Intrauterine Resuscitation: Fetal Heart Rate Categories & POISON Mnemonic

All right. So, this is intrauterine resuscitation mini lecture. Um, I'm adding my face down here. I had a

request that um it would be helpful to see me talking when we do the mini lectures. Uh, so I'm going to try to

incorporate that for the ones that um I can. Um, it won't be all of them, but I'll try my best. Uh, so when we talk

about intrauterine resuscitation, we have to remember that we always start with interpretation of our fetal heart

rate and our contraction. just like we talked about in the last mini lecture in class. Um so our fetal heart rate we

have four categories baseline variability accelerations decelerations and then for our contractions we also

have four categories frequency duration intensity and then our resting tone. resting tone is going to require our

hands to be on the abdomen on the belly uh to palpate in between contractions and that intensity um we're going to ask

the patient for subtractive and then if we are not using internal monitors which more than likely we aren't those are

less frequent uh we will be palpating during the contractions to palpate intensity.

So keeping in mind we always have to start with our interpretation. And when we talk about what's normal or

abnormal uh within the fetal heart rate, we have categories. This is a standardized process. Categories that

tell us um what to do next or how concerned we need to be in regards to what we're seeing on the fetal monitor.

Um so category one all the way over to the right where it's green. Everybody's happy. It's reassuring. We have a normal

baseline. We have moderate variability which is what we want and we don't have any concerning decelerations meaning if

we do have decelerations it's usually like an early which we know are not concerning. Um we don't have tachiscy of

the uterus. We don't have deep variables. We don't have late decelerations. We can have accelerations

because that's a positive thing but it's not um we don't jump into action if we don't have accelerations. So, it's great

if we see them. We don't freak out if we don't see them for a little while. So, that's our category one. Um, and

depending on the patient situation, that might be like we're satisfied and we get to take the patient off the monitor

completely or if they still need to be like we have a reason to continue monitoring them just in case something

changes, then we continue monitoring, but we don't have to intervene, we don't have to do anything else different.

Category two is our um indeterminant category. So this is the keep watching and we likely might be doing some kind

of intervention. Now what that intervention is is variable. It might be very something very minimal. It might be

something more intense. Um but it's the ones where we see concerns in the fetal heart rate whether that's in response to

contractions in labor or not. Um but it's something that tells us like we're not completely category 1, but it's not

so bad that we need to do something like eently which puts us in category 3. So, this might be, for example, um the

patient's having more contractions they would like than we would like them to. Maybe we have them on ptocin and they're

contracting more than five times every 10 minutes or they only have 30 seconds of resting tone between contractions or

um baby is starting to show some really deep variables with every contraction. We used to have moderate variability and

now we're down to minimal. um those kinds of changes to which we know if we don't do something to fix them over time

they will lead to baby losing its reserve and put us closer to that category 3 or do something that changes

us to category 3. So we don't we don't just sit on a lot of those things and watch them happen and not do anything

because if we don't do anything then we're going to end up in a worse situation later. Category three then is

um evidence of changes in the fetal heart rate that mean we are in emergent

situation now we either need to fix the problem immediately or we need to be moving towards delivery in the next 30

minutes or less. This is our fix to deliver fix or deliver category. Um, and even if you can't remember all of the

things that go in each category, um, because especially if you look up the individual criteria for category 2, it

has so much in it. Um, if you can remember the fix or deliver, it's an emergency situation, or everybody's

happy and everything's reassuring, and then just remember that everything else falls in the middle. Um, so unless we

have a perfectly happy strip of which we know we don't need to do anything or a catastrophically bad strip to which we

have minutes to do something about it or we end up with a poor outcome, everything else falls in the middle into

that category too. So, um, backing up to category 3 that that fix or deliver things that would constitute that. Um,

if we have an absent variability, that's bad all around. Um, but if we we need to still couple that with something else

terrible. If we have absent variability out of a baby um but nothing else, that still actually puts them in category 2.

