Reading Your Records guide

The monitoring strip

Four things to read. ^{1 4}

Baseline rate. The average over 10 minutes. Normal is 110 to 160 beats per minute.

Variability. The small wiggle from moment to moment. Moderate variability is reassuring.

Accelerations. Brief rises. Generally a good sign.

Decelerations. Early ones mirror the contraction and are not concerning. Variable ones are abrupt drops, usually cord compression. Late ones begin after the contraction starts and recover after it ends.

Count contractions. Pick any 10 minute window and count the peaks. More than five, averaged over 30 minutes, is tachysystole.

Write down the times when anything changed.

The notes beside it

Take the times from the strip and find them in the nursing notes.

Look for what was seen, what was done, when a physician was notified, when they responded, and the time any decision was made. ⁵

The numbers at birth

Apgar at 1, 5 and 10 minutes. The 10 minute score is the one most linked to outlook. ²

Cord blood gas, arterial and venous. pH, base deficit, lactate. Guidance describes an umbilical artery pH below 7.0 with a base deficit of 12 mmol per litre or more as one of the findings associated with an acute event around the time of birth. ³

Resuscitation record. The time of birth, the time ventilation started, the time compressions started, and who was present. ⁶

The placental pathology report

Usually filed separately from both charts, and often the most informative document in the whole record, because it describes the weeks and months before labor rather than the hours during it. ³

It can show infection of the membranes, clots, long-standing poor blood flow, and evidence of abruption.

Build one timeline

One line per event, in time order, pulling from every document.

Time / what happened / which document it came from

A timeline lets you ask precise questions. It cannot tell you whether the care met the standard. That takes a physician expert who reviews the whole record. ³