No One Likes A Purple Baby

You can’t always tell a “bad” baby by the fetal heart strip.

That is to say, some babies look fantastic during labor and all the way through pushing, but when kiddo is born and the big moment comes, they just can’t seem to get the hang of “life on the outside”.

The majority of babies transition well.  When L&D nurses talk about babies “transitioning”, we mean the process that takes place immediately after birth where baby goes from being in-utero and fully dependent on mom’s body to breathe, feed, and remove waste to suddenly having to do all of that for himself.

Like I said, most babies figure it out on their own within moments of being born.  They take a surprised breath, and with a bit of drying and physical stimulation, they start to cry, their skin turns pink, and wa la!  Life doesn’t really begin as much as it just continues.

Still, my hospital requires that at all births, there is a nurse present for mom and a second nurse present for baby.  This ensures that if there is an emergency with either, both have their own dedicated staff member present and fully in-tune with their history and their treatment. The last night I worked, I got a great reminder of just why we require two RNs to be present at all births.

The Scenario

The nurse who had the patient in room 2, Barb, was an experienced L&D nurse who had an orientee, Marcy, working with her.  When one of my other coworkers mentioned that Barb and Marcy’s patient was about to deliver, I took a look at the strip and started heading down the hall.  As I was “up”–patient-less and waiting for an assignment–I was ideally free to help in the meantime.

“Well, I dunno, Sophie.  She should be good.  She has Marcy in there with her, and she’s almost off orientation.”  Breanna called from the desk.

“Oh, it’s no problem.” I replied, keeping in mind the happy FHR strip I had just seen on the monitor.  “You never know, after all.”

“True.”  Breanna agreed plainly.

As I arrived in the room with the doctor and the surgical tech, I prepared the bassinet, laying out the blankets, placing a blanket on mom’s chest, and making sure that suction, oxygen and my emergency equipment was functioning and turned on.

Barb and Marcy were helping their patient push, which was taking longer than they had expected for the first-time mom, but baby was clearly at about a +2 station and making progress with each push.  About five minutes later, baby’s head emerged, followed by the rest of his body with one last push.

As the doctor cut the cord, I stepped up at the bedside, drying and stimulating the baby as he was placed on mom’s chest.  APGARs are a little low on this one, I noted as I realized the baby wasn’t crying, had central cyanosis, and he wasn’t moving much.  Moments later, I heard the distinct sound of grunting on the end of each breath and retractions appeared around baby’s sternum.

Seconds into meeting this new little boy, it became obvious that he would require a little extra attention.  I kicked my assessment skills into high gear as I reached for my stethoscope to take a closer look.

Drying, Stimulating and Crying

Drying a baby is important as babies have difficulty maintaining their own temperatures, so the longer baby stays wet, the more likely it is for him to get cold and potentially experience some of the consequences thereof: dropping blood sugar, lethargy, and low blood oxygen to name a few.  While some of the “goop” (AKA: vernix) that baby is born in has been shown to protect baby against infection and help regulate baby’s temperature, making sure baby is dry is of paramount importance immediately after birth.  It is important to note that while some of the vernix will come off with drying, enough will stay on the newborn to provide the benefits associated with delayed bathing (which is a topic for another post!).

A natural result of drying baby is the stimulation that occurs when the blanket makes contact with his skin, and this stimulation usually causes babies to cry.  Crying will naturally help to clear any fluids that baby might have gulped on his way out, therefore opening his lungs and getting him used to the idea of breathing on his own.

Skin Color

Cyanosis is a general term that refers to a bluish coloring of the skin due to a lack of blood flow or poor oxygenation.  A little cyanosis of the hands and feet actually isn’t uncommon in newborns and is called acrocyanosis.  Acrocyanosis occurs normally as baby transitions from being in-utero to having to breathe on his own after birth: slower or decreased blood circulation to the extremities is normal as baby’s body learns to support itself through breathing.