Are we going to do something about it? Absolutely. Are we going to rush them to the O? No. But if we have absent

variability and we're starting to see lates with more than just sporadically, like recurrent contractions, if we are

seeing absent variability with recurrent variables that are significantly deep, we're going to do something about that

really quickly. um fetal brada cardia. So a fetal heart rate baseline of less than 110 um consistent we would we would

be very concerned about that. That is not the same for tacocardia. Fetal tacoc cardia while it is concerning and while

we will do something about it or look for the reason that it's there um we can we can handle tacocardia brada cardia is

detrimental. So those aren't always um some people like to put those in the same category and they're completely

different. The the reason for that being the cause of fetal brada cardia is completely different than the cause of

fetal tacoc cardia for very very different um very different causes very different outcomes for the fetus uh very

different interventions based on what we would do to fix it. Um other things that would constitute a category 3 sinosoidal

pattern big deal. um we will talk about a little bit in class what that looks like and it's not a super common

occurrence and it means very detrimental things if it's true sinusal. Um and then if we have an abrupt deceleration that

ends with um whether it's a prolonged deceleration that we can't get to come back up to baseline or it's a prolonged

acceleration that ends up leading to fetal brada cardia which would put us back up to to category 3. All of those

things would be like a we need to fix or deliver right now. Um I will not say that

every how do I put that? Sometimes we have a category 2 strip but it's a severe enough category 2 where we're not

to category 3 like we have to fix it within the next few minutes but we're not going to sit and let the patient

labor for much longer than that. Um and we'll go through some strips in class as to what that looks like and what those

things would be. Um, but this is the categories we use and it's very um consistent terminology. The that way

that all um when we look at research that tells us what the evidence-based practice is for whatever the fetal strip

shows us, uh we default to this because it keeps it consistent and it keeps us um supporting patients or intervening

when we need to in a way that we know promotes best outcome. So, the ve chop pneummonic, um, if

you've seen this, great. If you've talked about it with somebody, awesome. If we've already covered it in class,

fantastic by the time you watch this. Um, the veh chop pneummonic isn't going to, um, it doesn't tell you what all to

do when you see a change in the fetal heart rate. But if you can remember the vehop pneummonic, you can, it

essentially tells you what's causing the change that you're seeing. And if you know what's causing the change, you know

how to intervene for the cause. So variable D cells, the ones look like a V, really sharp down, really sharp

increase back to baseline, those are caused by cord compression. So that means the umbilical cord for whatever

reason is being compressed. Whether that be it's around baby's neck and that's being compressed. Whether that be it is

positioned between baby and the uterine wall and when the contraction happens, it's pressing on that cord. um whatever

that might be, something is pressing on the cord, compressing the cord and that pressure um that change in pressure and

change in blood flow stimulates the barrel receptors which is deeper than a level you need to know but within the

fetus that causes it to change its heart rate in reaction. Um so if we know it's chord compression, we

see a variable, we know chord compression uh is the cause, we know how we can fix it. Um early decelerations,

that's your E in the veto. Uh early decelerations are caused by head compression. So these are lined up. What

causes them? Head compression causes our early decelerations. So if we see early decelerations and our patient is in

labor and we know the fetus is head down with its head in the cervix um or you know in the birth canal in the pelvis,

it's not illogical to think that their head might be compressed at some point. Like that's absolutely going to happen.

So when we see early decelerations and we know they're caused by a head compression if we are well aware that

our patients in labor, we don't we don't have to do anything about about early D cells. We document

them and we move on. Um they're not concerning, they're not detrimental, it's not going to lead to hypoxia for

the fetus. The only time I would I have ever been any bit concerned about early decelerations is if I have a like

pre-term high-risisk patient who is there um either outpatient like coming in for a visit or inpatient because

we're monitoring them and we have them on the monitor even for just an ST and they throw out a couple contractions and

baby has head compression and early D cells with each contraction. That is a patient that is not in labor. I prior to

that didn't think that baby's head was low enough for that to happen. Um that might be something that warrants

