day one and week eight even is that you’re concerned. We expect you to be concerned, and we expect you to be on your own freaking out about the strip. We’re like, “It’s okay. It’s okay. You’re fine, you’re fine.” Maybe by year one we’re like, “Okay, you got to…,” but we know that even when you’re off orientation, you’re going to be anxious, and we were too.
Anyways, I’m nervous about it. It’s going to be June 12, around 3:00 P.M., I believe, if you’re not doing anything and you want to hang out. Writing classes is not easy. I think it’s because one, I have Sarah to compare to, which is challenging, so Sarah, I need all the advice. Sarah, I need all of the advice. She inhaled her tongue in her nerves. I’m just kidding.

Sarah Lavonne:
I’m so not intimidating, but I’m here. I’m your ally.

Justine:
You are my life.

Sarah Lavonne:
I’m cheering you on.

Justine:
Also, we’ve been to so many bad classes, and we don’t like to waste anyone’s time. I think those two things are always lingering of you want them to walk out with nuggets and being like, “Yeah, that was worth it. That was worth my time.” Honestly, we are busy people and your time and money are important.

Sarah Lavonne:
Can I tell you my pet peeve when it comes to classes? You may have heard this before, but let me call it my pet peeve. Do you know what it is?

Justine:
I don’t know.

Sarah Lavonne:
When I say it? You’re going to be like, “Oh, well duh.”

Justine:
Yeah, go ahead. I don’t know. Say it.

Sarah Lavonne:
Well, it’s when you go to a class and somebody talks at you and then they’re like, “And there you go,” versus…

Justine:
“And now what?”

Sarah Lavonne:
… “And now what?” Give me the me “Now what.” Tell me I need to do with it. I’m here to learn. I want to apply. Luckily, yes, I’m a smart person, but you are the expert. You’re talking to me. What do you want me to do with this information? I realize that a hemorrhage is this much with an EBL or a QBL and when you should do either one, and ideally you’re doing Q all the time. I understand that, but what do you want me to do? What practice change? What are your tips for me? The practical piece. You’ll see practical everywhere anytime I’m auditing a class, anytime I’m helping people develop a class, anytime I’m making a class myself, it is like, “Here’s the knowledge. Here’s the patho, but here’s what you do with it.”
There will always be practical application. Sometimes that’s a little more nuanced because it may not be like, “Give this medication at this dose, in this route, in this time,” etc. It may be a little more like, “This is what therapeutically this looks like. Let me model it for you.” Holy moly, it makes me nuts. Any of you listening, pay attention next time you’re at any of these classes, or a lecture, or a conference, or a workshop, or whatever and how often people are like, “Here’s the info.” And you’re like, “I read that. Thanks. What do you want me to do with it?” It makes me crazy.

Justine:
Yeah. Honestly, that’s one of the things I see when I’m being taught by MDs versus nurses. I’ve noticed.

Sarah Lavonne:
That’s a really good point.

Justine:
There was a conference recently that I didn’t want to go to and I didn’t go to because it was all MD speakers. Mind you, I love MDs and I think they’re super smart, but they don’t always know how to tell me what to do as a nurse.

Sarah Lavonne:
Well, why would they?

Justine:
Right. Exactly.

Sarah Lavonne:
Of course. That’s actually a very good point. If you’re somebody that puts on a conference, that is something to pay attention to. We went to conference recently, you and I, and there was a pediatric… She was amazing.

Justine:
Oh, she was amazing.

Sarah Lavonne:
A pediatric nurse…

Justine:
She’s an RN.

