Fillable Mock Scenario (University of Northampton)

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Mock Scenario (University of Northampton)

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Mock Scenario
Midwifery
We have developed this scenario to provide an outline of the performance we expect
and the criteria that the test of competence will assess.
The Code outlines the professional standards of practice and behaviour which sets
out the expected performance and standards that are assessed through the test of
competence.
The Code is structured around four themes – prioritise people, practise effectively,
preserve safety and promote professionalism and trust. These statements are
explained below as the expected performance and criteria. The criteria must be used
to promote the standards of proficiency in respect of knowledge, skills and attributes.
They have been designed to be applied across all fields of nursing and midwifery
practice, irrespective of the clinical setting and should be applied to the care needs
of all persons.
Please note - this is a mock OSCE example for education and training purposes
only.
The marking criteria and expected performance only applies to this mock scenario.
They provide a guide to the level of performance we expect in relation to nursing and
midwifery care, knowledge and attitude. Other scenarios will have different
assessment criteria appropriate to the scenario.
Evidence for the expected performance criteria can be found in the reading list and
related publications on the learning platform.
Theme from the Code
Expected Performance and Criteria
Promote professionalism
Behaves in a professional manner respecting others
and adopting non-discriminatory behaviour.
Demonstrates professionalism through practice.
Upholds the person’s dignity and privacy.
Prioritise people
Introduces self to the person at every contact.
Actively listens to the person and provides
information and clarity.
Treats each person as an individual showing
compassion and care during all interactions.
Displays compassion, empathy and concern. Takes
an interest in the person.
Respects and upholds people’s human rights.
Upholds respect by valuing the person’s opinions
and being sensitive to feelings and/or appreciating
any differences in culture.
Checks that person is comfortable, respecting the
patient’s dignity and privacy.
Infection prevention and
control
Adopts infection control procedures to prevent
healthcare-associated infections at every contact.
Applies appropriate personal protective equipment
(PPE) as indicated by the nursing or midwifery
procedure in accordance with the guidelines to
prevent healthcare associated infections.
Disposes of waste correctly and safely.
Care, compassion and
communication
Seeks permission/consent to carry out
observations/procedures at every person contact.
Checks person’s identity correctly both verbally,
and/or with identification bracelet and the respective
documentation at every person contact.
Uses a range of verbal and nonverbal
communication methods. Displays good verbal
communication skills by appropriate language use,
some listening skills, paraphrasing, and appropriate
use of tone, volume and inflection. Good non-verbal
communication including elements relating to
position (height and patient distance), eye contact
and appropriate touch if necessary.
Practice effectively
Maintains the knowledge and skills needed for safe
and effective practice in all areas of clinical practice.
Organisational aspects of
care specific to specific
skills
Ensures people’s physical, social and psychological
needs are assessed.
Completes physiological observations accurately
and safely for the required time using the correct
technique and equipment.
Ensures any information or advice given is evidence
based including using any healthcare products or
services.
Documentation
Documents all nursing and/or midwifery procedures
accurately and in full, including signature, date and
time.
Writes person’s full name and hospital number
clearly so that it can be easily read by others.
Records the date, month and year of all
observations.
Charts all observations accurately.
Scores out all errors with a single line. Additions are
dated, timed and signed.
Writes the record in ink.
Preserve safety
Supplies, dispenses or administers medicines within
the limits of training, competence, the law, the NMC
and other relevant policies, guidance and
regulations.
Medicine management
The Mock OSCE is made up of four stations: assessment, planning, implementation
and evaluation. Each station will last approximately fifteen minutes and is scenario
based. The instructions and available resources are provided for each station, along
with the specific timing.
Scenario
Lisa Molloy is currently 36 weeks gestation. This is her first pregnancy and she has
been low risk throughout. She comes to her antenatal clinic appointment and her
blood pressure is 145/100mmHg.
You will be asked to complete the following activities to provide high quality,
individualised midwifery care for the woman.
Station
You will be given the following resources
Assessment – 15 minutes
You will collect, organise and
document information about the
woman.
A partially completed handheld
pregnancy record document (pages 1-
56)
Assessment overview (page 57) and
Modified Early Obstetric Warning Score
(MEOWS) chart for you to record her
observations (pages 70-71)
Planning – 15 minutes
You will complete the planning
template to establish how the care
needs of the woman will be met using
an SBAR (situation, background,
assessment, recommendation)
approach.
A partially completed midwifery care plan
for two midwifery issues that you have
identified to ensure communication with
the antenatal assessment unit is woman-
centred and relevant (pages 58-60)
Implementation – 15 minutes
You will administer medications while
continuously assessing the woman’s
current health status.
Implementation overview and Medication
Administration Record (MAR) (pages 61-
65)
Evaluation – 15 minutes
You will document the care that has
been provided so that this is
communicated with other healthcare
professionals, provide a record of
clinical actions completed,
disseminate information and
demonstrate the order of events
relating to individual care.
Evaluation overview and transfer of care
letter for a community midwife (pages
66-69)
A blank Modified Early Obstetric Warning
Score (MEOWS) chart (pages 70-71)
On the following page, we have outlined the expected standard of clinical
performance and criteria. This marking matrix is there to guide you on the level of
knowledge, skills and attitude we expect you to demonstrate at each station.
Assessment Criteria
Clean hands with alcohol hand rub, or wash with soap and water, and dry with
paper towels.
May verbalise or make environment safe.
Introduces self to woman and gain consent.
Check ID with woman; verbally, against wristband (where appropriate) and
paperwork.
Recap antenatal history to date.
Complete maternal blood pressure, temperature, pulse, respirations and oxygen
saturations.
Asks about fetal movements.
Explains urinalysis and checks reagent strips expiry date.
Completes hand hygiene and puts on gloves.
Inserts reagent strip into the urine to cover the reagent areas.
Reads reagent strip following manufactures recommendations.
Disposes of equipment correctly.
Remove gloves and completes hand hygiene.
Documents maternal blood pressure, temperature, pulse, respirations and oxygen
saturations and urinalysis accurately.
Explains reason for referral to Antenatal Assessment Unit.
Verbal communication is clear and appropriate.
Close assessment appropriately and may check findings with the woman.
Planning Criteria
Handwriting is clear and legible for problems one and two.
Identifies and documents appropriate Situation for problems.
Identifies and documents appropriate Background for problems.
Identifies and documents appropriate Assessment for problems.
Identifies and documents appropriate Recommendations for problems.
Ensure midwifery interventions are current / relate to EBP / best practice.
Care plan is individualised and woman-centred.
Professional terminology used in care planning.
Confusing abbreviations avoided.
Ensure strike-through errors retain legibility.
Print, sign and date.
Implementation Criteria
Clean hands with alcohol hand rub, or wash with soap and water, and dry with
paper towels.
Introduce self to woman.
Seek consent prior to administering medication.
Check ID with woman; verbally, against wristband (where appropriate) and the
Medication Administration Record (MAR).
May refer to previous assessment results.
Must check allergies on chart and confirm with the woman in their care, also note
red wristband where appropriate.
Before administering any prescribed drug, look at the woman's prescription chart
and check the following:
Correct:
Person
Drug
Dose
Date and time of administration
Route and method of administration
Ensures:
Validity of prescription
Signature of prescriber
The prescription is legible
Identify and administer drugs due for administration correctly and safely.
Check the integrity of the medication to be administered; dose and expiry date.
Provide a correct explanation of what each drug being administered is for to the
woman in their care.
Omit drugs not to be administered and provides verbal rationale.
Accurately record drug administration and non-administration.
Evaluation Criteria
Clearly describe reason for initial referral.
Record date of antenatal appointment.
Identify Situation.
Identify Background.
Identify Assessment.
Identify Recommendations.
Documents allergies and reactions.
Documents plan of care and future appointments.
Identifies potential areas for parent education.
Identifies member of the MDT who need to be aware of discharge.
Ensure strike-through errors retain legibility.
Print, sign and date.
Appendices
Midwifery
PRIVATE & CONFIDENTIAL
1
These Maternity Notes are a guide to your options during pregnancy, childbirth and life with your new baby and are intended to help
you and your partner make informed choices. The explanations in these notes are a general guide only, and not everything will be
relevant to you.
Please feel free to ask any questions. Additional information is also available via NHS Choices - www.nhs.uk or in leaflets which you
may be given by your health care professionals as and when needed.
You should keep these notes with you at all times and bring them to all appointments and when you go into labour. After the birth
of your baby these notes will be kept by the hospital and filed in your records.
Postcode
Maternity Unit
Trust
Address
Notes
Perinatal
© Perinatal Institute - Version 17.2 (November 2017) Product code IPERI-58
Date of printing December 2017
For information about content, go to www.preg.info, e-mail notes@perinatal.org.uk or call 0121 607 0101
For supplies, contact Harlow Printing Ltd: www.harlowprinting.co.uk Tel 0191 496 9731, Fax 0191 454 6265
If found, please return the notes immediately to the owner, or her midwife or maternity unit.
Whilst every effort has been made to ensure the accuracy of this publication, the publishers cannot accept responsibility for any errors, omissions, or mistakes.
All rights reserved. No part of this publication may be reproduced in any form, stored in a retrieval system of any nature, or transmitted in any form or by any
means including electronic, mechanical, photocopying, recording, scanning or otherwise without the prior written permission of the copyright owners except in
accordance with the Copyright, Designs and Patents Act 1988.
www.uk-sands.org0808 164 3332Stillbirth & Neonatal Death Charity (SANDS)
www.hmrc.gov.uk/taxcredits/0345 300 3900Tax Credit Information
www.tommys.org0800 014 7800Tommy’s Pregnancy Line
www.workingfamilies.org.uk0300 012 0312Working Families (Rights & Benefits)
116 123Samaritans
www.samaritans.org
RCM information for women
www.rcm.org.uk/your-pregnancy-resources-for-women
Support Groups/additional information
www.alcoholconcern.org.uk0203 907 8480
www.citizensadvice.org.ukCitizens Advice Bureau (CAB)
Antenatal Results & Choices (ARC) www.arc-uk.org0845 077 2290
www.bladderandbowelfoundation.orgBladder and Bowel Foundation Helpline 01926 357 220
www.childline.org.ukChildline 0800 1111
www.cafamily.org.uk
0808 808 3555
Contact a family (Disability)
Alcohol Concern
www.talktofrank.com0300 123 6600Frank About Drugs
www.gingerbread.org.uk0808 802 0925Gingerbread
www.laleche.org.uk0345 120 2918La Leche League (breast feeding)
www.maternityaction.org.uk
www.mind.org.uk
0808 802 0029Maternity Action Advice Line
www.miscarriageassociation.org.uk01924 200 799Miscarriage Association
www.nationalbreastfeedinghelpline.org.uk0300 100 0212National Breastfeeding Helpline
www.nct.org.uk0300 330 0700National Childbirth Trust (NCT)
www.gbss.org.uk Group B Strep Support Group
0300 123 3393MIND – for better mental health
www.nationaldomesticviolencehelpline.org.uk
www.nhs.uk
www.nhsdirect.nhs.uk
www.nhs.uk/start4life
www.smokefree.nhs.uk/smoking-and-pregnancy
www.nspcc.org.uk
0808 200 0247
0300 123 1044
111
National Domestic Violence Helpline
National Pregnancy Smoking Helpline
www.familylives.org.uk0808 800 2222Parentline Plus
0800 028 3550NSPCC’s FGM Helpline
NHS Information Service for Parents
NHS Choices
NHS Non-Emergency Number
0144 441 6176
2
TATTERELL NHS TRUST
TATTERELL MATERNITY HOSPITAL
WALNUT STREET
TATTERELL
HOSPITAL 01457 278 123
DELIVERY SUITE 01457 278 456
L L 1 2 V W X
page
a
D M YD M YD M Y
Age ParityBooking BMI EDD
Next of Kin
Name
Address
Relation
Emergency Contact
Name
Address
Centre
Primary care contacts
Other(s)
Maternity contacts
Named Midwife
Maternity Unit
Antenatal Clinic
Community Office
Delivery Suite
Ambulance
GP
Postcode
(GP)
Initial Surname
Plan of care
Depending on your circumstances, you and your partner will have the choice between midwifery based care or maternity team based care during
your pregnancy. Please discuss your choices/options with your midwife. This will be based on your individual medical and obstetric history.
Date recorded Planned place of birth Lead professional Reason if changedJob title
Communication needs
Assistance required
Yes
Details Your preferred name
Interpreter
Do you speak English
What is your first language
No
YesNo
Preferred language
D M YD M YD M YD M Y
D M YD M Y
D M YD M Y
Date
of birth
Unit
No.
Address
Postcode
First name Surname
D M YD M YD M Y
Personal details
NHS
No.
PERSONAL DETAILS
NHS Information Service for Parents
Sign up for emails and texts at www.nhs.uk/start4life
Health Visitor/Family
Nurse Practitioner
3
LISA
MOLLOY
41 ALMOND CLOSE, TATTERELL
01457 278 648
07123 456 789
0 1 0 1 9 6
0 1 4
5 6 9
2 4 9 8
LISA
ENGLISH
ENGLISH
N/A
SALLY BROWN
JANET EDGLEY
PAUL CLARKE
41 ALMOND CLOSE, TATTERELL
PARTNER
L L 1 2 T B U
23
26
0
N/A
TATTERELL HOSPITAL
SALLY BROWN
MW
BOOKING
TATTERELL MATERNITY HOSPITAL
01457 278 012
01457 278 789
01457 278 456
01457 278 345
01457 278 123
01457 278 678
BROWNLANDS
SMITH
L L 1 2 Y Z A
R
01457 278 648
PAUL CLARKE
07987 654 321
41 ALMOND CLOSE, TATTERELL
01457 278 648
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page
b
Signatures
PostGMC / NMC numberName
(print clearly)
Signature
Anyone writing in these notes should record their name and signature here.
Name
Unit No/
NHS No
4
AINE DARCEY
SONOGRAPHER
MIDWIFE
SALLY BROWN
0 1 4 5 6 9 2 4 9 8
LISA MOLLOY
Sally Brown
Aine Darcey
page
c
You will be offered appointments during your pregnancy to check you and your baby’s well-being. The date and time
of these can be recorded below.
Name
Unit No/
NHS No
Appointments
Day of weekDate Time ReasonWhere With
D M Y YMD
5
8 WE E K S
1 2 WE E K S
FRIDAY
14:00
U/S
A DARCEY
DATING & NTUSS
1 2 WE E K S
FRIDAY
14:30
HOSPITAL
PHLEBOTOMY
CONFIRMED SCREENING BLOODS
1 6 WE E K S
TUESDAY
10:30
GP
S BROWN
ANTENATAL APPT
1 9 WE E K S
MONDAY
09:00
USS
A DARCEY
ANOMALY USS
2 5 WE E K S
TUESDAY
09:30
GP
S BROWN
ANTENATAL APPT
2 8 WE E K S
MONDAY
11:00
GP
S BROWN
ANTENATAL APPT & BLOODS
3 1 WE E K S
TUESDAY
10:30
GP
S BROWN
ANTENATAL APPT
3 4 WE E K S
TUESDAY
11:00
GP
S BROWN
ANTENATAL APPT
3 6 WE E K S
TUESDAY
10:00
GP
S BROWN
ANTENATAL APPT
BOOKING
S BROWN
GP
TUESDAY
10:00
0 1 4 5 6 9 2 4 9 8
LISA MOLLOY
Mental health
page
d
* Signatures must be listed on page b for identification
Name
Unit No/
NHS No
Complete risk assessment page 12 and management plan page 13.
