Best Practices to establish baseline and document the FHT range

Question:

Today we have a question from Alana Damos, a midwife practicing in CA.

Having the steps laid out this way is very helpful. Thanks for taking the time and effort to simplify this information and have it easy to carry around with us. I do have some questions about establishing a baseline as I was just trying to establish it a different way. I can imagine listening for 10 minutes consecutively when I first arrive at my client's home, but I cannot really imagine listening for a full 10 minutes every time I want to reestablish baseline, which I typically try to do every 2 hours. Can you please offer some feedback and insight on what that looks like in your practice Augustine?

Answer:

Baseline is the foundation of what you know to be that baby's normal before there are any contractions and before there's any hard labor. We established a baseline when we first meet the client and it takes at least 10 minutes of consecutive listening to establish. It only works if we keep the baby on the monitor the whole time. If the baby's moving and falls off or the mom's moving and you can't continuously listen, you might need to listen longer than that. Or if there is marked variability. In other words, the range of the fetal heart tones lasts is higher than 25 beats per minute. You can't establish a baseline, so you would need to listen longer.

A decel and an accel are defined as FHT more than 15 beats off baseline for more than 15 seconds.

So let's say that we found a baseline of 140. Then the baby's upper range is 155 and that baby's lower range is 125. The variation in that babies heart rate isn’t more than 15 beats in any direction, so that's the normal range for this baby. Every time you go back to listen, let's say we're in active labor, so we're listening every 30 minutes. If we find a general number within these two range points, then the baseline is the same. There are no decels, there are no accels, we look for moderate variability that there are at least five to six beats difference, but not more than 25.

Category one in the NICHD assessment is that there's no decels, there may be accels, there's no bradycardia, there's no tachycardia, and baseline is between 110-160 and we have a normal variability. You could go on for hours, maybe eight or even 10 hours of active labor management checking every 30 minutes for at least 30 seconds (but hopefully 2 minutes at the end of a contraction to catch late decels) getting a baby in that normal range with moderate variability. And you could not reestablish a baseline because there isn't a new baseline because every check puts the baby back in that same range.

If, however, you came back and listened at that end of a contraction or through a whole contraction and the baby's baseline was 140 and now you're getting 160, 162, 165, 155, 160, 162, that is a different range. It's outside of that baby's normal range. So that is the time when you would be asked to reestablish baseline or conversely in the other direction, you could listen and you could go back in and you get a baby who's consistently 120, 117 120.

Now your question is, is there a new baseline? Are we having decels? Are we actually catching an accel from a baby who's now bradycardic right?

So there are lots of questions and we need to reestablish a baseline. So baseline does not need to be reestablished every 2 hours and it in fact does not need to be reestablished if we have a normal range compared to the original baseline. I hope that makes sense. It can be complicated, but once you put it into action, it's pretty straightforward.

Question:

Alana has a second part to her question, and it's, "I am also curious about how best to document the FHT range when we hear deep blips that do not count as decelerations. For instance, you may only get a six-second count of eight only one time and then have the majority of your counts be in the 13 to 15 range. I feel a bit indiscriminating to document my range 80 to 150 which looks like nasty marked variability when that blip I heard was only 6 seconds. Any thoughts on this?

Answer:

It's a great question. I actually get this question a lot and I feel a little conflicted about it. So let me explain my reasoning.

I think that we actually should record the range that we hear, even if it includes steep variations. Unfortunately, I do know that many parts of the country are highly litigious and very discriminatory towards the midwifery model of care in general and that if you did write that 80 to 150, someone might think you're missing something really important.

So I would say I want midwives to use their best judgment given the environment that they're practicing in, and I wish that we could be respected for the skill that we have. I wish that we could be trusted in our assessment, but unfortunately, that's not always happening. So in an ideal world, you would write 80 to 150 comma moderate variability, comma no decels osculated. And that would be the clarity to someone reading that to say, Oh, this baby is having a dip, but it's not a technical decel, and this is not the huge range. It just occasionally drifts like that or even goes higher. And of course, you would want to include the baseline first in that 140 comma 80 to 150, moderate variability, no decels.

However, if that would be a red flag in some kind of an investigative place or a transport even then I invite you to use your best judgment and record data that supports your assessment, not necessarily all the details you found. So if your assessment is that this is a Category 1 baby, they have no crisis going on, then it's not actually a decel. There's no bradycardia. We have a baby's recovering well, maybe having early decels, something where it's very, very obvious this baby's fine. Then instead you could write a conglomeration of the most often beated number. So something you might rate is 140s with a comma moderate variability. And then you're writing the most often beated number. You're not really lying. You're just omitting some of the details that might later be used against you for people that don't understand out-of-hospital fetal monitoring.

So an alternate way to chart this is : 140b, 140s to 150s, moderate variability, no decels.

This style omits that one little blip as you call it that could again potentially if they didn't trust your ability to assess decels be used against you.

So it is a tricky place when it comes to best Practices to establish baseline and document the FHT range.

I appreciate these questions so much. Thanks again for sending them in. If any of you are listening or watching and you want to know more, you want to have a question of your own answered, feel free to send that in. We're on all social media platforms @midwiferywisdom and of course on the website www.midwiferywisdom.com

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