Postnatal Notes for Baby - Version 10.1B
Pages from the notes

 

 
 
Home
About the Notes
Postnatal Notes Survey

Results of the Field Trial

View the Pages for Mother
View the Pages for Baby
Information for Professionals
Training Information
Birth to Five Book
Costs and Ordering
Consent Protocol
Feedback

 

 

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 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


Version 10.1 (February 2010)

 

Page 1: Lists personal details, mothers name and number and parent’s contact number. Space to document first and second feed summary. Section to record details of parent education relating to baby care. Contact numbers for carers if the baby is not with the mother.
 
 
 
Page 2: Baby alerts are listed and any which apply are ringed and are transferred to the key to risk highlighting the need for vigilance, alerting carers to the possible need for further investigations, treatment or referral. There is a space to record if no alerts are identified. Clinical findings from the first baby assessment and Vitamin K administration are recorded here. Page 3: Management plan provides space to document specific care requirements based on the baby’s needs, significant maternal history, the baby alerts and key to risk. Neonatal investigations can be recorded here.
 
 
 

Page 4: Written information for parents to support the purpose of Baby checks and common postnatal complications.

 

Page 5: Written information for parents to support the purpose of Baby checks and common postnatal complications.

 

 
 
 

Page 6: Provides space to record clinical findings on the assessment of baby well-being stickers. Free text can also be documented contemporaneously.

Page 7: Provides space to record clinical findings on the assessment of baby well-being stickers. Free text can also be documented contemporaneously.

 
 
 

Page 8: Provides space to record clinical findings on the assessment of baby well-being stickers. Free text can also be documented contemporaneously.

Notes Page in PDF
Pages 8 & 9

Page 9: Provides space to record clinical findings on the assessment of baby well-being stickers. Free text can also be documented contemporaneously.

 
 
 

Page 10: Provides space to record clinical findings on the assessment of baby well-being stickers. Free text can also be documented contemporaneously.

 

Notes Page in PDF
Pages 10 & 11

 

Page 11: Includes a Special Features box for documenting key points relating to risk factors. The parent’s page is for parents to record concerns or questions they may have thereby engaging them in care planning.

 

 
 
 

Page 12: Information is provided on general baby care and safety. The Birth to five book is referenced for more information.

 

Page 13: Information on breastfeeding, based on the Baby Friendly Initiative, includes the benefits for mother and baby, positioning and attachment, milk production, expressing and storage of breast milk.

 
 
 

Page 14: Information on the general principles of breastfeeding and a checklist for midwives to document that all information has been given in line with UNICEF recommendations.

Notes Page in PDF
Pages 14 & 15

Page 15: Outlines the general principles of bottle feeding for mothers and a checklist for midwives to document that all information has been given to promote safe bottle feeding in line with DH recommendations.

 
 
 

Page 16: Written information for parents on important symptoms of common postnatal complications for babies. Details about potential healthcare professionals involved in postnatal care and how to access a supervisor of midwives. How to register the birth is explained, with space to document local information.

Page 17: Information on neonatal screening relating to the physical examination of the newborn, newborn hearing screen, blood spot test and early immunisations.

 
 
 

Page 18 and 19: Where the Personal Child Health Record (PCHR) is used, copies of page 3, 4, 5 and 6 for the neonatal examination of the newborn, baby discharge summary, early immunisations, vitamin K and newborn hearing screen are filled in and attached here using the gummed strip. Where the PCHR has not yet been issued the findings can be recorded directly onto these pages.

Page 18 and 19: Where the Personal Child Health Record (PCHR) is used, copies of page 3, 4, 5 and 6 for the neonatal examination of the newborn, baby discharge summary, early immunisations, vitamin K and newborn hearing screen are filled in and attached here using the gummed strip. Where the PCHR has not yet been issued the findings can be recorded directly onto these pages.

 
 
 

Page 20: Baby checklist (previously in Mother’s notes). 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.

 

 
 
 
  Stickers have been developed to record assessments of baby well being. This is support a more chronological flow of documentation and reduce duplication. These should be added to the notes on pages 6-10, and then documentation from the post natal check should be recorded on the sticker. Post natal day number, where the baby has been seen, whether labels have been checked and method of feeding should be recorded on the sticker. Space to document any referral to additional support has been included in the assessment. Prompts are included to review key to risk and management plan.

 

 

 

 

 
© Perinatal Institute 2010