Pregnancy and having a baby can be an exciting but also a demanding time. This can result in pre-existing symptoms
getting worse. It's not uncommon for women to feel anxious, worried or 'down' at this time. The range of mental
health problems women may experience or develop is the same during pregnancy and after birth as at other times in
her life, but some illnesses/ treatments may be different. Some women who have a mental health problem stop taking
their medication when they find out they are pregnant. This can result in symptoms worsening. You should not alter
your medication without specialist advice from your GP, mental health team or midwife.
Women with a severe mental illness such as psychosis, schizophrenia, schizoaffective disorder or bipolar disorders are
more likely to become unwell again than at other times. Severe mental illness may develop more quickly immediately
after childbirth and can be more serious requiring urgent treatment.
At your 1st appointment you will be asked how you are feeling now and if you have or have had any problems with
your mental health in the past. You will be asked about your emotional wellbeing at your appointments during
pregnancy and after the birth of your baby. These questions are asked to every pregnant woman and new mother.
The maternity team supporting you during pregnancy and after birth may identify that you are at risk of developing a
mental health problem. If this happens they will discuss with you options for support and treatment. You may be
offered a referral to a mental health team/specialist midwife/obstetrician.
If you are concerned about your thoughts, feelings or behaviour, you should seek help and advice.
Further information can be found about mental health including medication in pregnancy and breastfeeding via:
www.medicinesinpregnancy.org
www.nice.org.uk/guidance/cg192/ifp/chapter/about-this-information
1st Assessment. Have you ever been diagnosed with any of the following:
Psychotic illness, bipolar disorders, schizophrenia, schizoaffective disorder, post-partum psychosis
Depression
Generalised anxiety disorder, OCD, panic disorder, social anxiety, PTSD
Eating disorder e.g. anorexia nervosa, bulimia nervosa or binge eating disorder
Personality disorder
Self-harm
Is there anything in your life (past/present) which might make the pregnancy/childbirth difficult?
e.g. tokophobia, trauma, childhood sexual abuse, sexual assault
Help received (current or previous):
GP/Midwife/Health visitor support
Counselling/cognitive behavioural therapy (CBT)
Specialist perinatal mental health team
Hospital or community based mental health team
Inpatient (hospital name) Date(s)
Psychiatrist
Medication (list current or previous) drug name, dose and frequency
Partner
Does your partner have any history of mental health illness?
Family History
Has anyone in your family had a severe perinatal mental illness? (first degree relative e.g. mother, sister)
No Yes
Psychiatric nurse/care
coordinator
Depression identification questions
During the past month, have you often been bothered by feeling down,
depressed or hopeless?
During the past month, have you often been bothered by having little interest
or pleasure in doing things?
If yes to either of these questions, consider offering self-reporting tools e.g. PHQ 9
YesNoNo Yes
1st 2nd
YesNoYesNo
No
Yes
No Yes
Anxiety identification questions
During the past 2 weeks, have you been bothered by feeling nervous, anxious or on edge?
During the past 2 weeks, have you been bothered by not being able to stop
or control worrying?
Do you find yourself avoiding places or activities and does this cause you problems?
If yes to any of these questions, consider offering self-reporting tool e.g. GAD 7
6
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0 1 4 5 6 9 2 4 9 8
LISA MOLLOY
page
1
PREGNANCY
My Pregnancy Planner
▼
▼
▼
▼
▼
▼
25 weeks -
for women having their first baby/or
women receiving increased surveillance
Date
▼
▼
▼
42 weeks
▼
41 weeks
▼
▼
▼
▼
▼
40 weeks -
for women having their first baby/or
women receiving increased surveillance
38 weeks
36 weeks
▼
34 weeks
▼
▼
▼
▼
▼
31 weeks -
for women having their first baby/or
women receiving increased surveillance
28 weeks
Anomaly scan at 18 to 20 weeks
16 weeks
Screening results
▼
Dating scan
Screening tests
▼
First Contact
Booking Appointment
LMP
D M Y
D MMD Y Y
Estimated wks
gestation
ks
+
DW
During your pregnancy, you will be offered regular appointments with your healthcare team. They check that you and
your baby are well and provide support and information about your pregnancy to help you make informed choices. How
often these are, varies from woman to woman, and the frequency may need to be adjusted if your circumstances change.
As a minimum, you should be offered appointments at the following weeks of your pregnancy. You can write the date of
these appointments in the spaces provided. After each of your appointments, it is important you know when your next
one is, where it will take place and who it is with.
Health Visitor
Antenatal visit from 28 weeks
7
8 WEEKS
8 WEEKS
8 2
12 WEEKS
16 WEEKS
19 WEEKS
25 WEEKS
28 WEEKS
28 WEEKS
31 WEEKS
page
2
Complete risk assessment page 12/ management plan page 13
Your Details
Partner’s Details
Needs help understanding Pregnancy Notes
Has difficulty understanding English
Needs help completing forms
YesNo
Social Assessment-booking
Employment status
Occupation
Age leaving full
time education
Any difficulties reading / writing English
2nd Assessment
YesNo
Referred
Address
if different
Family name at birth
Faith /
Religion
Country
of birth
If not UK,
year of entry
Citizenship
status
Single WidowedMarried / CP Partner Separated Divorced
Sensory/physical
Disability
No Yes
Details
F/T P/T
Retired Student Home Sick U/E Voluntary
NFA Housing: Owns
Rents
With family/ friends UKBA
OccupationEmployed
U/E
First name Surname
Postcode:
Any household member had/has social services support
Do you have support from partner / family / friend
Entitled to claim benefits
(income support, child tax credits, job seeker etc.)
Name of social worker(s)/ Other multi-agency professionals
Does your partner have any other children. If yes, who looks after them?
(
Date of
birth
D M YD MMD Y Y
Citizenship
status
If not born in UK,
year of entry
Y Y Y Y
Y Y Y Y
Y Y
Temporary accommodation Care services
Other
Have you had a full medical exam since coming to the UK?
(if no refer to GP)
When did you stop?
Was this in the last 12 months?
Anyone else at home smoke?
Tobacco use - booking
Have you ever used tobacco?
If in pregnancy, how many weeks?
Are you a smoker?
No
Yes
W KS
D M YD MMD Y Y
record plan on page13
YesNo
(If mixed, tick more than one box) - is to describe where your family originates from, as distinct from where you were born.
Ethnic Origin
East African (e.g. Ethiopia, Kenya)
Central African (e.g. Cameroon, Congo)
South African – Black (Botswana, South Africa)
South African – Euro (South Africa)
West African (Gambia, Ghana)
Middle Eastern (e.g Iraq, Turkey)
Indian (e.g India, Sri Lanka)
This information is needed to produce a customised growth chart for your baby (page 14).
How long have you lived at your current address?
How many people live in your household?
Declined
British European
(e.g England, Wales)
East European
(e.g Poland, Romania)
Irish European (e.g Northern Ireland, ROI)
North European (e.g Sweden, Denmark)
South European (e.g Greece, Spain)
West European (e.g France, Germany)
North African (e.g Egypt, Sudan)
Baby’s fatherYou
Baby’s fatherYou
Pakistani (e.g Pakistan)
Bangladeshi (e.g Bangladesh)
Chinese (e.g China)
Other Far East (e.g Japan, Korea)
South East Asia (e.g Thailand, Philippines)
Caribbean (e.g Barbados, Jamaica)
Other
Baby’s fatherYou
Alcohol - booking
Drug use - booking
Alcohol units:
Pre-pregnancy
Do you drink alcohol?
YesNo YesNo
In the last 12 months, how often have you had a drink containing alcohol?
How many units of alcohol do drink on a typical day when you are drinking?
2nd
Do you currently use?
Details
Are you receiving treatment?
YesNo
YesNo
2nd
Details
Currently
record plan on page 13
record plan on page13
Have you ever injected drugs?
Have you ever shared drugs paraphernalia?
Have you ever used street drugs, cannabis,
or psychoactive substances (legal highs)?
1st
Any drug or alcohol concerns in the home?
Substance misuse referral
Declined Declined
record plan on page 13
e.g. daily, weekly
Smoking cessation referral
Smoke cigarettes
Smoke roll ups
Use NRT
Chew tobacco
Do you:
No Yes
No. per day
Use e-cigarettes
Result
Declined
CO screening?
1st 2nd
No Yes No. per day
Declined
Result
Consider using an alcohol screening tool
e.g. AUDIT-C
8
PAUL
CLARKE
MOLLOY
CHRISTIAN
0 1 0 1 9 5
BRITISH
BUILDER
N/A
N/A
N/A
N/A
N/A
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HAIRDRESSER
1 8
5 YEARS
2
N/A
0 3
0 0
0 0
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page
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Name
Unit No/
NHS No
The term ‘family’ here means blood relatives only - e.g. your children, your parents, grandparents, brothers and
sisters, uncles and aunts and their children (i.e. first cousins). Update management plan (page 13) if indicated.
Family History
* Signatures must be listed on page b for identification
Medical History
Complete risk assessment page 12 and management plan page 13.
Do you have / have you had:
Haematological (Haemaglobinopathies)
High blood pressure
Liver disease inc. hepatitis
Migraine or severe headache
Folic acid tablets
Vaginal bleeding in this pregnancy
Musculo-skeletal problems
Incontinence
(urinary / faecal)
Other
(provide details)
Pelvic injury
Operations
TB exposure
Thrombosis
Medication in the last 6 months
Infections
(e.g. MRSA, GBS)
Thyroid / other endocrine problems
No Yes
Details
Diabetes
Epilepsy / Neurological problems
Fertility problems
(this pregnancy)
Female circumcision / cutting
Cancer
Back problems
Exposure to toxic substances
Allergies
(inc. latex)
Anaesthetic problems
Cervical smear
Admission to A & E in last 12 months
On epilepsy medication?
Blood transfusions
Blood / Clotting disorder
Autoimmune disease
Physical Examination
Details
performed
Gynae history / operations
(excl. caesarean)
0.4mg
No Yes
5mg
Dose changed?
D M Y
D MMD Y Y
Start date
Gastro-intestinal problems
(eg Crohns)
Genital Infections
(e.g. Chlamydia, Herpes)
Hepatitis
B
C
Date
Result
D M Y
D MMD Y Y
D M Y
Admission to ITU / HDU
Cardiac problems
Inherited disorders
Renal disease
Respiratory diseases
Chickenpox / Shingles
No Yes
- thrombosis (blood clots)
- high blood pressure / eclampsia
- a disease that runs in families
Has anyone in your family had:
Has anyone had:
in your family in family of baby’s father
- need for genetic counselling
- a sudden infant death
- hearing loss from childhood
No Yes No Yes
- hip problems from birth
- learning difficulties
- stillbirths or multiple miscarriages
- heart problems from birth
- abnormalities present at birth
Is your partner the baby’s father
Is the baby’s father a blood relation
First cousin
Second cousin Other
- diabetes Type
Age of baby’s father
Details
- MCADD
Declined
9
2 3
0 1 4 5 6 9 2 4 9 8
LISA MOLLOY
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PENICILLIN - ANAPHYLAXIS
ANAEMIA
FERROUS SULPHATE
page
4
Feel free to ask your midwife or doctor – or look at NHS Choices: www.nhs.uk
Miscarriages. A miscarriage (sometimes called spontaneous abortion) is when you lose a baby before 24 weeks
of pregnancy. If this happens in the first 3 months of pregnancy, it is known as an early miscarriage. This is very
common with 10-20% of pregnancies ending this way. Late miscarriages, after 3 months but before 24 weeks are
less common, (only 1-2% of pregnancies). When a miscarriage happens 3 or more times in a row, this is called
recurrent miscarriage. Sometimes there is a reason found for recurrent or late miscarriage.
What if I’ve had a termination (abortion) but do not want anyone to know? This information can be kept
confidential between yourself, your midwife and obstetrician and can be recorded elsewhere.
Previous Pregnancies
Details of previous pregnancies and births are relevant when making decisions about the care you will be offered.
Your healthcare team will need to know important facts such as: where you gave birth, a summary of how your
pregnancy went and if you developed any complications, the weight of your baby and how you and your baby were
after the birth. Some of the main topics are outlined below and further information can be found on page 19 about
pregnancy complications and page 24 about labour and types of birth. This information will help you and your
healthcare team develop a personalised plan together which will support your choices/preferences. If there is anything
else you think may be important, please tell your midwife or obstetrician.
Para. This is a term which describes how many babies you already have. Usually early pregnancy losses are also
listed after a ‘plus’ sign. For example, the shorthand for two previous births and one miscarriage is ‘2 + 1’.
High blood pressure and/or pre-eclampsia. If you had this condition last time, you are more likely to have it
again, although it is usually less severe and starts later in pregnancy. It is more likely to happen again if you have a
new partner (page 19).
Intrahepatic Cholestasis in Pregnancy (ICP) (obstetric cholestasis) is a liver condition in pregnancy that causes
itching especially at night (page 19). If you were diagnosed with ICP in a previous pregnancy, you are at an increased
risk of developing it again.
Gestational Diabetes (GDM) can develop during pregnancy causing blood glucose (sugar) levels to become too
high (page 19). You are at increased risk if you developed GDM in a previous pregnancy.
Premature birth. This means any birth before 37 weeks. The earlier the baby is born, the more likely that it will
have problems and need special or intensive neonatal care. The chance of premature birth is increased because of
smoking, infection, ruptured membranes, bleeding, or growth restriction with your baby. Having had baby prematurely
increases the chances of it happening again.
Small babies (fetal growth restriction). If one of your previous babies was growth restricted, there is a chance
of it happening again. Arrangements will be made to monitor this baby’s growth more closely, offering ultrasound
scans and other tests as necessary (page 14).
Big babies (macrosomia). A baby over 4.5 kg is usually considered big - but this also depends on your size and
how many weeks pregnant you were when the baby was born. You may be offered a blood test to check for
gestational diabetes, which can be linked to having bigger babies.
Congenital anomaly. These are also known as birth defects or deformities. Some congenital anomalies are detected
during pregnancy, at birth or others as the baby grows older.
Placenta praevia describes the position of the placenta if it lies low in the womb. If you had this confirmed in the
last months of any previous pregnancy, you are at an increased risk of this happening again.
Placenta acreta happens when the placenta embeds itself too deeply in the wall of the womb. This is more common
with placenta praevia.
Bleeding after birth. Postpartum haemorrhage (PPH) means a significant loss of blood after birth (usually 500mls
or more). Often this happens when the womb does not contract strongly and quickly enough. There is an increased
risk of it happening again, so you will be advised to have a review with an obstetrician during pregnancy to discuss
options for your place of birth.
Postnatal wellbeing. The postnatal period lasts up to 6 weeks after the birth and it is during this time your body
recovers. However, for some women problems can occur e.g. slow perineal or wound healing, concerns with passing
urine, wind and/or stools. Some women may also experience mental health problems (page d).
Group B Streptococcus (GBS). If you’ve previously had a baby who was diagnosed with a GBS infection after
birth, you will be offered intravenous (drip) antibiotics when labour begins. The aim of offering you antibiotics in
labour is to reduce the risk of a GBS infection for this baby.
