Postnatal Notes for Baby - Version 6.1B
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The new Postnatal Notes for Baby are to be used in conjunction with Postnatal Notes for Mother. The dual documents ensure support of the mother-baby dyad whilst acknowledging that mother and baby are individuals. At the end of the period of midwifery care, both booklets are returned to the unit for filing.

Where the baby is with carers other than the mother, the Postnatal Notes for Baby booklet stays with the baby. Where the baby is admitted for neonatal intensive care or transitional care, then the Postnatal Notes for Baby booklet can be used in conjunction with that documentation.

The new Postnatal Notes intend to facilitate delivery of an improved standard for postnatal care tailored to the individual needs of the woman, the baby and her family. They reflect the NHS Agenda around public health offering an equitable service which is accessible, flexible, and culturally sensitive. Evidence based information is provided to enable mothers and their families to make informed choices, allowing them to engage in their plan of care based on:

1. The Guideline for Routine Postnatal Care which supports the need for offering parents information and guidance to enable them to assess their baby’s condition, identify warning signs if their baby is unwell and how to contact a healthcare professional or emergency services if required [1, 2]. This requires:
- Effective transfer of information and communication at significant times
- A reduction in conflicting advice [3]
- Increased awareness of risk [4, 5]
- A reduction of poor postnatal outcomes [2]

2. The Children’s NSF which promotes individualised, multi-disciplinary management placing emphasis on
helping new parents prepare for parenthood [3]. This requires:
- Care that identifies and responds in a systematic way to babies’ health needs based on best evidence
- Parent education specifically to equip families with parenting skills
- Robust feedback of neonatal screening results
- Enhanced and extended post birth care
- Improved access and flexibility for all
- Extended service provision with local options for care

The postnatal notes provide prompts for identification of risk factors to enable action to be taken, by appropriate personnel, which can be communicated effectively, supported by efficient documentation of the management process [1, 3, 4, 6].

The new Postnatal Notes for Baby contain:

• 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 the postnatal period – e.g. general baby care, safety, infant feeding, sudden infant death [1, 6, 7].
• Further prompts to discuss individual needs.
• Information on neonatal screening tests consistent with aims of the National Child Health Screening Committee [8]; prompts to confirm that information has been given to allow informed choice.

References

1. Guideline for Routine Postnatal Care (NICE, June 2006)
2. Bick, Macarthur and Knowles et al. Postnatal Care. Evidence and Guidelines for Management. 2002
3. National Service Framework for Children, Young People and Maternity services. Standard 11, Maternity Services. www.dh.gov.uk/childrensnsf
4. Confidential Enquiry into Stillbirths and Death in Infancy – 8th Annual Report
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. UNICEF UK Baby Friendly Initiative – www.babyfriendly.org.uk
7. Department of Health. Reduce the risk of cot death – www.dh.gov.uk
8. National Child Health Screening Committee - www.nsc.nhs.uk


 

Page 1: Lists personal details, mothers name and contact number. The first feed summary is the documentation of the midwife’s assessment of the feed prior to leaving the mother and baby after a home birth or prior to transfer home or to the postnatal ward. There is space to record details of parent education relating to baby care and contact numbers for carers if the baby is not with the mother.
 
 
 
Page 2: Baby alerts are listed and any which apply to the baby are ringed. These are then transferred to the key to risk highlighting the need for vigilance, alerting carers to possible need for further investigations, treatment or referral. Clinical findings from the first baby assessment are completed after a home birth or prior to early transfer home or after admission to the postnatal ward. Page 3: Management plan provides space to document specific care requirements, based on the baby’s needs, also identified by the mother’s history, the baby alerts and key to risk. 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 4: Baby checks are outlined, including some of the more common postnatal complications. This text can be referred to as and when necessary, so that the mother has information to keep after it has been explained by the health professional.

Page 5: Provides space to record clinical findings from the assessments of baby well-being. Free text can also be documented in the tables.

 
 
 

Page 6: Baby checks are outlined, including some of the more common postnatal complications. This text can be referred to as and when necessary, so that the mother has information to keep after it has been explained by the health professional.

Page 7: Provides space to record clinical findings from the assessments of baby well-being. Free text can also be documented in the tables.

 
 
 

Page 8: Provides space to record clinical findings from the assessments of baby well-being. Free text can also be documented in the tables.

Notes Page in PDF
Pages 8 & 9

Page 9: Provides space to record clinical findings from the assessments of baby well-being. Free text can also be documented in the tables.

 
 
 

Page 10: Provides space to record clinical findings from the assessments of baby well-being. Free text can also be documented in the tables.

 

Notes Page in PDF
Pages 10 & 11

Page 11: Provides space to record clinical findings from the assessments of baby well-being. Free text can also be documented in the tables.

 
 
 

Pages 12: Provides space to record clinical findings from the assessments of baby well-being. Free text can also be documented in the tables. Follow-on sheets with a gummed strip are available, to be attached on top of this page, so that the most recent documentation is always on display.

Page 13: Free text pages for all professionals providing care to document chronologically the care during the postnatal period, over and above the space on the assessment of baby well-being pages.

 
 
 

Page 14: Free text pages for all professionals providing care to document chronologically the care during the postnatal period, over and above the space on the assessment of baby well-being pages.

Notes Page in PDF
Pages 14 & 15

Page 15: Free text pages for all professionals providing care to document chronologically the care during the postnatal period, over and above the space on the assessment of baby well-being pages. Follow-on sheets with a gummed strip are available, to be attached on top of this page, so that the most recent documentation is always on display. This page also has an important Special Features box for key points relating to risk factors. Detailed action plans as a result of problems can be recorded on the management plan (page 5).

 

 

 
 
 

Page 16: Information is provided on general baby care, including baby-led feeding, sleeping positions, taking the baby out and safety aspects relating to the dangers of sleeping with a baby.

Page 17: Information on breastfeeding, based on the Baby Friendly Initiative, includes the benefits for mother and baby, positioning and attachment, milk production and expressing.

 

 
 
 

Page 18:

Outlines the general principles of breastfeeding for mothers and provides a checklist for midwives to document that all information has been given to promote successful breastfeeding in line with UNICEF recommendations.

Pages 19: Outlines the general principles of bottle feeding for mothers and provides a checklist for midwives to document that all information has been given to promote successful bottle feeding in line with DOH recommendations.

 
 
 

Page 20: General information provided on important symptoms of some of the more common postnatal complications for babies. These can be referred to as and when necessary, so that the mother has access to written information. Details are also given on the potential healthcare professionals involved in postnatal care. How to register the birth is explained, with space provided to document local registration information.

Page 21:

Gives information on neonatal screening relating to the physical examination of the newborn, newborn hearing screen, blood spot test and early immunisations.

 
 
 
Page 22: Where the Personal Child Health Record (Red Book) is used, copies of page 3 and page 4 for the neonatal examination of the newborn are filled in and attached to page 22 using the gummed strip. Where the red book is not used, the findings are recorded directly onto page 22. Page 23: Where the Personal Child Health Record (Red Book) is used, copies of page 5 for baby discharge summary, early immunisations, and vitamin K, and copies of page 6 for newborn hearing screen are attached to page 23 using the gummed strip. Where the red book is not used, the findings are recorded directly onto page 23.
Page 24: Important symptoms and reducing the risk of cot death are highlighted with prompts for how to access help in an emergency. Space is provided to record the signatures of every professional who writes in these notes.

Page 24
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 Birth to Five 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.

 

 

 

 
© Perinatal Institute 2005