Central cyanosis means that a baby looks purple or blue in his or her trunk.  When the infant’s chest, abdomen or face appear purple, it can be a sign that baby isn’t getting enough oxygen all around.  Though central cyanosis isn’t in and of itself indicative of decreased oxygenation, it is an indication to place an SPO2 monitor on baby’s right hand and make sure that the discoloration you’re seeing isn’t from low O2 levels.

Muscle Tone and Startle

Decreased movement is another potential sign of trouble.  When babies cry, they naturally tense their legs and arms.  In general, crying is a whole-body experience for a newborn.  Also, in addition to the stimulation of having been born, the noise and light associated with birth often triggers baby’s startle reflexes, and if baby doesn’t have good muscle tone and good reflexes pretty quickly after birth, this can point to trouble.

Of note: this can be a sticking point for babies born by C-section.  Vaginal birth and the process of emerging from the birth canal–and all the squeezing that entails–can naturally stimulate a baby as he’s being born and also force fluid out of baby’s lungs.  C-section babies aren’t privy to this particular set of benefits, however, and as a result, sometimes babies born by C-section require a little extra attention to get them to perk up after birth.

Retractions and Grunting

Retractions are a fancy term for when the skin pulls in around baby’s ribs and sternum as he tries to breathe.  The direct result of a baby working extra hard to pull in air, retractions are a sign of respiratory distress in newborns.

The same goes for grunting, which initially sounds like baby is humming a song.  As baby exhales, he closes his glottis (which normally covers the airway when you’re swallowing food or fluids), which causes a distinctive “ah-ah-ah-ah-ah” sound.  In doing so, he causes a change in pressure in his chest that helps improve his oxygenation.  If a baby is resorting to grunting, chances are, he will need some assistance in the breathing department, whether that be suctioning, oxygen administration, chest percussion, or a combination of all three.  Grunting can be a last-ditch effort to open baby’s lungs before things go south, and I’ve seen grunting babies decline from grunting to assisted ventilations (bagging) to intubation (ventilator) depending on the source of their respiratory compromise.

*Of note: breathing is a big deal.  I know that sounds like a given, but in most babies who require resuscitation, breathing is the culprit of their distress.  Say you have a baby who’s born at term with central cyanosis and a no heart rate.  Even before you consider starting chest compressions–even if baby didn’t have a heartbeat at all–per Neonatal Resuscitation Guidelines (NRP), you must give adequate assisted ventilations (bagging) before starting chest compressions.  Most of the time, correcting problems with baby’s breathing will correct everything else.

APGAR Scores

At one minute, five minutes and ten minutes after birth, nurses assess something called an APGAR score.  This quick, objective assessment looks at five categories: skin color, heart rate, breathing effort, muscle tone, and reflex irritability.  At most, baby can get a “2” in each category.  At the least, he can get a “0”.  So on a scale from 0 to 10, an APGAR score tells a provider quickly how a baby is transitioning.

At one minute, my baby scored as follows:
Breathing: 1 -irregular, discoordinated breathing efforts
Heart rate: 2 -pulse is 150bpm, normal range
Muscle tone: 1 -baby has some muscle tone present, but less than normal
Reflex irritability: 2 -baby’s reflexes are normal
Skin color: 0 -baby has central cyanosis

Total APGAR: 6
(As a reference, most babies are born with APGAR scores of 8-9.  A score of less than 7 indicates a need for medical attention).

Back to the Scenario

With baby’s physical assessment looking borderline, I took the baby to the warmer with his mother’s enthusiastic permission.  I placed an SPO2 (blood oxygen) monitor on baby’s right hand and looked for a baseline.  Heart rate was in the 170’s–up from when I had listened to him on mom–and his blood oxygen was lower than normal.

With audible gurgling and coarse lung sounds, suction was in order.  I suctioned baby’s nose and mouth quickly, immediately pulling out some thick, clear secretions.  Suctioning can be an irritating process to a baby which can have the added benefit of making baby cry.  My baby did just that.  He cried immediately after I suctioned him, producing more fluid from his mouth and nose.  A few suctions later, baby’s heart rate came down, his O2 went up, his retractions stopped and grunting significantly decreased, and we were looking at a much happier boy.

