Whether you’re interested in becoming a labor and delivery nurse or are just trying to survive your L&D rotation, you will at some point come into contact with fetal heart rate monitoring and the VEAL CHOP mnemonic. If you’ve never heard of fetal heart rate monitoring and have no idea what a fetal heart rate pattern is, stick with me on this one.
I will preface this by saying I am not a labor and delivery nurse, but I’ll be damned if I’m not a pro at researching information I’m not clear on!
What is Fetal Heart Rate Monitoring?
Fetal heart rate monitoring is performed by healthcare providers during pregnancy. It is a way to measure the heart rate and rhythm of a baby (while said baby is still in the womb). Pretty neat, huh? According to Johns Hopkins, the idea behind fetal heart rate monitoring is this:
The average fetal heart rate is between 110 and 160 beats per minute. It can vary by 5 to 25 beats per minute. The fetal heart rate may change as your baby responds to conditions in your uterus.
Babies are often considered tachycardic if their fetal heart rate baseline is greater than 160 bpm, and bradycardic if less than 110 bpm.
Just like in adults, determining fetal heart rate patterns can tell you some important information about how the fetus is doing in the womb. Assessing how well the baby is handling what’s going on in the uterus can help prevent complications like fetal hypoxia, and allow you to intervene before anyone has to suffer catastrophic birth complications.
Some other terms you might see when it comes to fetal heart rate monitoring include electronic fetal monitoring (EFM), fetal heart rate (FHR), and maternal heart rate (MHR).
There are two main ways to perform fetal heart rate monitoring: External or internal.
External fetal heart rate monitoring
External fetal heart rate monitoring is by far the least invasive way to assess fetal heart rate patterns. When you see a healthcare professional performing a Doppler ultrasound during a routine prenatal visit, this is a method of external fetal heart rate monitoring. When a woman is in labor and gets a monitor strapped to her belly, this is another method of external fetal heart rate monitoring.
One downside to this type of monitoring is the amount of interference that can occur as mom or baby moves. It can be scary when the baby changes position and you are suddenly unable to hear the heartbeat (even if it’s still there). It’s very important to have the monitors placed appropriately to avoid unnecessary scares.
Internal fetal heart rate monitoring
Internal fetal heart rate monitoring is far more invasive and is therefore reserved for more cases where there is a higher risk for complications. This method involves placing an electrode (which is pushed through the cervix) onto the baby’s scalp. If you’re wondering why you would ever opt for this when external fetal heart rate monitoring is an option, it’s usually because
This method gives better readings because things like movement don’t affect it. But it can only be done if the fluid-filled sac that surrounds the baby during pregnancy (amniotic sac) has broken and the cervix is opened. Your provider may use internal monitoring when external monitoring is not giving a good reading. Or your provider may use this method to watch your baby more closely during labor
Providers may also place an internal monitor on the mom’s uterus to measure contractions. This is often referred to as an intrauterine catheter.
Now that we’ve got the basics down, let’s see how the VEAL CHOP nursing mnemonic comes into play.
What is the VEAL CHOP nursing mnemonic?
As you well know, nursing mnemonics are one of the best ways to survive nursing school. When it comes to fetal heart rate monitoring, whoever came up with VEAL CHOP was definitely onto something. There are tons of different complications and nursing interventions to remember when observing fetal heart rate patterns. The VEAL CHOP nursing mnemonic is designed to help you remember the different fetal heart rate patterns and their potential causes.
The image below gives you a great idea of what VEAL CHOP stands for:
VEAL CHOP is often (but not always) accompanied by MINE, which also includes nursing interventions for the various fetal heart rate patterns. As always, allow me to explain.
How is VEAL CHOP Nursing Mnemonic Used?
The best way I can describe how to use VEAL CHOP (MINE) is with the following image from Nurseslabs
To use this chart, start on the left side and work your way across to the right. For example, if you identify a variable deceleration (V), then the cause might be cord compression (C), and your nursing intervention would be maternal repositioning (M). Once you get the hang of it and can remember the basic premise, it’s actually quite simple!
VEAL CHOP nursing interventions – “MINE”
We often only use the VEAL CHOP nursing mnemonic, but there’s an important third part: “MINE”. If you’re going to work in a labor and delivery setting at any point, it’s important to know the last portion of the VEAL CHOP mnemonic. If you’re a visual learner like I am, then your best bet is to write down a chart like the one above and keep it on you as a cheat sheet.
In the interest of making sure you can put it all together, I’m listing all the components of VEAL CHOP MINE together for you here.
Understanding VEAL CHOP
HOKAY so now we know what VEAL CHOP stands for. Let’s take a look at how to use it. If you’re a visual learner like me, this overview of what different fetal heart rate decelerations look like is very helpful.
In explaining these to you, I am using the American College of Obstetricians and Gynecologists (ACOG) and perinatology.com as my sources to give you the most accurate description.
V: Variable decelerations + C: Cord Compression + M: Maternal repositioning
What variable decelerations are
Decrease in FHR by 15 bpm or greater, lasting greater than (or equal to) 15 seconds, but less than 2 minutes in duration.
Onset, depth, and duration vary with each uterine contraction.
With variable declarations, there isn’t a rhyme or reason to the declarations, and it’s much harder to determine a pattern for them. The important thing about this is the FHR always recovers (this pattern lasts less than 2 minutes).