Baby Weight Conversion Chart
lb oz g
2 0 907
2 2 964
2 4 1021
2 6 1077
2 8 1134
2 10 1191
2 12 1247
2 14 1304
3 0 1361
3 2 1417
3 4 1474
3 6 1531
3 8 1588
3 10 1644
3 12 1701
3 14 1758
lb oz g
4 0 1814
4 2 1871
4 4 1921
4 6 1984
4 8 2041
4 10 2098
4 12 2155
4 14 2211
5 0 2268
5 2 2325
5 4 2381
5 6 2438
5 8 2495
5 10 2551
5 12 2608
5 14 2665
lb oz g
6 0 2722
6 2 2778
6 4 2835
6 6 2892
6 8 2948
6 10 3005
6 12 3062
6 14 3118
7 0 3175
7 2 3232
7 4 3289
7 6 3345
7 8 3402
7 10 3459
7 12 3515
7 14 3572
lb oz g
8 0 3629
8 2 3685
8 4 3742
8 6 3799
8 8 3856
8 10 3912
8 12 3969
8 14 4026
9 0 4082
9 2 4139
9 4 4196
9 6 4252
9 8 4309
9 10 4366
9 12 4423
9 14 4479
lb oz g
10 0 4536
10 2 4593
10 4 4649
10 6 4706
10 8 4763
10 10 4819
10 12 4876
10 14 4933
11 0 4990
11 2 5046
11 4 5103
11 6 5160
11 8 5216
11 10 5273
11 12 5330
11 14 5216
10
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page
5
Name
Unit No
Name
Unit No/
NHS No
Complete risk assessment p12/management plan p13
Para
Early Pregnancy Losses
Previous Births
Insert additional sheets here, and number them 5.1, 5.2 etc
Is current pregnancy with a new partner?
No Yes
Year Gestation CommentsNature of loss
Y Y Y Y
W ks
Y Y Y Y
W ks
Y Y Y Y
W ks
+
Child’s Name & Surname Date of birth Age GestationBirthweight
Place of booking / Place of birth
Anaesthetic
None
Epidural/Spinal
General
Normal
Assisted
Caesarean
Delivery
Normal
Retained placenta
Haemorrhage
3rd stage
Intact
Episiotomy
Tear
Perineum
1
o
3
o
2
o
Postnatal summary
Labour
onset
Spontaneous
Induced
Planned Caesarean
Labour details
Condition since Where now
Antenatal summary
/4
o
G m s
Boy
Girl
ks
+
DW
Formula
Breast
Mixed
D M Y
D MMD Y Y
Complications
SGA or FGR
Congenital Anomaly
HELLPPIH
PND
PP
PET
GDM
ICP
Placenta praevia
Placenta accreta
Centile
Baby GBS Infection
Child’s Name & Surname Date of birth Age GestationBirthweight
Place of booking / Place of birth
Anaesthetic
None
Epidural/Spinal
General
Normal
Assisted
Caesarean
Delivery
Normal
Retained placenta
Haemorrhage
3rd stage
Intact
Episiotomy
Tear
Perineum
1
o
3
o
2
o
Postnatal summary
Labour
onset
Spontaneous
Induced
Planned Caesarean
Labour details
Condition since Where now
Antenatal summary
/4
o
G m s
Boy
Girl
ks
+
DW
Formula
Breast
Mixed
D M Y
D MMD Y Y
Complications
SGA or FGR
Congenital Anomaly
HELLPPIH
PND
PP
PET
GDM
ICP
Placenta praevia
Placenta accreta
Centile
Baby GBS Infection
Child’s Name & Surname Date of birth Age GestationBirthweight
Place of booking / Place of birth
Anaesthetic
None
Epidural/Spinal
General
Normal
Assisted
Caesarean
Delivery
Normal
Retained placenta
Haemorrhage
3rd stage
Intact
Episiotomy
Tear
Perineum
1
o
3
o
2
o
Postnatal summary
Labour
onset
Spontaneous
Induced
Planned Caesarean
Labour details
Condition since Where now
Antenatal summary
/4
o
G m s
Boy
Girl
ks
+
DW
Formula
Breast
Mixed
D M Y
D MMD Y Y
Complications
SGA or FGR
Congenital Anomaly
HELLPPIH
PND
PP
PET
GDM
ICP
Placenta praevia
Placenta accreta
Centile
Baby GBS Infection
Child’s Name & Surname Date of birth Age GestationBirthweight
Place of booking / Place of birth
Anaesthetic
None
Epidural/Spinal
General
Normal
Assisted
Caesarean
Delivery
Normal
Retained placenta
Haemorrhage
3rd stage
Intact
Episiotomy
Tear
Perineum
1
o
3
o
2
o
Postnatal summary
Labour
onset
Spontaneous
Induced
Planned Caesarean
Labour details
Condition since Where now
Antenatal summary
/4
o
G m s
Boy
Girl
ks
+
DW
Formula
Breast
Mixed
D M Y
D MMD Y Y
Complications
SGA or FGR
Congenital Anomaly
HELLPPIH
PND
PP
PET
GDM
ICP
Placenta praevia
Placenta accreta
Centile
Baby GBS Infection
11
0 1 4 5 6 9 2 4 9 8
LISA MOLLOY
page
6
Feel free to ask your midwife or doctor – or look at NHS Choices: www.nhs.uk
Screening for Down’s (T21), Edwards’ (T18) and Patau’s (T13) syndromes
Blood Tests and Investigations
The first half of pregnancy is a time when various tests are offered to check for potential problems, by blood tests (pages
6-7) and ultrasound scans (pages 8-9). The tests listed here are the ones offered by the NHS. Further information is available
in the leaflet, ‘Screening tests for you and your baby’ from your midwife or via www.gov.uk. Do not hesitate to ask what
each test means. The choice is yours and you should have all the relevant information to help you make up your mind,
before the visit when the test(s) are done.
Prenatal Screening and Diagnosis
Family Origin
Family history - first degree relative BMI 30
>
kg/m
Gestational diabetes
Polycystic ovarian syndrome Previous baby’s birth weight > 4.5kg or >90th centile Antipsychotic medication
The screening tests are designed to find out how likely it is that the baby has Down’s, Edwards’ or Patau’s syndrome. Inside
the cells of our bodies there are tiny structures called chromosomes. There are 23 pairs of chromosomes in each cell. With
each of the individual syndromes there is an extra copy of a particular chromosome in each cell. The tests available will
depend on how many weeks pregnant you are. If you are too far on in your pregnancy to have the combined test for Down’s
syndrome, you can choose to have the quadruple test. If you are too far on in your pregnancy to have the combined test
for Edwards’ and Patau’s syndrome, the only other screening test is a mid-pregnancy (anomaly) scan which will look for
physical abnormalities. These tests are available for women with a singleton (1 baby) or twin pregnancy.
The combined test involves having a blood test and an ultrasound scan. A blood sample is taken from you, between 10
and 14 weeks to measure the levels of substances naturally found in the blood. The ultrasound scan is performed between
11 weeks and 2 days and 14 weeks and 1 day, to measure the fluid at the back of the baby’s neck (nuchal translucency
measurement, NT). A computer programme is used to work out a result for you. You will be given two separate results: -
one for Down’s syndrome and another for Edwards’ and Patau’s syndrome.
The quadruple test is available if you are too far on in your pregnancy to have the combined test. This test is for
Down’s syndrome only. A blood sample is taken from you, between 14 weeks and 20 weeks to measure the levels of
substances naturally found in the blood. A computer program is used to work out a result for you. The result: your
midwife or obstetrician will discuss your results with you. Higher-chance result: you will be offered a diagnostic test to
find out for certain if your baby has Down’s, Edwards’ or Patau’s syndrome. There are two tests: – CVS or amniocentesis.
For more information about these tests see page 8. Lower-chance result: if your result is lower than the recommended
national cut off, you will not be offered a diagnostic test. A lower-chance result does not mean that there is no chance
at all of the baby having Down’s, Edwards’ or Patau’s syndrome.
Mid-stream urine - a sample of your urine is tested to look for asymptomatic bacteriuria (a bladder infection with no symptoms).
Treating it with antibiotics can reduce the risk of developing a kidney infection.
Anaemia is caused by too little haemoglobin (Hb) in the blood. Hb carries oxygen and nutrients around the body and to the
baby. Anaemia can make you feel very tired, faint/feel dizzy, and have a pale complexion. If you have any of these symptoms,
speak to your midwife. If you are anaemic, you will be offered iron supplements and advice on your diet.
Blood group & antibodies. It is important to know whether you are rhesus positive (Rh+ve) or negative (Rh-ve), and whether
you have any antibodies (foreign blood proteins). If you are Rh-ve, you will be offered further blood tests to check for antibodies.
If your baby has inherited the Rh+ve gene from the father, antibodies to the baby’s blood cells can develop in your blood. To
prevent this, you will be advised to have an anti-D injection if there is a chance of blood cells from the baby spilling into your
blood stream (e.g. due to vaginal bleeding, amniocentesis or CVS and after the birth). It is recommended that anti-D is given
routinely to all Rh-ve mothers in later pregnancy.
Sickle Cell and Thalassaemia are inherited blood disorders which affect haemoglobin and can be passed from parent to child.
All pregnant women in England are offered a blood test to find out if they carry a gene for thalassaemia, and those at high risk
of being a sickle cell carrier are also offered a test for sickle cell. Genes are the codes in our bodies for things such as eye colour
and blood group. Depending on your results, a test from the baby’s father may be requested. If the baby’s father is a carrier
you will be offered diagnostic tests to find out if the baby is affected.
Hepatitis B is a virus which infects the liver and can cause immediate or long-term illness. Specialist care is needed for pregnant
women with hepatitis B. If you are a carrier, or have become infected during pregnancy, you will be advised to have your baby
vaccinated in the first year of life to reduce the risk of the baby developing hepatitis B.
Syphilis is a sexually transmitted disease which, if left untreated, can seriously damage your baby, or cause miscarriage or stillbirth.
If detected, you will be referred to a specialist team and offered antibiotic treatment. Your baby will need an examination and
blood tests after birth and may need to be treated with antibiotics.
HIV (Human Immunodeficiency Virus) affects the body’s ability to fight infection. This test is important because any woman can
be at risk. It can be passed to your baby during pregnancy, at birth or through breastfeeding. Treatment given in pregnancy can
greatly reduce the risk of infection being passed from mother to child. If you decline testing for hepatitis B, syphilis or HIV, your
midwife will refer you to a specialist screening team, who will discuss your decision in more detail. You can request retesting for
hepatitis B, HIV or syphilis at any time if you change your sexual partner or think you are at risk. If any of these tests are positive
e.g. hepatitis B, syphilis or HIV, you will be referred to a specialist screening team as soon as possible for an individualised plan
or care. Your partner will be offered testing to see if they need any treatment.
Rubella (German measles). Testing is not routinely offered. Avoid being in contact with anyone who has a rash at any time
during your pregnancy. If you come into contact with someone with a rash or you develop a rash, contact your midwife/GP
immediately for advice. If you delay getting advice, it may not be possible to give you a diagnosis or the right treatment.
Additional tests are offered as necessary, such as to check for infections which can cause damage to your baby, but rarely cause
problems for you. Contact your midwife /GP immediately for advice, if you develop any rashes or if you think you have been in
contact with: Chickenpox, Cytomegalovirus (CMV), Parvovirus (slapped cheek) or Toxoplasmosis (page 20).
Chlamydia is a sexually transmitted infection which can result in problems for you and your baby e.g. pelvic inflammatory
disease, miscarriage and premature birth. If you are under 25, you may be offered either a vaginal swab or urine test. If positive,
you and your partner will be offered antibiotics.
Methicillin Resistant Staphylococcus Aureus (MRSA) is a bacterium which sometimes cause wound infections and can be
difficult to treat as it is resistant to some antibiotics. Hospitals may offer testing if you are booked for an elective caesarean
section, have any wounds or have previously tested positive for MRSA.
Oral Glucose Tolerance Test (OGTT) is to find out if you have gestational diabetes (page 19). A blood test is taken after fasting
and you will be advised how long to not eat. You will then be asked to drink a glucose drink and a further blood test will be taken
two hours later. You may be offered this test if you have a history of the following:
Anxiety identification questions
During the past 2 weeks, have you been bothered by feeling nervous, anxious or on edge?
During the past 2 weeks, have you been bothered by not being able to stop
or control worrying?
Do you find yourself avoiding places or activities and does this cause you problems?
If yes to any of these questions, consider offering self-reporting tool e.g. GAD 7
12
page
7
Action
Signed*
Screening explained
NHS Screening
Programme leaflet
given
Screening offered
YesNo
Results
YesNo
Accepted by mother
Signed*
Date taken
D D M M Y Y
Gestation
Site
Dose
Signed*Batch No.
Anti D prophylaxis If Rh-ve
Leaflet(s)
given
Care provider Care provider
Date
*Signed
Comments
Signed*
Date given
YesNo
Accepted
D D M M Y Y D D M M Y Y
W ks
W ks
Gestation
D D M M Y Y
D D M M Y Y
OGTT
MRSA
Results Action Signed*Date taken
Care provider Care provider
Comments
Signed*
Additional tests
Date
*Signed
Explained Accepted
D D M M Y Y D D M M Y Y
Leaflet(s)
given
Date
(if indicated)
YesNo
D D M M Y YD D M M Y Y
Explained
YesNo
Accepted
by mother
Haemoglobin
Blood group
Antibodies
Hepatitis B
Syphilis
HIV
Booking
Results Action Signed*Date taken
Thalassaemia
Mid-stream urine
Sickle cell
Date
D D M M Y Y
D D M M Y Y
If no:
why
Choice of screening
T21, T18/T13 (All the conditions)
T21 only T18/13 only
YesNo
Screening for Down’s (T21), Edwards’ (T18) and Patau’s (T13) syndromes
Test
type
Care provider
*Signed
Date
D M Y
T21
T18
T13
OGTT
Date
*Signed
YesNo
Care provider Care provider
Comments
Signed*
D D M M Y Y D D M M Y Y
Results Action
Signed*Date taken
Care provider Care provider
Comments
Signed*
Tests from Father
Date
*Signed
Explained Accepted
D D M M Y Y D D M M Y Y
Leaflet(s)
given
D D M M Y Y
D D M M S Y
D D M M Y Y
D D M M Y Y
Date
Leaflet(s)
given
Care provider Care provider
Comments
Signed*
Date
*Signed
D D M M Y Y D D M M Y Y
28-week check
Haemoglobin
Antibodies
Results Action
Signed*
Date taken
Explained
YesNo
Accepted
Date
Results to be recorded above
D D M M Y Y
D D M M Y Y
D D M M Y Y
D D M M Y Y
D D M M Y Y
Re-offer tests for
infections
if
declined at
booking
D M Y
* Signatures must be listed on page b for identification
Name
Unit No/
NHS No
Investigations
If additional blood tests / investigations are required update management plan p13.