In the end, this baby did well.  He was brought back to his mother and monitored for the rest of his time in L&D, but he transferred to postpartum without issues and was discharged normally with his mom a few days after he was born.

However, this scenario just goes to show: a happy strip doesn’t mean a happy baby, and it pays to stay on your toes at all times!

Fetal Heart Monitoring: How to Make an L&D Nurse Run

It isn’t uncommon in the course of my shift for me to be sitting at the computer, happily charting away, when a well-intentioned family member/friend/visitor of a laboring mom bellies up to the counter, locks eyes with the big-screen fetal heart monitor, and starts asking questions.

Now, fetal heart monitoring is much more complicated than what I can explain in the span of this blog.  There is introductory (basic) FHM, which, once passed, is one of the factors that allows a newly minted L&D nurse to work independently.  Then there is intermediate FHM, which is a follow-up course that goes into more detail and depth on how to read, interpret and respond to the information we gather from our laboring moms and babies.

So what’s the big deal with fetal heart monitoring?  Pretty easy: when you walk into a room and see a laboring mother, you see one patient.  I see two (at least, assuming this isn’t a multiple birth!).  However, of those two patients, there is one patient that I cannot directly assess because that patient is inside the other patient!  So why do I watch the monitor like a hawk?  Because the information on that monitor is my only direct look into how patient #2 is doing.

Let’s get into some basics.  A fetal heart strip is divided into two parts: the top part is the fetal heart rate itself.  This is represented by a line that moves vertically across the page to represent the baby’s heart rate in beats per minute (bpm).  The bottom part is tracing the mother’s contractions.

FHR Basics 1

FHR Basics 2

FHR Basics 3

Now, in a normal term pregnancy, I expect to see a certain amount of variability in the fetal heart rate, or the “bounce” present in the FHR.  Variability is determined by looking at the fetal heart rate pattern between contractions and is a result of the fetus’s immature sympathetic and parasympathetic (vying nervous systems) pulling on each other like a tug-of-war.  Sympathetic nervous system gets the upper hand and you have an increase in FHR.  Parasympathetic nervous system gets the upper hand and you have a decrease in FHR.  Pretty easy, right?

The FHR in the first example above tells me that baby is probably pretty darn happy in there.  Especially if there are accelerations present, this typically indicates a content baby with a good placenta and good oxygen exchange.

Since what goes up must come down, there also exists a phenomenon called decelerations in fetal heart monitoring.

FHR Basics 4

Early decelerations are usually a sign of head compression.  When a contraction squeezes on baby and baby is getting low in the vaginal vault (and hence, close to delivery), this can trigger the baby’s vagus nerve (not Vegas, vagus!), which in turn slows the heart rate as the contraction gets stronger and squeezes harder.  With this kind of deceleration, the heart rate should return to normal as the contraction lets up.  L&D nurses like to see early decels because it usually means there’s a baby coming soon!

Late decelerations, on the other hand, especially if paired with minimal or absent variability, can be a sign of fetal distress.  What a late deceleration tells me as an L&D nurse is that baby isn’t coping well with the stress of labor.  During a contraction, blood flow to baby is temporarily suspended as the uterus contracts and cuts off the vessels leading into and out of the uterus.  Normally, the blood that remains in the placenta and in baby during a contraction is oxygenated enough that a baby typically won’t notice the temporary lack of fresh O2 during a contraction.  However, if baby is stressed from labor and her oxygen levels are low anyway, she may really take offense at her O2 source being cut off for any amount of time, and as a result, her heart rate drops as she’s not able to compensate.  Of note: late decelerations can also be a result of an epidural, which can decrease maternal blood pressure and therefore decreases the amount of blood and O2 going to baby.

Fixes for late decelerations include: changing mom’s position to improve blood flow to the uterus, placing O2 on mom (and thus increasing the O2 going to baby), turning down/turning off Pitocin (decrease the frequency and strength of contractions so baby isn’t getting squeezed as much), turning up IV fluids (increasing the blood volume so baby is better perfused), IV ephedrine (a drug that increases maternal blood pressure if that’s the culprit) and, of course, delivery (no more contractions–yay!).  If you’ve ever seen an L&D nurse (or perhaps a crowd of them) come running into a room, throw a laboring mom all over the bed and go through some variation of the steps above, you’ve probably witnessed them reacting to late decelerations.

