The Pregnancy Notes Exemplar

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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 Pregnancy Notes should be completed.

The Pregnancy Notes have been developed in line with best practice and are based on the latest evidence and national recommendations. One of the principle aims is to facilitate a partnership between the principle stakeholders in antenatal care – mother, baby and care providers. The notes place emphasis on patient safety and informed choice. The notes are designed to facilitate comprehensive history taking, promote effective communication between the mother and multi-disciplinary team.

Good history taking in early pregnancy is the foundation on which maternity care is built. The correct use of the Pregnancy notes ensures that the woman’s needs are assessed holistically, including her physical health, medical history, social circumstances, psychological well-being and educational needs.

Vulnerable women such as those who cannot speak English, migrant mothers, families known to social care and women who misuse illegal drugs and are alcohol dependant are known to have poorer pregnancy outcomes. It is imperative that maternity care provision is sensitive to the individual needs of the mother and her family, in order to minimise difficulties in both accessing and maintaining contact with maternity services.

The comprehensive risk assessment identifies individual risk factors for the expectant mother; thus assisting identification of the correct maternity pathway for her. This information should then be used to develop a management plan individualised to the needs of the women, ensuring safe, high quality maternity care.

The notes are hand held by the expectant mother. This approach encourages two-way communication, so the expectant mother and her family are fully informed and able to contribute to the decision making process. All clinical care and management plans are documented within the hand held record encouraging openness and transparency. Effective communication within the multi-disciplinary team helps to prevent avoidable loss and accurate, contemporaneous record keeping is a fundamental component of good maternity practice.

For further information, please contact the specialist midwives at the Perinatal Institute:

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