additional assessment just because why is that baby's head so far engaged and is this patient in labor and we don't

know it kind of thing. It still doesn't mean that I'm concerned that the baby is lacking oxygen in any way or hypoxic in

any way. That would just be like ooh that's the only thing that causes those. Maybe we should check her. Maybe she's

dilated. Maybe she's in labor and we didn't know. Otherwise, if your patient's in labor and they're showing

early D cells, document, move on with life. Not concerning. No intervention needed. Um, accelerations are caused by

oxygenation. Oxygen is a great thing. We would love the fetus to be oxygenated. That's positive. So, when we see

accelerations, we document them. We move on. We're reassured that our baby is oxygenated. Great. Love that for

everybody. The L is for our late decelerations. This is one that is always, always, always bad. Always

requires intervention. Always requires documentation and notification. Late Dy cells are never a good thing. Lady Dy

cells are caused by placental insufficiency. That's the P in our chop. Um placental insufficiency can is a kind

of an umbrella term for a variety of things. It can be poor oxygenation to the placenta. It can be poor blood

profusion to the placenta. It can be a poorly operating placenta if especially if we're talking about like a post-term

um pregnancy or a um patient who has a chronic abruption situation or there are um sometimes with certain complications

such as like pree we have Doppler flow issues where like we know that the umbilical cord and the placenta the

blood flow doesn't always go the direction it should. The vessels aren't shunting to the appropriate spaces the

way they should. Um, it can mean any any of these things, but essentially bottom line, the placenta is not giving baby

what it needs. Whether that be perfusion, blood volume, whether that be oxygenation, whether that be taking um

waste away from baby, whatever it is, the placenta is not functioning as it should. So, that's our ve chop

pneumonic. And again, it doesn't tell you how to fix anything that you're seeing, but if you can remember how

those um causes line up to the changes, if you know the cause, you can identify how to fix it. So, that's the shop. And

then we have our next pneummonic. So this is our true intrauterine resuscitation pneummonic is our poison.

Um which I know is seems like kind of counterintuitive to think of the word poison when you're trying to fix

something. Um but that's what makes it so great. It's easy to remember. Uh so the P is for position changes and that

is position changing for mom. Uh so if we change mom's position in labor, that changes the pressure off the cord, for

example. or if the uterus is um blood flow isn't going the way we want it to and baby's looking funky and we switch

mom to her other side. Uh left side for mom is theoretically anatomically uh the position that should allow for

the most um blood flow the most perfusion to the uterus is on mom on our left side. Um, we know that because

anatomically it has to do with the the way the aorta and the vennea run. Um, and how that oxygenated blood makes its

way to the uterus. So, we know that anatomically, theoretically, left side is our go-to. I will say that, you know,

90% of the time that works and it's great and baby's happier when mom's on her left side. But, we know that there

are exceptions to every rule and it that doesn't change for fetal monitoring. It doesn't change for pregnancy. Um, so

sometimes you'll have mom on her left side and baby starts looking like crap and you flip her to her right and all of

a sudden baby looks better for whatever reason and that's fine. So it's not that we only have one position change we can

do. Um, left side is usually our go-to, but if left side isn't working, we will try a different position. Um, the

position change for mom can help with your blood flow. It can decrease cord compression. Um, it can make changes

that help support baby's perusion and oxygenation. Second or the first O there being

oxygen. Um, this is one that we still leave in here because it's on Inlex. This hasn't changed. It is still in

practice. Um, but evidence is leaning the other way for oxy hyper oxygenating mom. Um, if we don't have a specific

reason to do so. Okay. So for the purposes of this course and the purposes of our exams and the purposes of INLEX,

you're still going to incorporate that oxygen is a intrautin resuscitation measure. When you are in practice, when

you are in clinical um you will note if you see a baby strip that looks bad, as long as mom's oxygenation levels are

appropriate above 95% that we will no longer place oxygen on moms for intrigue or resuscitation.

