The Perinatal Institute has completed a set of notes to support good quality record keeping and aid supervision and training. The scenario is intended to show clinicians how the Postnatal Notes should be completed.

The notes have been designed to be used ensuring support for the mother-baby dyad whilst acknowledging they are individuals.

The Postnatal Notes have been developed in line with best practice and are based on the latest evidence and national recommendations. The notes support a comprehensive risk assessment at the onset of the postnatal period, taking into account all risk factors identified during the antenatal and intrapartum periods. This facilitates the delivery of an improved standard of care tailored to the individual needs of the mother, baby and family.

A clear, individualised management plan can be documented ensuring safe, high quality maternity care. The management plan should be reviewed/amended throughout the postnatal period to reflect the woman’s and baby's individual changing needs.

The notes are issued to the mother straight after delivery and are hand held; this approach facilitates communication between health care professionals and the woman. The time specific explanatory pages included within the notes are up-to-date evidence based to explain to women “what to expect” during the postnatal period, thus enabling women to be more informed and able to contribute to the decision making process.

Good record keeping is the cornerstone of best practice and has been repeatedly emphasised in patient safety reports. It is a fundamental component of excellence in maternity care provision and the improved communication assists in reducing harm and avoidable loss. The completed Postnatal Notes provide an accurate, contemporaneous record of the clinical care provided and represents the chronological process of the early postnatal period.

For further information, please contact the specialist midwives at the Perinatal Institute: notes@perinatal.org.uk