Pregnancy
Notes Version 9.1 - Updated January 2009
Pages from the notes
The Pregnancy Notes aim to facilitate a partnership
between the principal stakeholders in antenatal
care – mother, baby and care provider – and
place emphasis on patient safety and informed
choice. Their aims correspond to those of the
NHS Agenda:
1. The NHS National Plan [1] promotes
many objectives relevant to maternity, including
- partnership:
seeking to make all parts of the health and social
care system work better together
- patient care: informing
and empowering expectant mothers so that they can be more involved
- prevention: focusing
the health system on the causes of ill health
2. There is a concerted effort towards Tackling
Health Inequalities and on providing a
sure foundation through a healthy pregnancy
and early childhood [2]. The Notes place emphasis
on tailoring care, and on the importance of
individual needs in a multicultural maternity
population.
3. ‘Building a Safer NHS for Patients’ has
aims to reduce the occurrence of avoidable harm
[3]. Many instances of adverse perinatal outcome
are potentially avoidable [4] and are often linked
to lack of communication. The hand-held maternity
record is an important means of communication
between care providers. Furthermore, mothers
are engaged in the process and are able to understand
and monitor their care. Prompts for care providers
to record that information has actually been
given is also likely to reduce litigation.
The Pregnancy Notes contain:
Ample explanatory notes on ‘what to
expect’. Mothers want ‘information
that is up-to-date and evidence based, answers
common problems, discuss options and offers
practical advice’; socially disadvantaged
mothers want at least as much information as
other groups [5].
Prompts for midwives to
discuss various public health issues which
are relevant during pregnancy – e.g.
employment rights, emotional support and
domestic violence [6], the baby friendly
initiative [7], smoking cessation [8].
Further prompts to discuss
individual needs, access to services, and
preferences for birth.
Information on antenatal
screening tests consistent with aims of the
National Screening Committee [9]; prompts
to confirm that information has been given
to allow informed choice.
Details of family history
consistent with recommendations from working
party of the Joint Royal College Committee
on Medical Genetics.
An emphasis on improved
fetal growth screening, consistent with lessons
from analyses of perinatal mortality [4].
The Notes incorporate ‘customised antenatal
growth charts’ which adjust for individual
maternal variation due to constitutional
differences, ethnic group etc. The use of
these charts improves the detection of fetal
growth problems and reduces unnecessary investigations
and admissions to hospital [10].
Guidance for professionals
in accordance with recommendations outlined
by NICE [11].
REFERENCES
1.
Department of Health (2004) The NHS Plan www.dh.gov.uk
2.
Department of Health (2003) Tackling
health inequalities www.dh.gov.uk
3.
Department of Health (2001) Building
a safer NHS www.dh.gov.uk
4.
Confidential Enquiry into Stillbirths
and Death in Infancy (2001) - 8th Annual
Report Chapter 3, incl. Commentary
on ‘Unexplained Stillbirths ’www.cemach.org.uk
5.
Singh d & Newburn M. 2000. Access
to Maternity Information and Support. Experiences
and needs of women before and after giving
birth. National Childbirth Trust, London
6.
Confidential Enquiry into maternal and
child Health (2007) - Saving Mothers’ Lives:
Reviewing maternal deaths to make motherhood
safer - 2003-2005. www.cemach.org.uk
Page 1: Lists
personal details as well as a 'plan
of care' - including planned
place of birth and lead professional
- and place to record reasons if
the plan had to be changed.
Pages 2 & 3:Booking
Assessment, details are asked
about medical, social and mental
health history including smoking,
alcohol intake, and drug use. There
is space to repeat the assessments
twice more during the pregnancy.
We ask about Ethnic Origin instead
of Ethnic Group. The classification
is needed for customised growth
charts, and to identify who should
be offered screening for haemoglobinopathies. Family
history is in accordance
with recommendations of the Joint
Royal Colleges' working party
on Medical Genetics.
Pages 4 & 5:Previous
pregnancies: An explanation
of the terms and their relevance
to this pregnancy is given. There
is space to summarise ante-and
postnatal care etc. Early pregnancy
losses are listed separately.
Pages 6 & 7:Antenatal
Screening: Investigations
are explained, including the
limitations of screening. Text
follows current National Screening
Committee guidelines. Prompts
are provided to ensure that various
tests have been discussed with
the mother, and whether she agrees
to have them.
Pages 8 & 9:
Ultrasound: Investigations
are described - reason, possible
findings, accuracy etc. Prompts
to discuss implications and
whether mother has agreed.
Reasons for the preferred method
of dating pregnancy by ultrasound,
is explained. Diagnostic tests
under ultrasound control (CVS,
amniocentesis) are described.
Ultrasound measurements are
recorded in tabular form, including
estimated fetal weight which
can be plotted on customised
growth chart. NB - Charts for
BPD, HC AC, FL etc are not
provided in the hand held notes
as there is no evidence that
their plotting in third trimester
offers additional value, and
erroneous measurements outside
of the normal range can cause
unnecessary concern. However
any unit still wishing to plot
head, abdomen or femur measurements
individually can do so.
Pages 10 & 11: In
line with NHS Information Authority
guidance on patient data collection,
space is included to record that
discussion has taken place. Pregnancy
planner: Space to document
visit schedule. Important
symptoms including warning
signs (headaches, decreased fetal
movements etc) are explained,
with prompts to confirm that
they have been discussed. Risk
Assessment: space to document
any risks identified. Management
Plan: space to document specific
care requirements, based on the
individual’s needs.
Page 13: This page
(the reverse of the sheet on which
the growth chart is printed out
and attached into the notes) is
blank and can be 'customised' according
to each individual unit's wishes.
Page 14: The customised
growth chart is generated
after the pregnancy dates have
been determined by ultrasound,
and attached in the notes by
the adhesive strip on page 12.
The chart can be used for plotting
fundal height and estimated fetal
weight and is printed with the
gestation week as well as the
actual date (day, month), calculated
by the computer from the given
EDD. The program also calculates BMI. The
software is available free from www.gestation.net with software support
provided by the Perinatal Institute.
Page 15: Provides
space to record clinical findings
from antenatal visits. Follow-on
sheets with a gummed strip are
available, to be attached on top,
so that the most recent documentation
is always on display.
Pages 16 & 17: Includes
an explanation of some of the more
common pregnancy symptoms and
complications. These can be
referred to as and when necessary,
so that the expectant mother has
some information to take away with
her after it has been explained.
On the right, summaries of contacts
with other health professionals
such as day unit, inpatient episodes
or contacts with external agencies
can be recorded. An important Special
Features box for risk factors
and action plans is on the top
of page 17.
Pages 18 &19 : gives
general pregnancy information and public
health messages - smoking, diet,
domestic violence, and prompts for
discussion between midwife and expectant
mother, with space to record maternal
preferences, which can be discussed
at any point in the pregnancy. Also
included is information from the Baby
Friendly Initiative for breast
feeding and prompts for preparing
for your new baby.
Pages 20 & 21: Explanations
and choices about labour and birth -
where to have the baby; fetal monitoring,
pain relief etc, and prompts for
discussion, with space to record
maternal preferences.
Page 22:Appointments and
why they have been given; section
for recording signatures of
every professional who writes in
these notes; and a list of support
groups, with space to add more.
NOTE: Frequent
reference is made to the web address, www.preg.info where mothers and professionals
are able to gather further information.
It also has a link to the DOH website,
allowing mothers to view the Pregnancy
Book using a search engine to access
individual topics. For professionals,
there are references and links to
evidence and guidelines to support
the statements made in the Notes.