Causes of variable decelerations: Cord compression
Think of things that impact or compress the umbilical cord, like
- Knot in the umbilical cord
- Premature rupture of membranes (PROM)
- Fetal or maternal position
- Umbilical cord prolapse
- The nuchal cord becoming entangled (for example the umbilical cord twists around the baby’s body part)
The American Pregnancy Association states that “cord compressions will occur during labor with most of those being mild and of less concern”. If left untreated, however, this can progress to an emergency, so it’s important to think of it as a possible cause. In some cases, this can progress to requiring an emergency cesarean birth.
Nursing interventions: Maternal repositioning
The idea is to relieve umbilical cord compression. The fastest and least invasive way to try this is by maternal repositioning.
- Flip mom onto her side or into Trendelenburg position
- Discontinue oxytocin or anything placing an extra “squeeze” on the baby’s head
- Check for cord prolapse or imminent delivery by vaginal exam
- Give oxygen to Mama
E: Early decelerations + H: Head compression + I: Identify labor progress
What early decelerations are
Symmetrical, gradual decrease (and return) of the FHR associated with a uterine contraction.
You might hear the term “Nadir of the (fetal) deceleration.” This is the peak of the uterine contraction.
See how the fetal heart rate is at its lowest point during the peak of the uterine contraction? That’s all this means.
Causes of early decelerations: Head compression
The biggest cause of early decelerations (and head compression) is labor. Baby’s head can undergo compression as it tries to descend into the birth canal. This can be slightly more common in premature labor or babies in a transverse or breech position.
Nursing interventions: Identify labor progress
This NIH article gives a great overview of early decelerations and their nursing interventions:
As early decelerations are not associated with decreased fetal oxygenation or metabolic acidosis, they do not require any treatment. However, it is crucial to continue to monitor FHR tracings throughout labor to recognize any patterns that may be a concern regarding changes in the acid-base status of the fetus.
Checking how far along mom is during labor and further assessing if any interventions are needed is usually sufficient for early decelerations.
A: Accelerations + O: Oxygenated or ok + N: No interventions
What accelerations are
Visually apparent, abrupt (onset to peak < 30 seconds) increase in FHR from baseline.
The ACOG differentiates accelerations based on estimated gestational age (EGA). They state
- < 32 weeks EGA: peak ≥ 10 bpm above baseline, duration ≥ 10 seconds but < 2 minutes from onset of the acceleration to return to baseline.
- ≥ 32 weeks EGA: peak ≥ 15 bpm above baseline, duration ≥ 15 seconds but < 2 minutes from onset of the acceleration to return to baseline.
If you’re finding all of these descriptions too complicated (honestly same), the important thing to know is that fetal accelerations are a GOOD thing and are completely normal. If you see an increase in FHR by about 15 bpm and it lasts for 15 seconds, you probably have a fetal heart rate acceleration on your hands!
Causes of accelerations: Oxygenated or OK (aka normal)
Babies living their best life in utero. Seriously, accelerations are a good thing as long as they meet the above criteria. A normal fetal heart will have some accelerations.
Nursing interventions: None (…unless you don’t see any accelerations)
Since we want to see accelerations, your nursing interventions might include things that would increase the baby’s heart rate. Unlike decelerations, you’re trying to induce accelerations (not remove them). Some methods for this include:
- Give mom a glass of ice water or something sugary like orange juice (probably the most effective intervention I’ve seen used)
- Rocking moms abdomen
- Pressing on baby’s head through the cervix (although to be honest if you did this to me during my labor I’d probably slap you)
L: Late decelerations + P: Placental insufficiency + E: Execute Interventions
What late decelerations are
Onset, nadir, and recovery of the deceleration occur after the beginning, peak, and ending of the contraction, respectively.
Basically, late decelerations occur slightly after the uterine contraction, and they are generally not ideal.
You do not want to see a late deceleration. Per the NIH:
Late decelerations are one of the precarious decelerations among the three types of fetal heart rate decelerations during labor. They are caused by decreased blood flow to the placenta and can signify an impending fetal acidemia.
Causes of late decelerations: Placental insufficiency
If you see a late deceleration, think placenta! Anything that limits oxygen to mom (and therefore to the placenta) is much more emergent than some of these other decelerations.
- Excessive uterine contractions (think lots of contractions with no rest, as is the case with some induction medications).
- Maternal complications such as hypotension, hypoxemia, hypertension, or diabetes.
- Reduced blood supply to the placenta including conditions like intrauterine growth restriction (IUGR) or placental abruption.
Nursing interventions: Execute interventions ASAP
- Place mom on her left or right side or knee-chest position (to increase blood flow to the placenta)
- Discontinue oxytocin or any current medications that cause the uterus to contract
- Correct any hypotension with IV hydration
- Administer O2
- Anticipate emergency vaginal delivery or c-section if unrelieved
If none of this makes sense and you’re still a tad confused, here’s another great visual comparing the VEAL CHOP nursing mnemonic patterns.
I know this stuff can be pretty complicated, but remember that it takes practice to learn and respond to these things. Unless you’re working in an L&D setting every day, you will likely not have to know this by heart. You got this!
I hope this description of the VEAL CHOP nursing mnemonic was everything you hoped for and more. Remember to check out more great information on nursing school topics HERE.Â
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