13
BOOK ING
9 WEE KS
BOOK ING
9 WEE KS
BOOK ING
9 WEE KS
BOOK ING
9 WEE KS
BOOK ING
9 WEE KS
BOOK ING
9 WEE KS
BOOK ING
9 WEE KS
9 WEE KS
BOOKING
BOOK ING
NAD
COMBINED
LISA MOLLOY
0 1 4 5 6 9 2 4 9 8
BOOK ING
9 WEE KS
BOOK ING
NAD
110
O
POS
NAD
NAD
NAD
NAD
NAD
BOOKING
9 WEE KS
BOOK ING
NAD
9 WEE KS
BOOKING
BOOKING
28 WEEKS
95
NAD
29 WE E KS
29 WE E KS
28 WEEKS
NAD
28 WEEKS
28 WEEKS
28 WEEKS
B O O K I N G
1 2 WEEKS
1:1864
1:2306
1:2306
✔
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FERRITIN STUDY - NAD
NA - RH +VE (POSITIVE)
Sally Brown
Sally Brown
Sally Brown
Sally Brown
Sally Brown
Sally Brown
Sally Brown
Sally Brown
Sally Brown
Sally Brown
Sally Brown
Sally Brown
Sally Brown
Sally Brown
Sally Brown
Sally Brown
Sally Brown
Sally Brown
Sally Brown
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Feel free to ask your midwife or doctor – or look at NHS Choices: www.nhs.uk
You will be offered one or two routine ultrasound scans in the first half of pregnancy (i.e. usually by 20 weeks). There are no
known risks to the baby or you from having a scan, but it is important to think carefully about whether to have a scan or not.
The scan may provide information that means you may have to make some difficult decisions. For example, you may be offered
further tests that have a risk of miscarriage. Some people want to find out if their baby has problems and some do not.
Further information can be found in the leaflet “Screening Tests for You and Your Baby” available from your midwife or
via www.gov.uk.
It is important to be aware of what the scans are intended for. Most scans fall into one
of three categories:
n Early scans to: date the pregnancy, check the number of babies,
look for possible physical problems and take specific measurements of
the baby if you have agreed to first trimester screening.
n Anomaly scan is recommended to be performed between 18 to 20+6
weeks of pregnancy to look for possible physical problems with the baby.
n Scans later in pregnancy are not for screening but are carried out
to monitor the baby’s wellbeing and development.
Ultrasound Scans
Diagnostic Tests for Chromosomal Abnormalities
Accepted
by mother
Explained
YesNo
Reasons for Scans
Dating pregnancies. It is important to know the size of the baby in your womb so that we know how mature the fetus is. Scan
dates are more accurate than menstrual dates if done before 22 wks. This is because it looks at the actual age of the fetus,
whereas menstrual dates are based on the first day of the last period which assumes fertilisation occurred 14 days later, this is
not always the case. Most babies are NOT born on their expected due date, but during a 4 week period around it. Usually babies
come when they are ready.
First trimester (early pregnancy). All pregnant women are offered an ultrasound scan at between 8-14 weeks of pregnancy.
This is called the dating scan. It is done to confirm the pregnancy and number of babies in the womb, calculate the expected date
of delivery and to check for major problems with the baby that may be detected at this early stage. You may also be offered
screening for Down’s, Edwards’ and Patau’s syndromes (page 6) at this time. This will depend on whether you have agreed to
have the screening test done and how many weeks pregnant you are at the time of scan.
Mid-pregnancy (anomaly). You will be offered a scan between 18 weeks and 20 weeks and 6 days. The purpose of this scan is
to look for structural problems in the way the baby is developing (sometimes called anomalies). The scan will look in detail at the
baby’s head, spinal cord, limbs, abdomen, face, kidneys, brain, bones and heart. In most cases the baby will be developing well,
but sometimes a problem is found. If a problem is suspected, you will be referred to a specialist team to discuss the options
available to you. However, it is important to know that ultrasound may not identify all problems. Detection rates will vary depending
on the type of anomaly, the position the baby is lying in, previous surgery to your abdomen and maternal size.
Later pregnancy. Scans can be performed in later pregnancy to check the baby’s well-being. This may be required if there are
concerns about how the baby is growing, or if you have any risk factors identified early in your pregnancy, that may affect the growth
and wellbeing of the baby e.g. high blood pressure/diabetes. The main measurement for this is the abdominal circumference, which
includes the size of the liver (the main nutritional store of the growing baby) and the abdominal wall thickness (related to fat reserves).
An assessment of liquor (fluid around the baby) and Doppler flow can be done if there are any concerns with the baby’s growth
(Doppler flow indicates how well the placenta is managing the blood supply needed for the baby). If the scan suggests any
concerns/problems, you will be referred to a specialist doctor to discuss the options available to you. Scans are sometimes also
done to identify the position of the placenta, which may have been low in the womb at an earlier scan. A low placenta increases
the risk of heavy bleeding later in pregnancy (page 19).
Sex of the Baby. Although we can sometimes tell the sex of the baby, they are NOT done for personal requests to find out what
the sex of the baby is.
Signed*: Care ProviderDate
D M Y
D MMD Y Y
Diagnostic tests (Amniocentesis or CVS) are usually offered to diagnose whether a baby has a chromosomal condition such as
Down’s, Edwards’ and Patau’s syndrome. They are not offered on a routine basis but in certain circumstances such as: a family
history of an inherited problem, a result of a screening test reported as a higher-chance result (page 6), abnormal scan findings
or you have had a previous pregnancy/or baby affected by a genetic condition. It is up to you whether you have further tests.
The risk of miscarriage from either of these tests is about 1 or 2 in a 100 (0.5% to 1%). The health care professionals looking
after you will discuss the options available.
Amniocentesis: involves removing a small amount of the fluid from around the baby using a fine needle. It is usually performed
after 15 weeks of pregnancy.
CVS (Chorionic Villus Sampling): involves removing a tiny sample of tissue from the placenta (afterbirth), using a fine needle.
It is usually performed from 11 weeks to 14 weeks of pregnancy. Occasionally results from a CVS are not clear and you will then
be offered an amniocentesis. There are two types of laboratory test which can be used to look at the baby’s chromosomes – a
full karyotype and a rapid test (PCR). A full karyotype checks all the baby’s chromosomes and takes 2 to 3 weeks for the results
to be available. PCR checks for specific chromosomes and results take up to 3 to 4 working days.
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* Signatures must be listed on page b for identification
Name
Unit No
Name
Unit No/
NHS No
Diagnostic Tests
Ultrasound Scan Details
MRI Scan Details
Date BPD HC AC FL EFW Plac
Lie/
Pres
Doppler Signed *AFGA
Comments
Comments
Comments
Comments
Comments
Comments
Tests explained
NHS Fetal Anomaly
Screening leaflet given
YesNo
YesNo
Comments
No. uterine insertions
Blood stained tap
Needle/cannula gauge
Aspiration method
Results
Date performed
Test offered
Test accepted
Test type Indication
*Signed
D D M M Y Y
D D M M Y Y
Care provider
*Signed
Date
D M Y
D MMD Y Y
D M Y
D MMD Y Y
Anti D required
Comments
Comments
Dating Scan
Anomaly Scan
Date
D M Y
D MMD Y Y
Signed*
LMP
Dates
Special points
for screening
To be entered also on page 17, and in the
customised growth chart programme
This date is used to determine the
best time for the dating scan
Anomaly
leaflet
Pregnancy Assessment
D M Y
D MMD Y Y
Agreed EDD
D M Y
D MMD Y Y
Print out attached to notes
Signed *
Gestation Comments
Yes No
Gestation
W ks
NT
ks DW
W
ks D
Skull & Ventricles
Cerebellum
Heart 4-chamber view
Heart outflows
Arms - 3 bones left
Arms - 3 bones right
Legs - 3 bones left Legs - 3 bones right Placental site
Spine - long
Cord insertion
Stomach / Diaphragm
Spine - Transverse
Kidneys & Bladder
Face
Insert additional sheets here for multiples (eg twins or triplets)
Date FH CRL BPD HC
Print out
(Y/N)
No. of
fetuses
FL
Method of dating
D
FH - Fetal Heart, CRL - Crown Rump Length, BPD - Biparietal Diameter, HC - Head Circumference, FL - Femur Length, NT - Nuchal Translucency
GA - Gestational Age, Pres - Presentation, AC - Abdominal Circumference, EFW - Estimated Fetal Weight,
Plac - Placenta, AF - Amniotic Fluid.
Comments
15
1 9 W E E K S
POSTERIOR
19 WEEKS
1 9+ 3
171.2
152
31.9
POST
NORMAL
FHHR
N/A
N/A
USS
NIL
Y
1
Y
58.4
1.2
1
+4
2
12 WEEKS
N/A
GENDER NOT DEFINED. NO OBVIOUS ABNORMALITIES NOTED
ALTHOUGH ALL ANOMALIES CANNOT BE EXCLUDED.
LISA MOLLOY
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Unit No/
NHS No
Feel free to ask your midwife or doctor – or look at NHS Choices: www.nhs.uk
www.saferpregnancy.org.uk
Blood or blood products are only ever prescribed in specific medical conditions or emergency situations. If you have any
objections about receiving these, please discuss this with your midwife and obstetrician, so that a personalised plan of care
can be made.
Treatment discussed
YesNo
Agrees to receiving blood
or blood products
Management plan initiated
YesNo
YesNo
Signed*
Date
Blood products
Agrees to baby receiving
blood or blood products
YesNo
Pregnant women are more at risk from serious complications of seasonal flu such as bronchitis, chest infection and pneumonia.
Flu in pregnancy also increases the risk of miscarriage, prematurity, fetal growth restriction and stillbirth. It is recommended
you should have the seasonal flu vaccine. It is safe to have at any stage in pregnancy and will pass on protection to your baby
which will last for the first few months of their lives. The vaccine is available from September until January/February and is free
to pregnant women. Ask your GP/pharmacist/ midwife where you can get vaccinated. If you develop flu like symptoms, you
must seek medical advice immediately. There is treatment to reduce the risk of complications.
Seasonal Flu
Flu vaccine given
Antiviral medication
Date given
Medication Dose Signed*
Date commenced
Seasonal flu discussed
No Yes
Agrees flu vaccine
If no, reason declined
Duration of course
Given by whom
No Yes
No Yes
D M YD MMD Y Y
D M Y
D MMD Y Y
D M Y
D MMD Y Y
Some of the information in these notes, about you and your baby will be recorded electronically, this is to help your health professionals
provide the best possible care.
The National Health Service (NHS) also wishes to collect some of this information about you and your baby, to help it to:
• monitor health trends • increase our understanding of adverse outcomes
• strive towards the highest standards • make recommendations for improving maternity care.
The NHS has very strict confidentiality and data security procedures in place to ensure that personal information is not given to unauthorised
persons. The data is recorded and identified by NHS number, and your name and address is removed to safeguard confidentiality. Other
information such as date of birth and postcode are included to help understand the influences of age and geography. In some cases, details
of the care are looked at by independent experts working for the NHS, as part of special investigations (e.g. confidential enquiries) by regional
and/or national organisations, but only after the records have been completely anonymised. While it is important to collect data to improve
the standard and quality of the care of all mothers and babies, you can ‘opt out’ and have information about you or your baby excluded. This
will not in any way affect the standard of care you receive. For further details, please ask your lead professional (page a).
However your information will be shared with other agencies such as safeguarding teams, where there are concerns for you or your child’s
safety. In these cases information will be shared without your consent.
Signed*
Care Provider
Date
Data collection and record keeping discussed
Information Sharing
D M Y
D MMD Y Y
Important symptoms
Most pregnancy symptoms are normal, however, it is important to be aware that certain symptoms might suggest the possibility of
serious pregnancy complications. The ticked boxes indicate which topics have been explained to you. (For further details see pages
14, 17 & 19 or www.nhs.uk for more information). Contact your midwife or maternity unit immediately if any of these occur:
Abdominal (stomach) pains
Membranes (waters) breaking early
Severe headaches
Blurred vision
Itching, especially at night
Changed or reduced fetal movements
Further advice / Comments
Care provider should sign, following discussion with mother
Signature*
Symptom or complaint
Vaginal bleeding
Date
D M YD M Y
Leaflet given
Whooping cough is a serious disease that can lead to pneumonia and permanent brain damage, in some cases a risk of dying.
If you have the whooping cough vaccination during pregnancy, it can help protect your baby from getting the disease in their
first weeks of life. Babies are at an increased risk until they are vaccinated. If you have been vaccinated before or had whooping
cough yourself, the vaccine is still recommended. You should be offered the vaccine from 16 weeks of your pregnancy. If you
have not been offered the vaccine, please ask your midwife or GP where you can get it done. It can be given at the same time
as the flu vaccine.
Whooping cough (Pertussis)
Pertussis discussed
No Yes
Agrees to vaccine
If no, reason declined
No Yes
Vaccination given
Date given
Given by whom
No Yes
D M Y
D MMD Y Y
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BOOKING
BOOKING
BOOKING
BOOKING
BOOKING
LISA MOLLOY
0 1 4 5 6 9 2 4 9 8
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Name
Unit No
Name
Unit No/
NHS No
* Signatures must be listed on page b for identification
Antenatal venous thromboembolism (VTE) assessment - booking and repeat if admitted
Yes
High risk thrombophilia and no VTE
Hospital Admission
Any surgical procedure e.g. appendicectomy
Medical Co-morbidities e.g. cancer, heart failure,
active SLE, IBD or inflammatory polyarthropathy,
nephrotic syndrome, type 1 DM with nephropathy,
sickle cell disease, current IVDU
Any previous VTE except a single event related
to major surgery
Complete risk assessment and update management plan as necessary (page 13)
Age>35 years
Family history of unprovoked or oestrogen-
provoked VTE in first degree relative
Parity ≥3
OHSS (first trimester only)
BMI >30
Smoker
Gross varicose veins
No risks identified
Immobility e.g. paraplegia, PGP
Current pre-eclampsia
Transient risk factors:
Dehydration / hyperemesis
Current systemic infection
Long distance travel
Signature*
Date
M YD MMD Y Y
High risk
Requires antenatal prophylaxis with LMWH
Refer to Trust-nominated thrombosis in pregnancy expert team
Intermediate risk
Consider antenatal prophylaxis with LMWH
Seek Trust-nominated thrombosis in pregnancy expert
team for advice
Lower risk
Mobilisation and avoidance of dehydration
fewer than three risk factors
↓
↑
Update management
plan as necessary
Signature*
Date
D MMD Y YD MMD Y YD MMD Y Y
Four or more risk factors:
prophylaxis from first trimester
Three risk factors:
prophylaxis from 28 weeks
Single previous VTE related to major surgery
IVF/ART
Low risk thrombophilia
High risk thrombophilia and no VTE
Hospital Admission
Any surgical procedure e.g. appendicectomy
Medical Co-morbidities
e.g. cancer, heart failure,
active SLE, IBD or inflammatory polyarthropathy,
nephrotic syndrome, type 1 DM with nephropathy,
sickle cell disease, current IVDU
Any previous VTE except a single event related
to major surgery
Gestation
Age>35 years
Family history of unprovoked or oestrogen-
provoked VTE in first degree relative
Parity ≥3
OHSS (first trimester only)
Smoker
Gross varicose veins
Immobility e.g. paraplegia, PGP
Current pre-eclampsia
BMI > 30
Single previous VTE related to major surgery
IVF/ART
Low risk thrombophilia
Transient risk factors:
Dehydration / hyperemesis
Current systemic infection
Long distance travel
No risks identified
Multiple pregnancy
Multiple pregnancy
Yes
W
ks D
+
Yes
W
ks D
+
Yes
W
ks D
+
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* Signatures must be listed on page b for identification
Name
Unit No/
NHS No
Anaesthetic assessment
D M YD MMD Y Y
Seen by:
Signature*
Date
(Please tick which pathway is indicated)
Manual handling/tissue viability risk assessment
Maternity Payment Pathway System
Referred: to:
NoYes
Signature*
Date
D M YD MMD Y Y
D M YD MMD Y Y
Referred: to:
NoYes
Signature*
Date
Standard Intermediate Intensive
Signature
& date
D M YD MMD Y Y
Risk assessment
Obstetric factors
Mental health factors
Medical factors
Social factors
No Yes
Booking assessment
Referral required
No Yes
Second assessment
No Yes
Gestation
VTE assessment performed
VTE pathway initiated
OGTT booked
Asprin required
To
Review of primary care/GP records
Signature*
D M YD M Y D M YD M Y
Date
BMI pathway initiated
Management Plan updated
W
ks D
W
ks D
Low/Med/
High Risk
Low/Med/
High Risk
+
+
It is important to reassess your individual circumstances throughout the pregnancy as it may mean a change to your plan of care.
