Pregnancy Notes Version 7.1
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The new Pregnancy Notes intend 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 new 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 a birth plan.
  • 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. The NHS Plan. www.nhs.uk/nationalplan/nhsplan.htm
2. Tackling Health Inequalities www.doh.gov.uk/healthinequalities
3. Building a safer NHS for patients. www.doh.gov.uk/buildsafenhs
4. Confidential Enquiry into Stillbirths and Death in Infancy - 8th Annual Report
Chapter 3, incl. Commentary on ‘Unexplained Stillbirths’ www.cemach.org.uk/publications
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 Deaths in the UK www.cemd.org.uk/
7. UNICEF UK Baby Friendly Initiative – www.babyfriendly.org.uk/commun.htm
8. ‘Smoking Kills’ Executive Summary, DoH: www.doh.gov.uk/tobacco/smokexec.htm
9. National screening committee www.nsc.nhs.uk/
10. Gardosi J & Francis A. Controlled trial of fundal height measurement plotted on customised antenatal growth charts. Br J Obstet Gynaecol 1999;106:309-17.
11. NICE Antenatal Care Clinical Guideline. October 2003 – www.nice.org.uk

PREGNANCY NOTES

NB - These notes are currently only drafted in English. We intend in future to include information in other languages.
Page 1: This lists various details as well as a 'plan of care' - including planned place of birth and lead professional - and space to list the reasons if the plan had to be changed.
 
 
 

Page 2: We ask about Ethnic Origin instead of Ethnic Group. ONS categories are less detailed but can be extracted. The classification here is consistent with coefficients for customised growth charts, and helps to identify the mothers who should be offered screening for haemoglobinopathies. This page also aims to record a number of socio-economic circumstances, and whether the mother can read and/or understand the writing.

Page 3: Details are asked about smoking, alcohol intake and drug use. Family history is in accordance with recommendations of the Joint Royal Colleges' working party on Medical Genetics

 
 
  

 

Page 4: Previous pregnancies:
An attempt is made to explain the relevance of most terms used on the opposite page when asking about the past obstetric history.

 

Page 5: Previous Births are listed, with space to summarise ante-and postnatal course etc. Early Pregnancy Losses are listed separately. Recording of TOPs is noted to be optional.

 
 
  

 

Page 6: Antenatal Screening - blood tests are explained, including the limitations of screening. Text follows current National Screening Committee guidelines. All tests offered on opposite page are listed.

 

Page 7: Prompts are provided to ensure that various tests have been discussed with the mother, and whether she has agreed. Space provided to record results of routine and any additional tests.

 
 
 

Page 8: Ultrasound investigations are described - reason for, 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.

Page 8 & 9
Pages 8 & 9

Page 9: Ultrasound measurements - recorded in tabular form, including estimated fetal weight which can be plotted on a customised growth chart. Note - Charts for BPD, HC AC, FL etc are not provided in the hand held notes as 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 units still wishing to plot head, abdomen or femur measurements individually can do so.
 
 
 

Page 10: Pregnancy Planner: Space to document visits schedule.Important symptoms including warning sign (headaches, decreased fetal movements etc) are explained, with prompts to confirm that they have been discussed.

Page 10 & 11
Pages 10 & 11

Page 11 Management Plan: Space to document specific care requirements, based on the individual's needs.
 
 
  

Page 12:  The nature of Antenatal Checks are explained, fetal growth monitoring and customised growth charts are explained. The software is available free from www.gestation.net with software support provided by the Perinatal Institute.

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 means of 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 software also calculates BMI.

Page 14 & 15
Pages 14 & 15

Page 15: Provides space to record clinical findings from antenatal visits. Follow-on sheets with a gummed strip will be available, to be attached on top, so that the current recording is always on display.
 
 
  
Page 16: Includes an explanation of some of the more common pregnancy 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.

Page 17: Summary of day unit or inpatient episodes can be recorded. Top of page 17 has an important Special Features box for risk factors and action plans.
 
 
  
Page 18: This gives general pregnancy information incl public health messages - smoking, diet, domestic violence and breastfeeding. Page 19: A series of prompts to discuss the issues which are summarised on the opposite page, with space for maternal intentions and action plans. Includes also all points of the Baby Friendly Initiative for breast feeding
 
 
  
Page 20: Explanations and prompts for discussion about labour and birth - e.g. where to have the baby; fetal monitoring, pain relief options, details of what to expect if operative delivery is needed etc. Page 21: A series of prompts to discuss the issues which are summarised on the opposite page, with space to record preferences - thus formulating a Birth Plan.
 
 
  
Page 22 - Appointments and why they have been given; Section for recording the signature of every professional who writes in these notes; and a list of support groups, with space to add more. NOTE: On the bottom of each information page, there is reference to a web address, www.preg.info which mothers will be able to look up for further information; professionals will also find references and links to evidence and guidelines for the statements made in these pages.

 

 

 

  
© Perinatal Institute 2005