Looking for others policy on documentation of FHR during second stage of labor (with urge to bear down) if on continuous fetal monitoring- one source states "FHR must be evaluated every 5 min" Do others document a FHR every 5 min on the record? If not every 5 min, how often?
Apr 10, '07
Where I work we usually document every 15 min during second stage (routine healthy mom and babe), however we are required to "evaluate q 5 min" AEB entering your initials or some note via the comupter on the FM strip q 5 min.
That said, in the midst of pushing and providing actual ongoing nursing care and labor support during this time, I often or should I say almost always forget or get too involved with my pt to actually make a note or even enter my initials, and I know I am not the only RN who doesn't do it.
I do however make note of any position change, change in pt's status, request for xyz, voids, or other interventions...even if I just manage to press the "mark" button so that I know what time it occured. In my narrative I usually have a note along the lines of "Pt continues to push effectively. Continuous bedside support provided by this RN."
Evaluation is not the same as documentation.
Apr 11, '07
It is very had to document that often, but i too make a note or hit the mark button or write on the strip. like the other day i had a thin mec but moderate variables, pt being amnioinfused, while pushing, baby having prolonged decels x 5 mins..etc etc. it is pretty hard at the time but obviously charting is not the priority at the time. if i have a really bad strip with lots of things going on i usually get help, or it is offered. while pushing with this particular pt, i made sure to also include things like interventions for IUR, pt pos, progress, Vitals, OB present, notified...good question though Jemma. I always wonder what other RNs do
Apr 11, '07
Our protocol is documenting q15 min during second stage unless high risk and then we are supposed to do q5 miin. I too find it very hard to do when you are pushing with a mom for over an hour... Our charting is still on paper so I do try to get everything on the strip so I can chart from that if unable to during the delivery (which is the case most of the time)
Apr 11, '07
rninwch hit the nail on the head! In the AWHONN IFMC (formerly FHMPP), i the documentation section, we teach that "assessments are conducted at intervals appropriate to maternal-fetal condition. Documentation does not necessarily have to occur at the same intervals for every patient. For example, a tracing may be evaluated at intervals such as every 30, 15 or 5 minutes, depending on the status of the patient. A summary statement that reflects this evaluation may then be documented in the maternal medical record based on facility protocol." For example: "RN remains at bedside and EFM is continually monitored during pushing." It is also pointed out that "... as long as the facility standard or policy meets minimum guidelines for care, the policy is appropriate. Policies and procedures that are too rigid to allow for individualized care should be avoided."
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