Variable decelerations typically indicate that the umbilical cord is getting pinched.  They usually happen with or around contractions.  Whether baby is laying on it, squeezing it (I’ve seen it happen via ultrasound!), or the cord is around baby’s neck, body, foot, etc., if you’re seeing variable decels, usually the cord is in a wonky spot.  Thankfully, variable decels aren’t usually very concerning unless they’re really deep (down into the 80-bpm or lower range) or they don’t recover fairly quickly.

Prolonged decelerations, much like late decelerations, are a sign of fetal intolerance of labor.  The fixes are typically the same as those listed for late decels, though it has been my experience that especially with prolonged decels, if mom doesn’t deliver soon, she’ll probably be heading back for a C-section.

FHR Basics 5

Fetal tachycardia, or a fetal heart rate with a baseline of 160bpm or greater lasting for at least 10 minutes, can be normal, especially in a particularly active baby.  However, it can also be a sign of distress and indicate anything from maternal infection to fetal heart problems.  I have seen tachycardic strips as a result of mom smoking a cigarette before coming into triage.  I’ve also seen tachycardic strips as a result of uterine rupture and placental abruption.  I’ve seen even more as a result of maternal infection (whether that be an infection of the amniotic fluid or something as normal as the flu).  As a result, most L&D nurses hate, hate, hate to see strips where baby is tachy as it is usually a sign of trouble brewing.

Fetal bradycardia, while not uncommon when nearing delivery, is one of those things most L&D nurses really watch for.  Unless you’re close to delivery, there is no good reason for fetal bradycardia (at least that I’ve seen!), and most fetuses that exhibit sustained bradycardia are headed for the OR if they don’t shape up!

So, now that we’ve gone through the basics, perhaps you can appreciate the following.  I call it, “An Assessment of Fetal Well-Being  Based on the Facial Expressions of Your Average L&D RN”.

FHR 1

FHR 2

FHR 3

FHR 4

FHR 5

FHR 6

PS: if you’re interested in further exploring the concepts in this post, please reference the following webpage, which I have found to be very thorough!  Real-life FHM strips included!

http://www.brooksidepress.org/Products/Military_OBGYN/Textbook/LaborandDelivery/electronic_fetal_heart_monitoring.htm

 

Punting the Pain Scale

If you’re even remotely trained in anything related to medicine and/or if you have ever received any medical care of any kind, chances are, you’ve encountered the 0-10 pain scale that medical professionals use to assess the presence and intensity of pain in adults and older children.

Up until I worked in L&D, this scale worked pretty well to guide my practice in terms of treating and controlling pain.  In oncology, I had plenty of experience not only in using this scale, but understanding the nature of oncologic pain and keeping my patients comfortable despite their cancer, chemotherapy, radiation, surgery, and often rather dismal states of mind.

But when I moved to L&D, the way the pain scale–and indeed, pain itself–was approached was completely redefined.

On the medical units, pain was the enemy.  It was something to be kept at bay.  It was to be treated immediately, reassessed constantly, and warded off with some of our strongest drugs.

But on L&D, pain is an entirely different entity.  While some pain in L&D can be pathophysiological in nature, the vast majority of pain in L&D is not only normal, but it’s a good sign.  It’s a sign of a healthy and steadily progressing labor that will eventually lead to the birth of a baby.

Long gone were the days of running down the halls for pain medication.  If a woman wanted an epidural, she faced a 1-hour wait, assuming the anesthesiologist wasn’t in surgery.  If she wanted IV or oral pain medication, that was at the discretion of the OB and myself as the nurse in charge of her care.  Indeed, pain is part of the program on my new unit, and while it is arguably some of the most intense pain a woman will experience in her life, it is also universally accepted by the professionals on my unit as all in a shift’s work.

Along with understanding this new place pain had in my practice, I also began to understand the varying levels of pain tolerance in women and what these different levels and tolerances can mean when attempting to reconcile the subjective information the patient is giving you with the objective data you can gather on physical assessment.