Um, this actually kind of came about during COVID when everybody was very um cautious with the use of oxygen for

patients who could possibly have CO or had known COVID um to try to prevent um passing it to others that are taking

care of them. And there was research conducted and when we were not doing that that it wasn't really changing the

outcome for mom or baby. The previous thought was if we were hyper oxygenating mom, meaning um oxygen moves through the

placenta to baby bed passive diffusion. So if the oxygen concentrations in mom's blood were higher than what was in

baby's blood, even if those were not significantly different levels. So let's say mom's O2 saturation is 99%. But

theoretically baby's is 95. That that would still increase baby's oxygen even though both numbers were

okay, right? above what we would like. Um, so that was the theory behind it is if we could hyper oxygenate mom, it

would essentially pass some to baby and we weren't harming mom with the oxygen. Now we are through research is showing

that it really didn't make that much of impactful impact in the outcomes. So unless mom's

oxygen is lower than 95%. We don't usually use oxygen. Now, if mom is O2 sats are at 93, we're going to put

oxygen on her because that's that's out of our normal range and we want to um but for the purpose of this, we're still

going to consider oxygen as an intravenous resuscitation measure because not everything's caught up to

everything that it should. Um IV fluid bololis. So, this the the goal for this is to in increase perfusion by

increasing volume in the circulatory system. Um if we increase that volume, it increases profusion to uterus, which

hopefully helps our baby look better. Uh we also use this to correct maternal hypotension, especially if it's in

relation to um an epidural or spinal anesthesia cuz we know that's a side effect. Um the only patients who we get

I'll say is stingy or careful or maybe we don't include this one. um is if they are known hypertensive, if they are

already dealing with high blood pressure, we're not going to bully them with IV

fluids, at least not freely. Um we're going to be a lot more hesitant with those uh because we can make that

problem worse, right? And risk and benefit. Um S is for the speck and check. So this

is a sterile speculum exam or a sterile vaginal exam, one or the other depending on the patient situation. Most often

it's going to be a sterile vaginal exam. Um, and what we're looking for there is when we see certain changes on the

monitor, we think, okay, there are certain um, causes that could be causing the changes we're seeing. Some of those

causes are if the patient is having vaginal bleeding, if we're seeing changes that look like baby might not be

perusing well, do we have any vaginal bleeding that is pulling circulation and oxygen away from baby in the placenta?

Um, another is a cord prolapse. If we see a sudden variable that is super severe andor doesn't come back to

baseline, that could be caused by a severe chord compression. Did we drop a cord? Is the patient um is it possible

if she ruptured? Did she have a high station? Is there space for this cord to slip out? Um and we check for a cord.

The other thing we might see is um rapid descent of baby in labor. So let's say we have a mom who's been like 5 to 6 cm

and baby's looked great and all of a sudden we see some weird D cells and we're trying to figure out what's going

on. Um and we go to check her and she was 5 to 6 an hour ago and now she's 10 and complete and ready to push. And what

happened was she dilated really quickly and baby came down in the birth canal really quickly and now we're seeing the

the effects of that on baby um on the monitor. Now that doesn't always mean like that it's a bad thing like great

rapid descent and baby's ready to come out. But it does mean that we need all the people we need for delivery because

if baby's made that rapid descent then delivery is probably not far off. So that's one of the things that we just oh

we need to make sure that there's not a cord, there's not bleeding, there's not baby um that we weren't aware of. Um the

second O is turning off oxytocin or ptocin if it is running. If we have any changes on the fetal monitor that

indicate to us that baby is not tolerating labor um not tolerating contractions, losing their reserve um

and we have oxytocin running, we turn it off. If we are causing the situation that is impacting baby negatively, then

we stop causing that situation. Um, we can always turn it back on later once baby looks better, once they can

tolerate it. Uh, but we are we don't want to get to the point where we are causing a detrimental fetal heart rate

change that may or may not end up in emergency section in the O because of something we are giving mom to help her

progress in rel. And then the N is for notifying the healthcare provider. And it's at the end for a reason. Um