Your care providers can record these below.
Comment
Comment
Smoking
Drug/alcohol use
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* Signatures must be listed on page b for identification
Name
Unit No
Name
Unit No/
NHS No
Insert continuation sheets here, and number them 13.1, 13.2 etc
Management plan
Date/Signed *
Referred to
Management plan
Risk factor / special features
Highlight key points in special features box (page 17). If necessary, update the lead professional box on page a.
To deal with special issues during pregnancy, a personalised management plan will outline specific treatment and care agreed between you
and your care providers, including specialists. The aim is to keep you and your baby safe, and to ensure that everyone involved in your care
is aware of your individual circumstances. This plan will be updated and amended during pregnancy to reflect your needs.
Booking
Regular Medication
Drug Dose Frequency Date recorded Comments
e.g. discontinued, dose changed
D MMD Y Y
D MMD Y Y
D MMD Y Y
D MMD Y Y
D MMD Y Y
D MMD Y Y
D MMD Y Y
If you are taking any medicines or tablets, your midwife or doctor will write them here. If your care providers need to change how much
you take as your pregnancy progresses, or you need other medicines, they can also be written here.
D MMD Y Y
D MMD Y Y
D MMD Y Y
D MMD Y Y
D MMD Y Y
D MMD Y Y
D MMD Y Y
D MMD Y Y
D MMD Y Y
D MMD Y Y
D MMD Y Y
19
BOOKING
LISA MOLLOY
0 1 4 5 6 9 2 4 9 8
1 6 WEE KS
200 mg
3/12
LONG TERM FOR ANAEMIA
FERROUS SULPHATE
MIDWIFE LED CARE - UNCOMPLICATED
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PRINTER: Affix special tape here
Feel free to ask your midwife or doctor – or look at NHS Choices: www.nhs.uk
Insert customised growth chart here
Insert customised growth chart here
Antenatal Checks
Cephalic TransverseBreech
Assessing Fetal Growth
It is very important to attend antenatal and scan appointments that are made for you during your pregnancy. If you
cannot attend any appointments, please contact your midwife or the hospital to re-arrange. Your midwife or doctor
will check you and your baby’s health and wellbeing at each of these appointments. Please discuss any worries or
questions that you may have. If you have had any tests or investigations (pages 6 & 8), make sure that you ask for the
results at your next appointment.
Blood pressure (BP) is checked to detect pregnancy induced hypertension or pre-eclampsia (page 19). High blood
pressure may cause severe headaches or flashing lights. If this happens, tell your midwife or doctor immediately.
Urine tests You will also be asked to supply a sample of your urine at each visit to check for protein (recorded as +
or ++ = presence of), which may be a sign of pre-eclampsia and glucose which may be a sign of gestational diabetes.
Fetal movements You will usually start feeling some movements between 16 and 24 weeks. A baby’s movements
can be described as anything from a kick, flutter, swish or roll. You will very quickly get to know the pattern of your
baby’s movements. At each antenatal contact your midwife will talk to you about this pattern of movements, which
you should feel each day up to the time you go into labour and whilst you are in labour too. Become familiar with your
baby’s usual daily pattern of movements and contact your midwife or maternity unit immediately if you feel that
the movements have altered. Do not put off calling until the next day. It is important for your doctors and midwives
to know if your baby’s movements have slowed down or stopped. A change, especially slowing down or stopping,
can sometimes be an important warning sign that the baby is unwell and the baby needs checking by ultrasound and
Doppler. If, after your check up, you are still not happy with your baby’s movements, you must contact either your
midwife or maternity unit straight away, even if everything was normal last time. NEVER HESITATE to contact your
midwife or maternity unit for advice, no matter how many times this happens.
Fetal heart (FH or FHHR - fetal heart heard and regular). If you wish, your midwife or doctor can listen to the baby’s
heart with either a Pinard (stethoscope) or a fetal Doppler. With a Doppler, you can hear the heartbeat yourself. The use
of home fetal Doppler to listen to your baby’s heart beat is not recommended. Even if you detect a heartbeat this does
not mean your baby is well and you may be falsely reassured.
Liquor refers to the amniotic fluid, the water around the baby. A gentle examination of the abdomen can give an idea
of whether the amount is about right (recorded as NAD - no abnormality detected, or just N), or whether there is
suspicion of there being too much or too little, in which case an ultrasound is needed.
Lie and Presentation.
This describes the way the baby lies in the womb
(e.g. L = longitudinal; O = oblique, T = transverse), and which
part it presents
towards the birth canal (e.g. head first or cephalic = C,
also called vertex = Vx;
bottom first or breech = B or Br).
Engagement is how deep the presenting part - e.g. the baby’s head
is below the brim of the pelvis. It is measured by how much can be still felt through the abdomen, in fifths: 5/5 = free;
4/5 = sitting on the pelvic brim; 3/5 = lower but most is still above the brim; 2/5 = engaged, as most is below the brim;
and 1/5 or 0/5 = deeply engaged, as hardly still palpable from above. In first time mothers, engagement tends to happen
in the last weeks of pregnancy; in subsequent pregnancies, it may occur later, or not until labour has commenced.
Accurate assessment of the baby's growth inside the womb is one of the key tasks of good antenatal care. Problems
such as growth restriction can develop unexpectedly, and is linked with a significantly increased risk of adverse outcomes,
including stillbirth, fetal distress during labour, neonatal problems, or cerebral palsy. Therefore it is essential that the
baby's growth is monitored carefully.
Fundal height is
measured every 2-3 weeks from 26-28 weeks onwards, ideally by the same midwife or doctor. The
measurements are taken with a centimetre tape, from the fundus (top of the uterus) to the top of the symphysis (pubic
bone), then plotted on the growth chart. The slope of the measurements should be similar to the slope of the three
curves printed on the chart, which predict the optimal growth of your baby
.
Customised Growth Charts. These notes have been developed to support the use of customised growth charts
which are individually adjusted for you and your baby. The information required includes:
n Your height and weight in early pregnancy
n Your ethnic origin
n Number of previous babies, their name, sex, gestation at birth and birthweight
n The expected date of delivery (EDD) which is usually calculated from the ‘dating ultrasound’
The chart is usually printed after your pregnancy dates have been determined by ultrasound (preferably) or by last
menstrual period. If neither dates are available, regular ultrasound scans are recommended to check that the baby is
growing as expected. For further information about customised growth charts see www.perinatal.org.uk
After the chart is printed, it is attached as page 16, using the stick-on tape on the right of this page.
Growth restriction.
Slow growth is one of the most common problems that can affect the baby in the womb. If the fundal
height measurements suggest there is a problem, an ultrasound scan should be arranged and the estimated fetal weight (degree
of error 10-15%) plotted on the customised chart to assess whether the baby is small for gestational age. If it does record as
small, assessment of Doppler flow is recommended, which indicates how well the placenta is managing the blood supply needed
for the baby. If there is a serious problem, your obstetric team will need to discuss with you the best time to deliver the baby.
Large baby (macrosomia). Sometimes the growth curve is larger than expected. A large fundal height measurement is
usually no cause for concern, but if the slope of subsequent measurements is too steep, your carers may refer you for an
ultrasound scan to check the baby and the amniotic fluid volume. Big babies may cause problems either before or during birth
(obstructed labour, shoulder dystocia etc.). However, most often they are born normally.
20
page
* Signatures must be listed on page b for identification
Name
Unit No
17
Name
Unit No/
NHS No
Special features
Labour, delivery & postnatal
Paediatrician
to be present
Seniority
Reason
EDD
ParaAge
Medications
Key points (from management plan, page 13)
Allergies
BMIHeight
Weight
booking
+
Y YMD D M
Weight
3rd trimester
Paediatric alert form
Yes
SGA or FGR on scan
k g sk g sc m s
+-
BP
booking
Blood
group
Flu vaccine given Yes Declined
Antenatal visits
Care provider should reiterate discussion of important pregnancy symptoms including altered or reduced fetal movements (see pages 10 & 14)
Gest - Gestation; BP - Blood Pressure; Pres - Presentation; Eng - Engagement; Hb - Haemoglobin.
Signed*
Details and advice:(inc. infant feeding, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Emotional wellbeing discussed
Yes
Important symptoms discussed
Yes
Signed*
Details and advice:(inc. infant feeding, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Emotional wellbeing discussed
Yes
Important symptoms discussed
Yes
HbGest
Fetal
heart
BP Urine Pres Lie Eng
LiquorDate/Time
Next
contact
Fetal Movements
Felt
Discussed
Signed*
Details and advice:(inc. infant feeding, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
CO
level
Emotional wellbeing discussed
Yes
Important symptoms discussed
Yes
Signed*
Details and advice:(inc. infant feeding, smoking, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Signed*
Details and advice:(inc. infant feeding, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Emotional wellbeing discussed
Yes
Important symptoms discussed
Yes
Signed*
Details and advice:(inc. infant feeding, smoking, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Signed*
Details and advice:(inc. infant feeding, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Emotional wellbeing discussed
Yes
Important symptoms discussed
Yes
Signed*
Details and advice:(inc. infant feeding, smoking, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Signed*
Details and advice:(inc. infant feeding, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Emotional wellbeing discussed
Yes
Important symptoms discussed
Yes
Signed*
Details and advice:(inc. infant feeding, smoking, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Mental health and wellbeing discussed
Yes
Mental health and wellbeing discussed
Yes
Mental health and wellbeing discussed
Yes
Mental health and wellbeing discussed
Yes
21
2 6
0
MIDWIFE LED CARE
FERROUS SULPHATE
PENICILLIN
✔
PARTNER
✔
PARTNER
✔
-
-
LISA MOLLOY
0 1 4 5 6 9 2 4 9 8
2 3
110/60
1 5 7
6 5
O +
BOO K I NG
8
1 10/60
NAD
NAD
-
YES
-
-
-
128
-
1 6 / 4 0
1 6 WE E K S
1 6
1 10/60
NAD
NAD
-
YES
-
-
-
-
142
-
25 / 4 0
2 5 WE E K S
2 5
1 15/60
NAD
NAD
YES
YES
CEPH
LONG
-
NORM
140
-
2 8 / 4 0
2 8 WE E K S
2 8
1 15/60
NAD
NAD
YES
YES
CEPH
LONG
NAD
NAD
142
-
3 1 / 4 0
BOOKING COMPLETE, LONG TERM ANAEMIA - WELL CONTROLLED WITH FERROUS SULPHATE
200 mg. REVIEW BY GENERAL PRACTITIONER REGULARLY, HAPPY TO SEE GP FOR ANAEMIA.
OTHERWISE WELL.
WELL. NAUSEA HAS SETTLED NOW. BREAST FEEDING DISCUSSED. FERROUS SULPHATE
CONTINUES.
FEELS WELL. MAT B1 COMPLETED AND GIVEN. DISCUSSION REGARDING BIRTH PLAN.
ANTENATAL INFORMATION CLASS BOOKED. PREPARING FOR BABY INFORMATION GIVEN. SAW
HAEMATOLOGIST; FERROUS SULPHATE CONTINUES.
REMAINS WELL. GOOD DIET. CONTINUING TO WORK. NO PROBLEMS. FETAL MOVEMENTS FELT +
++
Sally Brown
Sally Brown
Sally Brown
Sally Brown
✔
✔
✔
✔
page
18
Antenatal visits
Care provider should reiterate discussion of important pregnancy symptoms including altered or reduced fetal movements (see pages 10 & 14)
* Signatures must be listed on page b for identification
Signed*
Details and advice:(inc. infant feeding, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Emotional wellbeing discussed
Yes
Important symptoms discussed
Yes
Signed*
Details and advice:(inc. infant feeding, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Emotional wellbeing discussed
Yes
Important symptoms discussed
Yes
Insert continuation sheets here, and number them.
HbGest
Fetal
heart
BP Urine Pres Lie Eng
LiquorDate/Time
Next
contact
Fetal Movements
Felt
Discussed
Signed*
Details and advice:(inc. infant feeding, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
CO
level
Emotional wellbeing discussed
Yes
Important symptoms discussed
Yes
Signed*
Details and advice:(inc. infant feeding, smoking, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
HbGest
Fetal
heart
BP Urine Pres Lie Eng LiquorDate/Time
Next
contact
Fetal Movements
Felt
Discussed
CO
level
Signed*
Details and advice:(inc. infant feeding, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Emotional wellbeing discussed
Yes
Important symptoms discussed
Yes
Signed*
Details and advice:(inc. infant feeding, smoking, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Signed*
Details and advice:(inc. infant feeding, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Emotional wellbeing discussed
Yes
Important symptoms discussed
Yes
Signed*
Details and advice:(inc. infant feeding, smoking, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Signed*
Details and advice:(inc. infant feeding, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Emotional wellbeing discussed
Yes
Important symptoms discussed
Yes
Signed*
Details and advice:(inc. infant feeding, smoking, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Signed*
Details and advice:(inc. infant feeding, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Emotional wellbeing discussed
Yes
Important symptoms discussed
Yes
Signed*
Details and advice:(inc. infant feeding, smoking, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Signed*
Details and advice:(inc. infant feeding, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Emotional wellbeing discussed
Yes
Important symptoms discussed
Yes
Signed*
Details and advice:(inc. infant feeding, smoking, lifestyle choices, pelvic floor exercises etc.)
/
D MMD Y Y
H M
M
H
W ks
D
+
revisedManagement plan:reviewedAccompanied With
No Yes
Mental health and wellbeing discussed
Yes
Mental health and wellbeing discussed
Yes
Mental health and wellbeing discussed
Yes
Mental health and wellbeing discussed
Yes
Mental health and wellbeing discussed
Yes
Mental health and wellbeing discussed
Yes
22
-
-
PARTNER
3 1 WE E K S
3 1
1 15/60
NAD
NAD
YES
YES
CEPH
LONG
NAD
NAD
138
-
34 / 4 0
3 4 WE E K S
3 4
120/70
NAD
NAD
YES
YES
CEPH
LONG
NAD
NAD
128
-
3 6 / 4 0
3 6 WE E K S
3 6
145 75
NAD
NAD
YES
YES
CEPH
LONG
NAD
NAD
128
3 8 / 4 0
TIRED BUT WELL. DISCUSSION REGARDING GOOD HYDRATION - COMPLAINED OF A HEADACHE
TODAY. BABY REMAINS ACTIVE.