A true story from my orientation experience: my preceptor, Melody, and I were finishing up a recovery on a patient who had recently delivered.  We had stepped out of the room and were hanging around the desk getting the chart ready to transfer and we kept hearing a lot of shouting from triage, and both of us, anticipating a fast delivery, got a little antsy.

About ten minutes later, my coworker, Karen, comes marching down the hall with her patient, a first-time mom whose water has broken and who appears to be in some rather intense labor.

A lesson I had learned early-on in L&D was this: especially in women experiencing childbirth for the first time, a pain rating can be a real wild card.  For some women, early childbirth is the most painful thing they have experienced in their lives, so when you get a first time mom who is having mild contractions but is nauseated and breathing through them as if she’s about to imminently deliver a baby elephant, you have to ask yourself two questions: is she just naïve to pain, or is something else going on here?  In the case of these patients (Karen’s included), one of three things was happening.

Option #1: Your patient has a low pain tolerance.

Often times, this is exactly what’s happening when you get a first-time mom who is presenting with pain that seems disproportionate to her labor stage.  In fact, that is so often the case that L&D nurses can get into the nasty habit of assuming that it’s true all the time.

Pain Scale 1

Pain Scale 2

Pain Scale 3

Pain Scale 4

Pain Scale 5

Karen was very fast to assume that her patient was simply not tolerating early labor all that well.  And in her defense, I was guilty of doing the same thing as were many of my coworkers, especially when it comes to a first-timer who was dilated to 1, wanted to go natural and was already rating her pain a 10/10.  That can be the makings of a very long, painful shift–for everyone.

However, the events of the next 30 minutes would teach me a lesson I’ll remember the rest of my life.

Complete 1

Complete 2

Complete 3

Complete 4

Option #2: Your patient is progressing faster than your objective assessment is telling you.

Yep, ol’ Karen had made a newbie’s mistake.  You see, the alternative to Karen’s patient having a low pain tolerance is this: Karen’s patient is presenting with a disproportionate amount of pain to her contraction strength/dilation/labor stage because her labor is moving faster than what we can physically assess.

Especially in a primip (first-time mom), you can see how this scenario could take a nurse by surprise.  I’d wager that 99% of the time, Karen would probably have been right in assuming her patient was, for lack of a better term, just a little bit of a wimp.  Dilated to 1, having mild contractions and presenting with that kind of pain?  Chances are, she’s probably not going to deliver imminently, despite what it may look like.

However, some women–even with their first babies–move so fast through labor and deliver so quickly that there is little to no opportunity for the nurse to reassess her patient’s pain before the baby is very nearly looking her in the eye.  I had no doubt that the contractions Karen initially palpated were mild.  But what about the one two minutes after that?  Five minutes?  Ten?  Chances are, if Karen had reassessed her patient just a tad bit earlier, she would have noticed a change in the quality of her contractions.  Especially in unmedicated first-time moms, reporting high levels of pain even in early labor isn’t necessarily unusual, and Karen likely had no reason to reassess her patient until the patient was presenting with a more urgent symptoms: the urge to poop, the urge to push, or a panic-inducing level of pain.

However, though that is the likely scenario, that may not have been the case at all.  Some women’s cervixes seem to dilate with contractions that, by all accounts, shouldn’t cause cervical change, and it isn’t until she’s complete and screaming for her nurse that you realize she’s delivering off contractions that are every 5-6 minutes apart and moderate in strength at best.  It’s mind-boggling and rare, but it does happen.

Option #3: Your patient is not mentally prepared for labor.

To pause and backtrack for a moment, please note that psychological distress, whether that be fear, feeling out of control, a pre-diagnosed condition like anxiety, a history of sexual abuse, and other emotional factors can also affect the physical level of pain reported by the patient.  I’ve found that not only can these factors present like pain on their own, but they can also intensify and aggravate pre-existing pain.

A triage patient who sticks with me to this day is a young first-time mom who was 39 weeks and came in for contractions.  When I went to the front desk to bring her back to triage, I found her sitting with legs spread in the assessment chair, sobbing and vomiting into a trashcan with several family members hovering nearby.