I've said many times nurses hold a lot of power and labor and delivery nurses hold a lot of autonomy and there's a lot

of ch um training that goes into understanding our role, understanding our scope, understanding the

interventions that we can do um independently. And when we have changes in the fetal

heart rate that warrant intervention, we need to try our nursing interventions first before we call the healthcare

provider if it's something we can fix because 90% of the time we have the interventions at our disposal that will

that will fix our problem. So usually by the time we get to notifying the provider, we are either saying, "Hey, uh

letting you know this happened. this is what we did and it fixed it but just wanted you to be aware this was the

situation or we are notifying because we are saying we had this change we have done XYZ we it's still happening we need

you to come lay eyes on the patient assess further and change plan of care whatever that might be um but if your

patient's having variable D cells and you call the provider and say she's having variable D cells with every

contraction 40 beats lower than baseline and they're going to say well what did you do about it.

Did you try to fix it? Um because we have interventions within our power that we should try first before before we get

to that point. Um so that's why we keep the N at the end. It's at the end because it's not your first intervention

for most things. There are a small small subset of circumstances in which there's not really much we're going to be able

to do to fix it. We need to call. Um but for the for the vast majority of changes, there are things we should be

doing first. If at the very least, even if we know we can't fix it, there are interventions we should do that will

support patient and baby and oxygenation and prevent hypoxia that we should put in place before we call to notify so

that we are not making the problem worse while we are changing the plan of care and moving forward. So ends at the end.

Um this brings me to critical thinking, right? We apply that to everything I

hope. Um and just because we have a whole list of intraven resuscitation measures does not mean that all of them

are always appropriate for every change that we see in the fetal heart rate. So we really need to think through the

rationale and the goal of each intervention that we want to apply so that we can identify which are indicated

for which change we're seeing. Um interventions should always be indicated supported by evidence. Um they should be

as minimally invasive, right? We we don't always jump to the most invasive, most severe intervention. We start we

start with the minimally and then we move our way forward. Um they should always be appropriate given the patient

situation. So just like I said with like an IV fluid bolis, that is absolutely an intervention for late decelerations.

But if my patient's blood pressure is already high, I am not going to overload them with fluids to try to fix a baby

problem cuz I'm going to make both problems worse eventually, right? If we're not profusing well, that's not

going to be helped by additional fluid. If we already have high blood pressure, we don't have a low blood pressure, low

profusion situation. Um, and then evaluated for response. Any intervention requires an evaluation. Whether it's

working, whether it's not, what do we do next? If it's not, what next steps need taken? Um, all interventions require

evaluation. So, to put that into context, um, an example, fetal heart rate baseline 185 with moderate

variability, positive accelerations, no decelerations. Patient's contracting every 5 minutes. Those contractions last

45 seconds to a minute. They're moderate in intensity and she is soft resting tone. So we know that the baseline 185.

That's fetal tacoc cardia. Okay. Uh we said 110 to 160 is our normal range. Fetal tacoc cardia most likely is caused

by a maternal fever. There are very few other things that can cause fetal tacocardia. It is almost always that mom

has a fever. Maybe she has an infection. Um but more than likely that's the cause. And I said fetal tacocardia is

notable. It's it it's worth paying attention to absolutely but it is not as um detrimental as fetal brain cardia. So

then when we look at our interventions position change not indicated for fetal tacoc cardia um we don't have a

profusion issue right we don't have a compression of the cord issue we don't have um an oxygenation issue because we

have moderate variability which tells us our fetus is well oxygenated and acceleration that tells us our fetus is

well oxygenated so we don't need oxygen. um an IV fluid bololis could absolutely help this patient. Not because it's

going to increase profusion, not because it's going to bring the fetal heart rate down to a normal baseline, but because

if the patient has a fever, which we are going to assess for, but more than likely that's our problem in this case.