Sarah Lavonne:
… She specialized in human trafficking and recognizing the signs of human trafficking. Mind you, she came from a pediatric background, so she’s looking at children, they’re medical assessments and what you would see and whatever. She’s talking about the emergency department because, of course, that’s her frame of reference. I will say that as much as I maybe didn’t get as much practical out of that, it was so important for me to have awareness on the issue. If that’s the point, I want to be told that as somebody who’s a learner, that the point of this… All I want you to do is… My goal is to create awareness around this issue, and then we’re not going to get into practical steps. Knowing your audience of saying, “I did want to know.”
In labor it’s different and in OB that’s different. For a pregnant person, what would we see? There was nothing discussed about that, which is totally fine because she was also talking to postpartum labor and NICU but also, I don’t think that was the point in her case. I think even just being aware of what’s the point and saying that if you’re an educator out there, and second that who’s speaking to you and having a frame of reference for what it takes from your vantage point will change how you learn. That’s also where I think about physiologic birth. The physiologic birth class is specifically for nurses. It’s for intrapartum nurses that are carrying through the nursing lens, through the nursing scope, through the, and mind you, we do have doulas there.
We have doctors that come. We have midwives that come, obviously much less than nurses, but the class is taught from your vantage point. That’s where I also think that how could a doctor teach on EFM for nursing because they’re not their role, their scope is different, right? That EFM, or I was going to say in ED. No one’s doing EFM in the ED other than us, but if we were taking into the ED like a crash C-section in the emergency department, they do not need to know much. First of all, they need to know how to call for help. It’s the same with NICU. You’ll hear me say this all the time where I’m like, “Just call the NICU.” I always had a very good NICU to call where I’m like, “I can get it started, but then please show up and then please take over. I’m done. No more than five minutes. I’m not starting a line on a newborn. Like what? No.”
I think knowing your audience and also understanding that’s what I love about Bundle Birth is it’s us nurses speaking to nurses from a nursing lens for the hospital setting. While that may create a very specific niche, and I think that yes, there are other specialties that can learn from it, I also think that that’s something that really sets us apart and that I’m really proud of and why it is important to me that anybody that is a nurse on our team is also functioning on the floor. I haven’t seen your class yet, but I saw your slides and I saw the outline, and I’m really excited about it. I think always I’m going to say let’s talk practical.
If the point is that I want you to walk away understanding and knowing the terminology like the back of your hand. I want you to be able to call a doctor and say that you’re concerned and have a script for that. The more practical tips that we can give, the better. That’s where I want to make sure that that’s always sort of the lens that Bundle Birth Programs are functioning through. That’s what you get through our entire mentorship program. That was where real talks come in. You learn that stuff, and then we sat down and we’re like, “Okay, but what does this mean for your practice,” all the way through mentorship. I’m excited to see how that all comes together for you.

Justine:
Yeah, I’m excited and nervous, and it might be a one one-time thing. No, I’m just kidding.

Sarah Lavonne:
I hope not.

Justine:
No, we have a vision to keep offering this. If you’re listening, I know we have people listening while in nursing school. “No, I really want to take that before I graduate.” This will hopefully be around when you graduate because we want to support our newer to specialty, new nurses, nurses that just want a refresher, nurses that are like, “Well, I have to start precepting, but I don’t necessarily know the language.” This is me formally inviting you to come hang out with me on June 12 for first ever online live class that I wrote. If it goes terrible, don’t tell me. Also, smile while you’re on the class. Send me little hearts. I wish it was the Instagram live so they could just heart every so often. Zoom should do that. That would be nice.

Sarah Lavonne:
They have the heart that comes on the screen.

Justine:
Put a heart on your screen. That would be really cute if everyone had hearts.

Sarah Lavonne:
Or a filter where there’s just a heart around you.

Justine:
Oh, yeah.

Sarah Lavonne:
There’s cute filters.

Justine:
Know that I’m nervous and dying inside, but excited to help anyone.

Sarah Lavonne:
You’re going to do great.

Justine:
I hope that people grasp onto what I’m trying to throw out there, and it helps someone. It helps someone feel less lost on those crazy busy L&D units that we’re just trying to make change on.
Thanks for spending time with us during this episode of Happy Hour with Bundle Birth Nurses. If you like what we’ve 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 BundlebirdNurses.com or follow us on Instagram.

Sarah Lavonne:
Now it’s your time to go and do a little internal assessment on how confident you feel about basic fetal monitoring. There is no shame. You may have done this for 30 years, and if you can’t and or you don’t feel totally confident about your basics in EFM, come join us for class. We’ll both be there and be hanging out with you as we all continue to push into being better, not only for ourselves, but also for the families that we care for. We’ll see you next time.