Documenting decelerations

[theamberdawns]

Today while I was taking a fetal monitoring course the instructor said that if she was documenting on a fetal strip and there was ONE late deceleration noted she would not document it unless the majority >50% of contractions had a late decelerations that followed.

What do you think? I have always documented all types of decelerations.....am I over charting?

[magicsauce]

Is there really such a thing as over documentation when it comes to decels? I would document what I saw, whether it was an early, variable, or late. Establishing a pattern for decels is key in determining fetal well being so I would say chart away :) They always said to make sure your documentation could paint a picture for someone reading the chart, so the more you document, the clearer that picture is. Especially if the strip were to ever end up in litigation.

[CEG]

While I wouldn't necessarily take any action based on seeing one decel I would document it. I would certainly both take action and document if 50% of contractions had decels. That seems a little off to me. Did she say what the course recommended? I would think both in terms of fetal well-being and in terms of liability you would want to make it clear that you were aware of what was there, documented it and did what you felt was appropriate. I think if 1/4 of all contractions had a late deceleration I would be letting the provider know, etc, not pretend it wasn't happening.

[babyktchr, BSN, RN]

Oh dear. Documenting and doing something about it certainly are two different things. You certainly should be documenting decels no matter what kind they are, and describing them. Now, I would not necessarily do something about ONE decel (no matter what the type is) but it does warrant further observation.

I am an AWHONN instructor and this is NOT what is taught in either the intermediate or advanced courses. It sounds like there is some kind of misinterpretation of NICHD nomenclature. You would deem something as "recurrent" if it is associated with >50% of contractions.

Keep in mind when dealing with decels the physiology assoicated with the kind of decel you are seeing and look at the big picture instead of focusing on the decel itself.

[SmilingBluEyes]

I would document I observed it and if they recur, document what I am doing about the situation.