The Birth 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 Birth Notes should be completed.

The intrapartum period is relatively short but requires close observation and monitoring and it is therefore important to have a comprehensive document that supports care provision and facilitates communication between the multi-disciplinary team.

The Birth 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 labour, taking into account all risk factors identified during the antenatal period. This facilitates the identification of an appropriate maternity care pathway and therefore a clear, individualised management plan can be documented ensuring safe, high quality maternity care. The management plan should be amended throughout the intrapartum period to reflect the woman’s individual changing needs.

Prompts in the notes enable clinicians to monitor progress and undertake risk assessments at appropriate points in labour. The partogram provides a clear demonstration of the journey through labour, with maternal pulse and fetal heart being adjacent thereby facilitating early identification of concerns and the cervicogram clearly demonstrating an obstructed labour.

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 improved communication assists in reducing harm and avoidable loss. The completed Birth Notes provide an accurate, contemporaneous record of the clinical care provided and represents the chronological process of labour.

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

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