REMAINS WELL. BABY ACTIVE. HAS NOW FINISHED WORK. FURTHER DISCUSSION REGARDING
LABOUR. ATTENDING PARENT EDUCATION CLASSES.
TIRED. BACKACHE. BLOOD PRESSURE RAISED - REFERRAL TO AN ANTENATAL ASSESSMENT
WARD.
Sally Brown
Sally Brown
Sally Brown
✔
✔
✔
✔
✔
✔
page
19
Feel free to ask your midwife or doctor – or look at NHS Choices: www.nhs.uk
www.saferpregnancy.org.uk
Pregnancy symptoms/complications
Common pregnancy symptoms. You may experience some symptoms during pregnancy. Most are normal and will not harm you or
your baby, but if they are severe or you are worried about them, speak to your midwife or doctor. You may feel some tiredness, sickness,
headaches or other mild aches and pains. Some women experience heartburn, constipation or haemorrhoids. There may also be some
swelling of your face, hands or ankles or you may develop varicose veins. Changes in mood and sex drive are also common. Sex is safe
unless you are advised otherwise by your health care team. Complications in pregnancy require additional visits for extra surveillance of
you and your baby’s well-being. Many conditions will only improve after the birth; therefore it may be necessary to induce your labour
or undertake a planned (elective) caesarean section.
Pregnancy sickness is common and for most women symptoms can be managed with changes to their diet and lifestyle. However, it
is not uncommon for pregnancy sickness to be severe and have a serious negative impact on the quality of your life and your ability to
eat and drink and function normally. If this happens, speak to your GP and request anti-sickness medication. These are safe to take at
any stage of pregnancy. It is important to treat pregnancy sickness at an early stage to prevent it from developing into the more serious
condition called hyperemesis gravidarum. If you are sick, wait at least 30 minutes before brushing your teeth or using a mouthwash. This
helps to protect your teeth from tooth decay. For further information visit www.pregnancysicknesssupport.org.uk
Abdominal pain. Mild pain in early pregnancy is not uncommon and you may have some discomfort due to your body stretching and
changing shape. If you experience severe pain, or pain with vaginal bleeding or need to pass urine more frequently - contact your midwife
or nearest maternity unit immediately for advice. Don’t wait until your next appointment.
Vaginal bleeding may come from anywhere in the birth canal, including the placenta (afterbirth). Occasionally, there can be an ‘abruption’,
where a part of the placenta separates from the uterus, which puts the baby at great risk. If the placenta is low lying, tightenings or
contractions may also cause bleeding. Any vaginal blood loss should be reported immediately to your midwife or nearest maternity
unit. You will be asked to go into hospital for tests, and advised to stay until the bleeding has stopped or the baby is born. If you have
rhesus negative blood, you will require an anti-D injection (page 6).
Abnormal vaginal discharge. It is normal to have increased vaginal discharge when you are pregnant. It should be clear or white and
not smell unpleasant. You need to seek medical advice if the discharge changes colour, smells or you feel sore or itchy.
Diabetes is a condition that causes a person's blood glucose (sugar) level to become too high. It may be pre-existing diabetes that is
present before pregnancy, or some women can develop diabetes during their pregnancy (gestational diabetes). High levels of glucose
can cross the placenta and cause the baby to grow large (macrosomia - page 14). If you have pre-existing or gestational diabetes during
your pregnancy, you will be looked after by a specialist team who will check you and your baby’s health and wellbeing closely. Keeping
your blood glucose levels as near normal as possible can help prevent problems/complications for you and your baby. Gestational diabetes
usually disappears after the birth, but can occur in another pregnancy. To reduce your future risks of diabetes: - be the right weight for
your height (normal BMI); eat healthily, cut down on sugar, fatty and fried foods and increase your physical activity (page 20).
High blood pressure. Your blood pressure will be checked frequently during pregnancy. A rise in blood pressure can be the first sign
of a condition known as pre-eclampsia or pregnancy induced hypertension. Contact your midwife or nearest maternity unit immediately
if you get: a severe headache/s, blurred vision or spots before your eyes, obvious swelling (oedema) especially affecting your hands and
face, severe pain below your ribs and or vomiting as these can be signs that your blood pressure has risen sharply. If there is protein in
your urine, you may have pre-eclampsia which in its severe form can cause blood clotting problems and fits. It can be linked to problems
for the baby such as growth restriction. Treatment may start with rest, but some women will need medication that lowers high blood
pressure. Occasionally, this may be a reason to deliver your baby early.
Thrombosis (clotting in the blood). Your body naturally has more clotting factors during pregnancy which helps prevent losing too much
blood during labour and birth. However, this means that all pregnant women are at a slightly increased risk of developing blood clots during
pregnancy and the first weeks after the birth. The risk is higher if you are over 35, have a BMI >30, smoke, or have a family history of
thrombosis. Contact your midwife or nearest maternity unit immediately if you have any pain or swelling in your leg, pain in your chest or
cough up blood.
Intrahepatic cholestasis in pregnancy (ICP) also known as obstetric cholestasis, is a liver condition in pregnancy that causes itching
on the hands and feet, but may occur anywhere on your body and is usually worse at night. It affects 1 in 140 women in the UK every
year. Having this condition may increase your risk of having a stillbirth, so you will receive closer monitoring of you and your baby’s health
during your pregnancy. If you have itching, blood tests will be offered to check if you have ICP. Treatment includes medication, regular
blood tests and having your baby at or around 37-38 weeks. After the birth, the itching should disappear quite quickly. A blood test to
check your liver function will be carried out before you are discharged from hospital after the birth and repeated about 6-12 weeks later.
Prematurity. Labour may start prematurely (before 37 weeks), for a variety of reasons. If you are planned to give birth in a birth
centre/midwifery unit or at home, you will be advised to transfer your care to a maternity unit with a neonatal unit/special care baby
facility. If labour starts before 34 weeks, most maternity units have a policy of trying to stop labour for at least 1-2 days, whilst offering
you steroid injections that help the baby’s lungs to mature. However, once labour is well established it is difficult to stop. Babies born
earlier than 34 weeks may need extra help with breathing, feeding and keeping warm.
Breech. If your baby is presenting bottom or feet first this is called a breech position (page 14). If your baby is breech at 36 weeks, your
health care team will discuss the following options with you: trying to turn your baby (ECV = external cephalic version); planned (elective)
caesarean section or a planned vaginal breech birth.
Multiple pregnancies. Twins, triplets or other multiple pregnancies need closer monitoring which includes frequent tests and scans,
under the care of a specialist healthcare team. You will be advised to have your babies in a consultant led maternity unit that has a neonatal
unit. Your healthcare team will discuss your options on how best to deliver your babies. It will depend on how your pregnancy progresses,
the position that your babies are lying and whether you have had a previous caesarean section.
Infections .Your immune system changes when you are pregnant and you are at a higher risk of developing an infection. It is very important
that if you are unwell and are experiencing any of the following symptoms, please seek immediate medical advice as treatment may be
required: - high temperature of 38C or higher, fever and chills, foul smelling vaginal discharge, painful red blisters/sores around the
vagina/bottom or thighs, pain or frequently passing urine, abdominal pain, rash, diarrhoea and vomiting, sore throat or respiratory infection.
Avoid unprotected sexual contact if your partner has genital herpes and avoid oral sex from a partner with a cold sore. Wash your hands
if you touch the sores. Wherever possible, keep away from people with an infection e.g. diarrhoea and sickness, cold/flu, any rash illness.
Group B Streptococcus (GBS) is a common bacterium carried by some women and rarely causes symptoms or harm. It can be detected
by testing a urine sample or a vaginal or rectal swab. In some pregnancies, it can be passed on to the baby around the time of birth, which
can lead to serious illness in the baby. The national recommendation is to offer antibiotics to women as soon as labour starts if: -
• GBS has been detected during the current pregnancy. • you have previously had a baby who developed a GBS infection. • you have a
high temperature (38
o
C or over) in labour. • you go into labour prematurely. • GBS was detected in a previous pregnancy and your baby
was not affected, you should be offered antibiotics in labour or be offered a test to screen for GBS late in pregnancy. If the test is positive
you will be offered antibiotics in labour.
23
page
20
Feel free to ask your midwife or doctor – or look at NHS Choices: www.nhs.uk
General information
Work and benefits. The ‘Parents Guide to Money’ is available via www.moneyadviceservice.org.uk and provides information on financial
aspects of having baby. You should discuss your options regarding maternity leave and pay with your employer early in pregnancy. An
FW8 certificate will be issued in early pregnancy entitling you to free prescriptions / dental treatment. Your midwife will issue your
maternity certificate from 20 weeks of pregnancy (Mat B1) to claim your entitlements. If you are under 18 or receive certain benefits,
you may be entitled to Healthy Start vouchers for free milk, fruit, vegetables and vitamins.
Dentist. It is important that you are registered with a dentist and have regular check-ups. Changes in your hormone levels and diet may
make your mouth more prone to disease which can lead to tooth decay. It is recommended that you brush your teeth twice a day for
at least two minutes.
Health and Safety issues. If you are working, your employer has a responsibility to assess any health and safety risks to you. For further
information contact your occupational health department or visit www.hse.gov.uk
Healthy eating. Make sure you eat a variety of different foods to get the right balance of nutrients for your growing baby and for your
body to deal with the changes taking place. You may feel hungrier than usual, but you don’t need to “eat for two”. It is recommended
that you should only increase your calorie intake by 200 calories per day during the last 3 months of pregnancy. Maintaining a healthy
weight during pregnancy can reduce the risk of complications for pregnancy, labour and birth. Dieting during pregnancy is not recommended
as it may harm the health of your baby. It is important to prepare and cook your food carefully to prevent food poisoning. Foods such as
ready meals, meat, poultry, shellfish and eggs need to be thoroughly cooked. Avoid pâté and mould-ripened soft cheeses; liver and liver
products and unpasteurised milk. You can safely eat peanuts during pregnancy or food containing peanuts (e.g. peanut butter), unless
you are allergic to peanuts or your health professional advices you not to. Have no more than 2 portions of oily fish a week and avoid
marlin, swordfish and shark. It is recommended that you take supplements of folic acid, which helps to prevent abnormalities in the baby,
e.g. spina bifida. The recommended dose is 0.4mg per day while you are planning to get pregnant and up to 13 weeks of pregnancy. If
you have: diabetes, BMI >30, taking anti-epileptic drugs or have a family history of fetal anomalies, the recommended dose is 5mg per
day. This is available on prescription from your GP. Vitamin D is needed for healthy bones, teeth and muscle development. To protect
you and your baby from any problems caused by low levels, a 10mcgs Vitamin D supplement is recommended. (this is contained in the
“Healthy Start” vitamins). Check with your midwife /GP/pharmacist if you are taking any other over the counter vitamins/supplements.
Vitamin A can cause harm to your baby if you take too much, so don’t take any supplements containing vitamin A (retinol). If you have
any questions about the food you eat, discuss with your midwife who can refer you to a dietitian if needed.
Body Mass Index is a guide to a healthy weight for your height and is calculated by dividing your weight in kilograms by your height in
metres squared. During pregnancy, there are increased risks if your BMI is less than 18 or more than 30.
Caffeine is a stimulant that is contained in tea, coffee, chocolate, energy and cola drinks. During pregnancy, its recommended that you
limit your daily caffeine intake is 200mgs per day. Try decaffeinated versions of tea/coffee or cola drinks.
Alcohol increases the risk of miscarriage, stillbirth, fetal growth restriction, premature labour and may lead to fetal alcohol spectrum
disorder (FASD) or fetal alcohol syndrome (FAS). Therefore, its recommended that pregnant women AVOID drinking alcohol during
their pregnancy. Alcohol crosses the placenta into the blood stream of your baby and could affect how your baby grows and develops.
Your midwife will ask you at your first appointment how many units of alcohol you drink. If you are finding it hard to stop drinking alcohol,
ask for help from your midwife/GP. They can help you and refer you for specialist support.
Drugs. Taking street drugs, including cannabis and psychoactive substances e.g. spice, meow meow (MCAT) during pregnancy is NOT
recommended; it may seriously harm you and your baby. If you take any prescription medication, you must discuss this with your GP to
ensure they are safe to continue. Check with your pharmacist about taking over the counter medicines especially pain killers containing
codeine which can become addictive.
Carbon Monoxide (CO) is a poisonous gas produced when tobacco products are burnt. It is found in inhaled, exhaled and passive
smoke. The CO replaces some of the oxygen in your bloodstream which means that both you and your baby have lower levels of oxygen
overall. As part of routine antenatal care your midwife will test your CO levels. Environmental factors such as exhaust fumes or leaky
gas appliances may also cause a high reading.
Smoking When you smoke, carbon monoxide, nicotine and other toxic chemicals cross the placenta directly into the baby’s blood stream
- so the baby smokes with you. This will reduce its oxygen and nourishment, and put your baby at risk of low birth weight, stillbirth,
premature birth and other problems. The sooner you stop smoking the better, to give your baby a healthy start in life. Your midwife can
refer you to a local stop smoking service for expert and friendly support to help you stop. If you need help to manage nicotine cravings
the safest products to use are nicotine replacement therapies such as patches and gum. If using an e-cigarette helps you to quit smoking
and stay smoke free, it is considered far safer for you and your baby than continuing to smoke. However, the potential risks to your baby
from exposure to e-cigarettes are not fully understood. It is illegal to smoke in a car or any other vehicle with people who are under the
age of 18. This is to protect babies, children and young adults from second hand smoke.
Home fire safety checks are available free of charge by your local fire service. All homes should have a working smoke alarm.
Hygiene. When you are pregnant your immune system changes and you are more prone to infections. It is important that you try to
reduce the risk of infections with good personal hygiene: washing your hands properly before and after preparing food, using the toilet
or sneezing/blowing your nose. Always wear gloves when gardening or handling cat litter as toxoplasmosis can be found in cat faeces. If
you feel unwell, have a sore throat or respiratory infection contact your midwife or GP immediately, you may need treatment.
Travel. If you are planning to travel abroad, you should discuss flying, vaccinations and travel insurance with your midwife or GP.
Car safety. To protect you and your unborn baby, always wear a seatbelt with the diagonal strap across your body between your breasts
and the lap belt over your upper thighs. The straps then lie above and below your ‘bump’, not over it.
Relationships. Some women find pregnancy to be a time of increased stress and physical discomfort. It can greatly affect your emotional
state, your body image and relationships. Discuss any problems or concerns you have with your midwife or GP.
Domestic abuse. 1 in 4 women experience domestic abuse at some point in their lives, and can start during pregnancy. There are
different kinds of abuse including physical, sexual, financial control, mental or emotional abuse. Where abuse already exists, it has been
shown that it may worsen during pregnancy and after the birth. Domestic abuse can lead to serious complications which affect you and
your baby. You can speak in confidence to your healthcare team who can offer help and support. You may prefer to contact a support
agency such as The National Domestic Violence Helpline.