As you might imagine, remembering my experience on orientation, I hustled this patient back to the triage room and immediately began to gather data.

To my surprise, as I began to interact with the patient and explained what I was doing and looking for as I assessed her, her pain dissipated before my eyes.  In the end, I concluded she was having extremely mild Braxton-Hicks (false labor) contractions and she was sent home.

As she was discharged, I reviewed what had happened.  The strength of those Braxton-Hicks contractions between the time she arrived and the time I sent her home hadn’t changed.  Her dilation hadn’t changed.  Her baby hadn’t changed position.  And she was still 39 weeks pregnant.  But when she came into triage, she had been crying and puking into a trashcan, and now she was disappearing out the double-doors, waving to me with a smile on her face.  What was the difference?

I had taken the time to build trust with her, teach her about the things that worried her, provided her with reassurance and education so she felt better prepared for the labor that was to come, and eased the worry from her mind.  And that rapport and confidence in one’s nurse can be some of the most potent pain relief of all.

Option #4: Your patient is being induced.

I know, I know. I added an option.  Now, this clearly doesn’t apply to Karen’s patient in the scenario above, but it does apply to many, many patients who will have babies in the US.  I hate to be the first to tell you this, but especially if you’re a first-time mom, induction can be painful.

First, before we even induce you, we have to check your cervix.  That involves a vaginal exam that can be rather unpleasant, especially if your cervix isn’t really ready for labor and is high in the vaginal vault and posterior (off to the back of baby’s presenting part–hopefully, the head!).  Cervical exams in this stage can feel like we’re reaching for your tonsils, and this is just the first of many.

If your cervix isn’t soft and dilated to a certain degree, we will likely choose to give you medication that will make your cervix thin and dilate before we start an IV medication like Pitocin to start, strengthen and stimulate contractions.  The reason being, if your cervix isn’t soft and thinned to a certain degree, it probably won’t open, even if we do get your contractions nice and strong and regular.

These medications are usually given vaginally, so that means another vaginal exam AND the added bonus of receiving a medication that can make you raw and sensitive in the area from which that you’re soon to push a baby.  Note that you can get multiple doses all of these drugs, and you will get more and more sensitive with each dose.  You will also get rechecked with each dose, so chalk up another vaginal exam with every drug.

If your cervix is stubborn and doesn’t want to change with medication, there is a method that is commonly used to manually (physically) dilate a cervix.  Some physicians will attempt to manually dilate digitally (with their fingers), but many will attempt to place a little balloon in the cervix, inflate the balloon, and therefore manually dilate the cervix.  If you thought the drugs were painful, I’d suggest before they use the foley balloon on you that you request to be discharge, pack your bags, and go home assuming you and baby are medically cleared.  (**Little known fact: as long as your water isn’t broken and you and baby are deemed safe after 1-2 hours of observation, this is perfectly acceptable!**)

When your cervix is favorable, unless you are already contracting steadily on your own, Pitocin is next on the list.  This is an IV drug that will make your contractions stronger, closer together, and more regular.  Those super-charged contractions are going to push baby down on what is likely a very sore private area, and most women who undergo inductions typically elect to receive epidurals so that they don’t end up experiencing the full scope of pain involved in induction.

So, with all that said, if your patient is presenting with higher levels of pain than what you’d expect, ask yourself the question: was she induced/is she being induced?  And if so, what with?

To Conclude…

Pain is a vital part of assessing patients in labor, but there is an added component of assessing a laboring patient for pain that the current pain scale model does not adequately encompass.  As a result, the nurse must compensate for this lack when talking with a laboring patient about pain.

To get an accurate pain assessment, make sure your patient feels as supported and informed in her care as possible.  Do your best to encourage and educate her if you sense her tolerance for pain is limited.  Be aware of treatments and medications that may cause the patient’s pain rating to be higher (or lower!) than expected.And of course, don’t dismiss a patient’s reports of increasing amounts of pain as blowing smoke unless you’re ready to catch!