Um they are going to have insensible fluid loss. They are going to lose fluid faster. So we definitely want them on

fluids absolutely because we need to replace what they're going to lose because of the fever. Um speck and check

not indicated for tacoc cardia oxytocin off. If we had oxytocin running on this patient if our variability was to

decrease or if we were starting to see decelerations then absolutely we would turn our ptocin off. But the fact that

we have moderate variability in ax cells with no d cells tacoc cardia in and of itself does not mean we need to turn the

ptocin off and change the plan. um notifying the healthcare provider. If the patient has a fever and we already

we haven't already diagnosed her with some type of infection, then that's concerning, right? Because that's a sign

of infection. Um if if the we're treating the patient for an infection and we have Tylenol ordered

that we can give her to bring down a fever and she has a fever, then we are going to give her Tylenol and try to

bring that down. And then more than likely, if we bring the mom step down, baby's heart rate's going to come down

and we'll be back in a normal range. So unless we have additional signs and symptoms of concern that are not already

diagnosed and or we have changes in the fetal heart rate that are concerning, then this does not require notification

because we there's nothing we're going to do to fix it other than what we're doing. Now again, if the patient has a

fever, we haven't diagnosed her with an infection. This is a new onset problem. she probably has cororeo and yes we need

to we need to identify that and and notify the doctor so we can get her antibiotics and and treat her like she

has cororeo. Um but if this is not a new new development this doesn't require any notification to anyone.

Another example um fetal heart rate baseline 145. We have minimal variability no axels late decelerations

with 2/3 of the contractions. She's contracting every 3 to four 3 to 4 minutes lasting 80 to 90 seconds.

They're strong to palpation. Her resting tone is still soft. We have ptocin running on this patient. Her protocol,

she has an epidural in place and her steraginal exam is 680 and zero. Um, so position changes. Yes, for this patient

absolutely position changes are indicated. We have late decelerations. We have placental insufficiency. Uh, we

want to try to improve our perusion to the placenta and a position change can help with that. So yes, let's stick this

patient on our left side. She's on her left side. Let's stick her in a different side. Change her position. Um,

oxygen possibly. What are the oxygen levels of patient? Um, do we think we can help that with hyper oxygenation?

Maybe if it's a profusion issues, you can maybe put that on. If the patient's oxygen levels 99 100, probably not going

to do much with it, right? Um, IV fluids possibly. We said profusion problem, placental insufficiency, fluids could

absolutely be warranted for this situation. Um however if again hypertensive patient not the right not

the right trial right um speck and check not indicated by these changes um we we this would not indicate we have a core

prolapse um more than likely we this is not a situation in which we have bleeding so that's probably not going to

be your cause it wouldn't hurt to look but unless there's a high risk for that otherwise probably would not be the

first guess um and this is not we know I mean unless the vaginal exam is change from what we just know. Six. The baby

did not make rapid descent. We're still at six. Um, oxytocin off. Absolutely. That should honestly be the first

intervention in this scenario. We have ptocin running. We have contractions that are frequent and lasting a pretty

long time. And baby is exhibiting signs that they are not tolerating it. We have late decelerations, poor profusion from

the placenta, and we have minimal variability, which means baby's oxygen reserves are decreasing. Um, so turning

the oxytocin off is 100% warranted in this situation. Um, notification. Yes. And this is going to look like we had

late recurrent late D cells with minimal variability. So, we turned the ptocin off and now baby looks like this and is

better or not. or we um turn the ptocin off, we change her position, we gave her some fluids, um and we're still having

late D cells and we can't get them to stop. We need you to come lay eyes on the patient and do something different.

Um but again, this is not one of those instances where we would call the provider and say, "Well, she has minimal

variability and late D cells. We didn't do anything yet. Like, we should do our interventions and try to

fix the problem." um even if it doesn't make the problem go away altogether, it still supports a better outcome than

allowing it to happen. Um so this is that's how we would handle that situation. And we're going to go through

more um examples in class and look at some strips and really put some context to what we're talking about. But this is

how we apply that critical thinking to what um resuscitation measures we have at our disposal and what we should do.

So that's it for this one.