Physical activity. Being active during pregnancy means you’re likely to maintain a healthier weight and can cope better with the physical
demands of pregnancy and labour. Physical activity during pregnancy is known to improve fitness, reduce high blood pressure and prevent
diabetes in pregnancy. There is no evidence of harm and walking for 150 minutes each week can keep you and your baby healthy. It can
also give you more energy, help you sleep better and reduce feelings of stress, anxiety and depression. Every activity counts in bouts of
at least 10 minutes. If you are already active, keep going, if you are not active start gradually. Activity can include walking, dancing, yoga,
swimming and walking up the stairs.
Pelvic floor exercises. It is recommended that you do pelvic floor exercises during pregnancy to help strengthen this group of muscles.
Your midwife will advise you how to do these.
Family and friends test. The survey has been designed for the NHS and your hospital to gain feedback on the services you have received.
It is a quick and anonymous way to give your feedback. For further information discuss this with your midwife.
24
page
21
* Signatures must be listed on page b for identification
Name
Unit No
Name
Unit No/
NHS No
Your carers
Midwife. Your midwifery team are usually the main care providers throughout your pregnancy. They provide care and support
for women and their families during pregnancy, childbirth and the early days after the birth. They will work in partnership with
you and your family to ensure you can make informed decisions about your care. Your midwives will arrange to see you at clinics
in the local community and will visit you at home after the birth of your baby. If you need to contact your midwife please refer
to the telephone numbers on page a of this booklet.
Student Midwives. Will work under the supervision of a qualified midwife. Students will be undertaking a degree course at a
university, but will spend time gaining experience in a clinical setting e.g. labour ward, antenatal clinic.
Maternity Support Workers. Support midwives as part of the midwifery team. They have had appropriate training and
supervision to provide information, guidance, reassurance and support for example with antenatal classes; infant feeding; which
improves the quality of care that the midwife is able to provide to you, your partner and your baby.
Obstetricians and Maternal-Fetal Medicine Specialists (MFM) are doctors who specialise in the care of women during
pregnancy and childbirth. You may be referred to their care at the beginning of your pregnancy if you already have a medical
problem, or during pregnancy if there are any concerns about your health or the health of the baby. They will discuss with you
a plan of care.
Health Visitors work within the NHS. All are qualified nurses/midwives who have done additional training in family and child
health, health promotion and public health development work. They work as part of a team alongside your GP, other community
nurses and your midwives. Your health visitor will visit you at home after you have had your baby, but will also see you during
your pregnancy.
General Practitioner (GP). Doctors who work in the community, providing care for all aspects of health for you and your
family throughout your lifetime.
Specialists. Some women with medical problems, such as diabetes, may need to be referred to a specialist for additional care
during pregnancy. They may continue to provide care for you after you have had your baby.
Ultrasonographers are specially trained to carry out ultrasound scans. They will perform your dating, mid-pregnancy (anomaly)
and any other scans you may need, based on your individual needs.
Plans for Pregnancy
Update management plan (page 13) as required
Social & Health Assessment Completed
Signature*
Date
M Y
D M YD M Y
Topics
Discussed
Your intentions or preferences
Travel safety
N/A
Employment rights
Maternity benefits
Health and safety issues
Healthy eating
Registered with a Dentist
Hygiene
Caffeine
Alcohol consider using an alcohol screening tool
(e.g. AUDIT-C)
Drugs
Physical activity
Pelvic floor excercise
Stresses in pregnancy
Feelings about pregnancy
Sex in pregnancy
Seat belts
Vitamin D / Healthy Start Vitamins
Support at home
Leaflets
given
Start date:
D M YD MMD Y Y
Signature*
and Date
Email:
D M Y
Please supply your email address to receive regular information and advice throughout your pregnancy and afterwards.
Self referral - home fire safety check
Working smoke alarm
Family and Friends test
Smoking
Effect on baby
Effect on mother
Smoke free homes
First appointment with smoking
cessation services
D M YD MMD Y Y
Quit date set
D M YD MMD Y Y
Start4Life Information Service for Parents is a free NHS service for mums and dads offering regular emails or texts throughout your pregnancy and beyond.
Get trusted NHS approved information, advice and tips including baby development, preparing for birth and what to expect as your baby grows, from
breastfeeding to immunisations and development stages, as well as wider advice on healthy lifestyles and how to find local support. Search Start4Life online
to sign up now. www.nhs.uk/start4life
Topics
Discussed
Your intentions or preferences
Travel safety
N/A
Employment rights
Maternity benefits
Health and safety issues
Healthy eating
Registered with a Dentist
Hygiene
Caffeine
Alcohol consider using an alcohol screening tool
(e.g. AUDIT-C)
Drugs
Physical activity
Pelvic floor exercises
Stresses in pregnancy
Feelings about pregnancy
Sex in pregnancy
Seat belts
Vitamin D / Healthy Start Vitamins
Support at home
Leaflets
given
Start date:
D M YD MMD Y Y
Signature*
and Date
Email:
D M Y
Please supply your email address to receive regular information and advice throughout your pregnancy and afterwards.
Self referral - home fire safety check
Working smoke alarm
Family and Friends test
Smoking
Effect on baby
Effect on mother
Smoke free homes
First appointment with smoking
cessation services
D M YD MMD Y Y
Quit date set
D M YD MMD Y Y
Start4Life Information Service for Parents is a free NHS service for mums and dads offering regular emails or texts throughout your pregnancy and beyond.
Get trusted NHS approved information, advice and tips including baby development, preparing for birth and what to expect as your baby grows, from
breastfeeding to immunisations and development stages, as well as wider advice on healthy lifestyles and how to find local support. Search Start4Life online
to sign up now. www.nhs.uk/start4life
25
16 WEEKS
1 6 W E E K S
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Feel free to ask your midwife or doctor – or look at NHS Choices: www.nhs.uk
Preparing for your new baby
Antenatal classes are an opportunity for you and your partner to find out about pregnancy, labour, birth and becoming new
parents. Ask your midwife/health visitor what is available in your area to suit you. There are often special classes for teenagers,
parents expecting multiple babies and non-English speaking parents.
Safe sleeping. New babies have a strong desire to be close to you after birth as this will help them to feel secure and loved.
Sudden Infant Death Syndrome (SIDS) is a sudden and unexpected death of a baby where no cause is found. While SIDS is rare,
it can still happen and there are steps parents can take to reduce the risk of it happening. These include: • Place your baby on
their back to sleep, in a cot or Moses basket in the same room as you for the first 6 months • Do not smoke in pregnancy or
let anyone smoke in the same room as your baby • Do not share a bed with your baby if you have been drinking alcohol, taken
drugs or if you are a smoker • Never sleep with your baby on a sofa or armchair • Do not let your baby get too hot or too
cold, keep your baby’s head uncovered • Place your baby in the “feet to foot” position. • Breastfeed your baby. • Infant
immunisations reduce the risk of SIDS. • Seek medical help if your baby is ill. For further information: www.lullabytrust.org.uk
Equipment. Every new parent needs some essentials for their new baby. In the early days, you will need clothes and nappies.
It may be advisable not to get too many until after your baby is born, so that you know what size to buy. You need something
for your baby to sleep in such as a cot or Moses basket. If you have a car, you must have a car seat and your baby must travel
in their seat. Think about other ways of carrying your baby when you are out, such as baby carriers/slings or prams/pushchairs.
Newborn screening. After birth, your baby will be offered some screening tests. The blood spot test is designed to identify
those few babies who may be affected by PKU, cystic fibrosis, congenital hypothyroidism, MCADD, MSUD, HCU, IVA, GA1
and haemoglobinopathy disorders. Two detailed examinations of the baby will be performed, one within 72 hours of the birth
and one is when your baby is 6-8 weeks old. These check your baby’s eyes, heart and lungs, nervous system, abdomen, hips
and testes (in boys). The hearing test is designed to find babies who have a hearing loss. Your midwife will give you a leaflet
explaining these screening tests. For further information visit www.screening.nhs.uk/annbpublications
Vitamin K. We need vitamin K to make our blood clot properly so we do not bleed easily. To reduce the risk of a bleeding
disorder, your baby should be offered vitamin K after birth. The most effective way of giving this is by an injection (oral doses
may be an option).
BCG. This is a vaccine offered to all babies who may be at higher than average risk from contact with TB (tuberculosis). These
include babies whose families come from countries with a high incidence of TB such as Asia, Africa, South and Central America
and Eastern Europe or babies born in a town or city where there is a high rate of TB. It is also offered to babies who have a
relative or close contact with TB, have a family history of TB in the past 5 years or who plan to travel to a high-risk country to
stay for more than three months. TB is a potentially serious infection which usually affects the lungs, but can also affect other
parts of the body. Treatment is with antibiotics. The BCG vaccination is usually given to the baby early in the postnatal period,
but in some circumstances, it may be delayed. Some maternal medical conditions or specific medications taken in pregnancy
can affect the immune system of the baby. In these instances, the vaccination should be delayed for about 6 months after the
baby is born. Please discuss this with your midwife if you think this may apply to your baby. Further information can be found
in the leaflet “TB, BCG vaccine and your baby” or visit www.nhs.uk/vaccinations
Hepatitis B. Some people carry the hepatitis B virus in their blood without having the disease itself. If a pregnant mother has
or carries hepatitis B, or catches it during pregnancy, she can pass it onto her unborn baby. Babies born to infected mothers are
at risk of getting this infection and should receive a course of vaccine and a test at twelve months to exclude infection. The first
immunisation will be offered soon after birth and then at one, two, three, four and twelve months.
Connecting with your baby. Taking time out to begin to develop a relationship with your unborn baby will have a positive
impact on your baby’s wellbeing and their brain to grow. You can begin to connect through talking or singing to your baby bump
and noticing when your baby has a pattern of movements. It is lovely to include your partner and / or other children too.
Greeting your baby for the first time. Holding your baby in skin to skin contact soon after birth is the perfect way to say
hello. Skin contact will help you both to feel calm, give you time to rest, keep warm and get to know each other. As your baby
recognises your voice and smell, they will begin to feel safe and secure. Take time to notice the different stages your baby goes
through to get ready their first feed.
Responding to your baby’s needs. New babies have a strong desire to be close to their parents as this will help them to feel
secure and loved. When babies feel secure they release a hormone called oxytocin which helps their brain to grow and develop.
If you are breastfeeding you can offer your baby your breast when he/she shows signs of wanting to feed, when they just want
a cuddle, if you need to fit in a quick feed or if you want to sit down and have a rest. If you choose to bottle feed, your baby will
enjoy being held close, and fed by you and your partner rather than by lots of different people.
Feeding your baby. You may already have some thoughts about how you will feed your baby, based on previous experience
or what others have told you. However, you don’t have to decide until after your baby is born. Breastfeeding provides everything
your baby needs to grow and develop. It also helps protect and comfort your baby. Your midwife will be happy to talk to you
about this. Further information can be found via: www.bestbeginnings.org.uk. If you decide to use formula milk to feed your
baby, your midwife will give you information about how to hold your baby for feeding and how to make up feeds safely.
Contraception. You need to start using contraception from 3 weeks after the birth. Don’t wait for your periods to return or
until you have had your postnatal check-up before you use contraception, you can get pregnant again before then. Longer lasting
methods e.g. Depo injection, implant and IUD/IUS (coil) are effective because you don’t have to remember to take pills or do
any preparation before you have sex and they are safe to use if you are breastfeeding. A coil can be fitted at the time of a planned
caesarean section, if this is something you are interested in having, speak to your midwife or obstetrician about it. For further
information about contraception visit www.fpa.org.uk
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* Signatures must be listed on page b for identification
Name
Unit No/
NHS No
Plans for Pregnancy and Parenthood
Topics
Discussed
Your intentions or preferences
Signature*& Date
Leaflets
given
Responding to your baby’s needs
Feeding your baby
Equipment
Newborn blood spot test
Preparing for your new baby
Home environment
Newborn physical examination
Parent education
Safe Sleeping
Vitamin K
Newborn hearing test
BCG discussed
Baby BCG indicated
Mother agrees to vaccine
Connecting with your baby
Talking to your baby
Noticing/responding to baby’s movements
How this can help your baby’s brain
development
Importance of comfort and love to help baby’s
brain develop
Responsive feeding
Value of breastfeeding as protection, comfort
and food
Getting off to a good start
Understanding how a baby breastfeeds
Where to get help including local support
groups
D M Y
D MMD Y Y
No Yes
If no, reason declined
Reason:
No Yes
No Yes
Greeting your baby for the first time
Skin to skin contact
Keeping baby close
Recognising feeding cues
Contraception
What methods of contraception
have you used in the past?
Postnatal contraceptive
plan made?
No Yes
Contraception method of choice
and who will provide this
Confirmation that a conversation has taken place around the topics outlined above
Comments
*
Signature & date
M Y
D M YD M Y
M Y
M Y
D M YD M Y
M Y
M Y
D M YD M Y
M Y
D M Y
D MMD Y Y
D M Y
D MMD Y Y
D M Y
D MMD Y Y
D M Y
D MMD Y Y
D M Y
D MMD Y Y
27
LISA MOLLOY
0 1 4 5 6 9 2 4 9 8
2 5 WE E K S
1 6 WE E K S
2 8 WE E K S
3 4 WE E K S
3 4 WE E K S
NOT APPLICABLE
HOPING TO BREASTFEED.
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Sally Brown
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Sally Brown
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Feel free to ask your midwife or doctor – or look at NHS Choices: www.nhs.uk
Labour and Birth
Choosing where to have your baby. Depending upon your individual needs and what services are available locally, you and
your partner will be able to choose where to have your baby. This may be at home, supported by a midwife, or in a midwifery
unit or birth centre. These are either based in the community or in hospital and they promote natural labour and childbirth.
Alternatively, you may choose to deliver in hospital supported by a maternity team. The team may include midwives, obstetricians,
paediatricians and anaesthetists. When making your choice it is important to consider all your personal circumstances and any
additional care needs you or your baby may need. You can discuss your wishes and options available with your midwife and/or
obstetrician if there are any pregnancy concerns. It may be possible for you to visit the unit during your pregnancy. This will give
you the opportunity to find out more about the facilities available. (Please note hospital sites are a smoke free environment.) You
may be given a list of things to bring to the birth centre or hospital when you go into labour e.g. something comfortable for you
to wear during labour, bras, pants, sanitary towels, toiletries, towels, dressing gown and slippers. For your baby: clothes and
nappies, a shawl or blanket and outdoor clothing.
Signs of labour. Most labours start spontaneously with irregular contractions. They will become more often, last longer and
feel stronger. It can take up to 24 hours for this to happen and you can stay at home until your contractions become stronger
and more regular. You may also have backache. The contractions are widening and shortening the neck of the womb. Sometimes
the waters break before labour starts, this is called spontaneous rupture of membranes (SROM). It can be a gush, leak or a trickle
of amniotic fluid which you cannot control. If you think your waters have broken or you are having strong regular contractions
you should contact staff in the delivery suite, who will advise you what you need to do. You may need an assessment, which could
include a vaginal examination. If your waters have broken, but you are not in labour, swabs will be taken to check for infection.
Labour often starts within a day of SROM. When you do go to hospital remember to take these notes and an overnight bag with
you. If there have been any pregnancy complications e.g. you have developed diabetes in your pregnancy or scans have shown
growth restriction with your baby, contact the delivery suite as soon as you start having regular contractions.
Inducing labour. It may be necessary to start your labour if there are problems in the pregnancy e.g. high blood pressure,
concerns about the baby’s growth or if you are 10-14 days overdue. If you are ‘overdue’ your midwife will offer you a membrane
sweep at 41 weeks. This is a vaginal examination which stimulates the neck of the womb, which may trigger labour. Contractions
can be started by inserting a pessary or gel into the vagina. It may take 24-48 hours to get you into labour, sometimes a hormone
infusion (drip) is used to speed up the labour. You and your baby will be closely monitored.
Assessment of progress. Many factors play a part in the way your labour progresses – including the ‘three Ps’: The POWERS
(how strong and effective the contractions are); the PASSAGE (the shape and size of your pelvis and birth canal) and the PASSENGER
(the size of the baby, and which way it is lying). Progress is assessed as necessary, and includes external and internal examinations
to check whether the baby is moving down in the birth canal and whether the cervix is opening.
Monitoring the baby during labour. Your baby’s heart beat will be monitored during labour. This is to detect any changes that
could suggest your baby is becoming distressed. The midwife can use; a Pinard stethoscope or a fetal Doppler to listen intermittently,
or continuously with a monitor. This will depend on your risk at the onset and during your labour.
Posture during labour and birth. You will be encouraged to move around during labour unless your chosen pain relief makes
this difficult. During the active pushing phase, many mothers wish to remain upright; there is evidence that birth can be easier in
a squatting or kneeling position. It is important that you find the position which is most comfortable for you.
Eating and drinking. If you feel like eating and drinking during labour, it is advisable you eat light meals and drink fluids, to keep
your energy levels up. Sometimes it is recommended you do not eat and drink, the midwife caring for you during labour will
advise you based on your individual circumstances.
Pain relief. Labour is painful, it is important to learn about all the ways you can ease the pain. There are many options and most
mothers do not know how they will feel or what they need until the day. In early labour, you may find: a warm bath, ‘TENS’
machine, breathing exercises and massage helpful. Other methods include: Entonox (gas and air), intramuscular injections of pain
relieving drugs, and epidurals. It is important to keep an open mind, choose what you feel you need.
Previous caesarean section. If you have had one caesarean section in the past you have a good chance (around 75%) of having
a vaginal birth this time. This is known as VBAC (vaginal birth after caesarean section). Your midwife/obstetrician will discuss with
you the reason for your last caesarean and options for childbirth this time. Labour after a previous caesarean section is monitored
more closely, in hospital, to make sure the scar on your uterus (womb) does not tear. If you have had two or more caesarean
sections in the past, your obstetrician will discuss with you the safest type of birth for this pregnancy.
Caesarean section. There are times when it is the safest option to have a caesarean section. A caesarean section involves major
surgery and should only be carried out for good reasons. The operation involves delivering your baby through a cut in your
abdomen. The cut is usually made just below the bikini line. It is usual for you to be awake during the operation, with an epidural
or spinal anaesthetic. A caesarean section may be planned e.g. if your baby is breech and did not turn (page 19). It may be done
as an emergency during labour, if your baby is distressed or the labour is unduly prolonged.
Instrumental delivery. Extra help may be needed if you have already progressed to pushing, but the delivery needs to be
speeded up. This could be because you are tired or your baby is becoming distressed. The ventouse method uses a suction cup
that fits on your baby’s head, while forceps are a pair of spoon-shaped instruments that fit around the head. The obstetrician
will decide which one to use at the time, based on the clinical situation.
Episiotomy and Tears. The perineum (area between the vagina and anus) stretches to allow the baby to be born. It usually
stretches well, but sometimes may tear. An episiotomy is a cut to make the vaginal opening larger. It is not done routinely but
may be necessary: to avoid a larger and more damaging tear, to speed up the birth if the baby is becoming distressed or at the
time of an instrumental delivery. You will have a local anaesthetic to freeze the area, or if you've already had an epidural, the dose
can be topped up before the cut is made. The same applies if stitches (sutures) are needed to repair the episiotomy or the tear.
The stitches will dissolve and will not need to be removed.
The placenta (afterbirth). The placenta and membranes usually deliver soon your baby is born. You will be offered an oxytocin
injection in your thigh which helps the uterus to contract more quickly and reduces the risk of heavy bleeding (postpartum
haemorrhage, PPH). Putting the baby straight to the breast helps release natural oxytocin hormone. Your baby’s umbilical cord
will usually be clamped and cut within 1 and 5 minutes following birth. This delay allows your baby to carry on benefiting from
blood from the placenta. This will depend on the way your baby responds immediately after birth.
28
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25
* Signatures must be listed on page b for identification
Name
Unit No/
NHS No
Preferences for birth
The birth of your baby is a very exciting time. The healthcare team looking after you will discuss the different options for
where you can give birth e.g. at home, at a midwifery unit or maternity unit. You may want to make a record of what you
would like to happen, such as what pain relief you would like or who you want to support you during labour and birth. A
personalised plan can then be developed between you and your carers, which outlines your choices/preferences.
Where to have your baby
Hospital / birth centre visit
What to bring
Who will be present
Can students be present
Topics
Discussed
Your comments
Leaflets
given
Delivery of placenta
Active management
Physiological
Delayed cord clamping
Signs of labour
contractions
waters breaking
Inducing labour
methods used
reason
Assessment during labour
of progress
of mother
of baby - including
fetal heart monitoring
Posture
during labour
during delivery
Eating and drinking
Pain relief
natural methods
entonox (gas and air)
injections
epidural/spinal
Caesarean section
Ventouse
Forceps
Breech
Water birth
Perineum
episiotomy
tear
Vaginal birth
Signature*
and Date
D M Y
D MMD Y Y
D M Y
D MMD Y Y
D M Y
D MMD Y Y
D M Y
D MMD Y Y
D M Y
D MMD Y Y
D M Y
D MMD Y Y
D M Y
D MMD Y Y
D M Y
D MMD Y Y
VBAC
29
WANTS TO AVOID INDUCTION OF
LABOUR.
2 8 WE E K S
2 8 WE E K S
AGREEMENT FOR ANY NECESSARY
ASSESSMENTS.
WOULD LIKE TO BE AS MOBILE AS
POSSIBLE.
WILL ACCEPT PAIN RELIEF AS REQUIRED.
HOPE TO AVOID/NO NEED AN EPIDURAL.
2 8 WE E K S
DOES NOT WANT A WATER BIRTH.
2 8 WE E K S
ACTIVE MANAGEMENT REQUESTED.
LISA MOLLOY
0 1 4 5 6 9 2 4 9 8
2 8 WE E K S
2 8 WE E K S
2 8 WE E K S
2 8 WE E K S
WANTS TO HAVE BIRTH IN HOSPITAL.
HOME AS SOON AS POSSIBLE.
PARTNER TO BE PRESENT.
STUDENTS WELCOME.
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Sally Brown
Sally Brown
Sally Brown
Sally Brown
Sally Brown
Sally Brown
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Any questions or comments?
This space is for you to write any questions or concerns you wish to discuss with your midwife, including any concerns you might have
about how you are feeling about your pregnancy, birth and looking after your baby.
Feel free to ask your midwife or doctor – or look at NHS Choices: www.nhs.uk
30
Abbreviations
page
27
AC
AF
BCG
BMI
BN
BP
BPD
Br
CAF
CCT
Ceph
CMW
CO
Con
CP
CRL
CTG
DVT
ECV
EFW
FH / FHHR
FBS
F/T
ETT
GA
GDM
GP
Hb
HELLP
CVS
EBL
EDD
Eng
FL
FY
FMF
GBS
Gest
Gms
HC
HDU
HV
HVS
Abdominal circumference
Amniotic fluid - fluid around your baby in the womb
Bacillus Calmette–Guérin, vaccine against TB
ART
Assisted reproductive technology
Body mass index
Batch number
Blood pressure
Bi-parietal diameter
Breech
Common assessment framework
Controlled cord traction
Cephalic
Community midwife
Carbon monoxide
Consultant
Civil partner
Crown rump length
Cardiotocograph
Deep vein thrombosis
External cephalic version
Estimated fetal weight
Fetal heart / Fetal heart heard regular
Fetal blood sampling
Chorionic villus sampling
Estimated blood loss
Expected date of delivery
Engaged
Femur length
Full time
Gestational age
Gestational diabetes
General practitioner - family doctor
Haemoglobin
Haemolysis Elevated Liver Enzymes Low Platelets
Foundation year doctor
Fetal Movements Felt
Group B streptococcus
Gestation
Grams
Head circumference
High dependency unit
Health Visitor
High Vaginal Swab
IOL Induction of labour
Endotracheal tube
FGR Fetal growth restriction
HCU
Homocystinuria (pyridoxine unresponsive)
GA1
Glutaric aciduria Type 1
DM Diabetes mellitus
IBD
Inflammatory bowel disease
PIH Pregnancy induced hypertension
PV Per vaginam
SLE Systemic lupus erythematosus
SGA Small for gestational age
Resp Respirations
PET Pre-eclampsia/eclampsia
Palp Palpation
PND Postnatal depression
PP Peuperal Psychosis
PPH Post-partum Haemorrhage
PR Per Rectum
Pres Presentation
PCR Polymerase chain reaction
P/T Part time
PKU Phenylketonuria
PGP Pelvic girdle pain
STR
Speciality training registrar (Doctor)
Temp Temperature
VBAC Vaginal birth after Caesarean Section
UKBA United Kingdom Border Agency
VTE Venous thrombo-embolism
SROM Spontaneous rupture of membranes
StM Student Midwife
TB Tuberculosis
U/E Unemployed
VE
Vaginal examination
U/S
Ultrasound
Wks Weeks
TENS
Transcutaneous electrical nerve stimulation
T Trisomy
LMP Last menstrual period
MCADD Medium chain acyl-coa dehydrogenase deficiency
MW / RM Midwife / Registered Midwife
Mls Millilitres
MMR Measles Mumps Rubella Vaccine
NFA No fixed abode
NT Nuchal translucency
Obl Oblique
ODP Operating department practitioner
LMWH Low-molecular weight heparin
MRSA Methicillin-resistant Staphylococcus aureus
MEOWS Modified Obstetric Early Warning System
NAD No abnormalities detected
No. Number
NVD / SVD Normal vaginal delivery / Spontaneous vaginal delivery
O
2 Oxygen
OGTT Oral glucose tolerance test
MRI Magnetic resonance imaging
MSW Maternity support worker
MSUD Maple syrup urine disease
IVDU
Intravenous drug user
IVF
In vitro fertilisation
OHSS Ovarian Hyperstimulation Syndrome
IVA Isovaleric acidaemia
ICP
Intrahepatic Cholestasis in Pregnancy
IV Intravenous
ITU Intensive therapy unit / intensive care unit
IPPV Intermittent Positive Pressure Ventilation
IUD Intrauterine Device
IUS Intrauterine System
31
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28
* Signatures must be listed on page b for identification
Name
Unit No/
NHS No
Other contacts / visits
e.g. day unit, delivery suite, inpatient summary or contacts with external agencies.
Date /time
Details:
reason for referral, investigations, plan of care, length of stay (if admitted)
Signed *
Follow
up
Where
seen
Gest
+
H M MH
Y
W ks
+
D
+
+
+
+
+
+
+
+
+
+
+
+
Insert continuation sheets here, and number them.
32
TODAY
RAISED BLOOD PRESSURE
MW
LISA MOLLOY
0 1 4 5 6 9 2 4 9 8
AN CLINIC
SEEN BY MIDWIFE - REFERRED FOR ASSESSMENT
Amber Lee
3 6
page
29
* Signatures must be listed on page b for identification
Name
Unit No/
NHS No
Presenting history
Special features
(ie medical history, A/N risk factors, mental health and wellbeing, allergies, drugs etc)
Tissue viability risk assessment
D M YD MMD Y Y
Referred: to:
NoYes
Signature*
Date
Manual handling risk assessment
D M YD MMD Y Y
Referred: to:
NoYes
Signature*
Date
*** Re-weigh on admission if booking BMI >30
DAY ASSESSMENT
Yes
No
Antenatal Admission
Are personal details on page a correct?
Date Time
Blood
group
BP at booking
Current gestation
(weeks + days)
Previous pregnancies
(>24 wks + <24 wks)
Where
seen
EDD
D M YD M YD M Y
VTE assessment
performed
Yes
D D D M M M YY Y Y
M YH MH M
++
VTE pathway
initiated
YesNo
Lead
professional
Total number of reduced fetal movement visits
No. of antenatal visits
5 or less
6-10
11 or moreUnbooked
Smoking/tobacco use
YesNo
Referral to smoking cessation services
DeclinedYes
CO reading (if performed)
Contractions
No. / 10 min
Yes No
Strength
Regularity
Observations
Oedema
Urine
Resps
Lie
Position
Engagement
(5ths palpable)
Fundal
height (cm)
Presentation
Estimated
liquor
Normal
Oligohydramnios
Polyhydramnios
Normal
Small
(<10th customised centile)
Large
(>90th customised centile)
Estimated
growth status
Fetal heart
Pinard
Doptone
CTG
Accelerations
Decelerations
Duration of assessment (mins)
Baseline
Variability
Rate
(bpm)
**Normal **Suspicious **Pathological
Pulse
(bpm)
Blood
pressure
MEOWS
score
Palpation
***Weight
on admission
/
Temp
Tissue viability
assessment
Manual handling
assessment
Yes
No
Fetal
movements
Yes
No
Contractions
Yes
No
Membranes
intact
Yes
No
Vaginal
bleeding
Yes
No
Pain
Yes
No
Yes No
Signs of
infection
Vaginal
loss
Comments
Signed*
Date/Time
M YD M YD M Y
H M M
H
Normal CTG where all features are reassuring
Suspicious CTG where there is 1 non-reassuring feature AND
2 reassuring features
Pathological CTG where there is 1 abnormal feature OR
2 non-reassuring features
** Definitions
Rate (Twin 2) (bpm)
Maternal pulse (bpm)
33
T O D A Y
1 1 3 0
ANTENATAL UNIT
MR JONES (CONSULTANT)
1 10 60
0+
0
ALLERGIES - PENICILLIN, ANAPHYLAXIS.
PAST MEDICAL HISTORY OF ANAEMIA - TAKING FERROUS SULPHATE.
LISA MOLLOY
0 1 4 5 6 9 2 4 9 8
3 6
NONE
LOW RISK PREGNANCY - FIRST EPISODE OF RAISED BLOOD PRESSURE TODAY.
✔
✔
SALLY BROWN (MIDWIFE)
✔
✔
Date/
Time
Notes Signed*
Antenatal Admission - Details
page
30
* Signatures must be listed on page b for identification
Name
Unit No/
NHS No
D MMD Y
Y
H MMH
34
LISA MOLLOY
0 1 4 5 6 9 2 4 9 8
Name
Unit No
Name
Unit No/
NHS No
page
31
* Signatures must be listed on page b for identification
BIRTH
Yes
High risk thrombophilia and no VTE
Hospital Admission
Any surgical procedure e.g. appendicectomy
Medical Co-morbidities e.g. cancer, heart failure,
active SLE, IBD or inflammatory polyarthropathy,
nephrotic syndrome, type 1 DM with nephropathy,
sickle cell disease, current IVDU
Any previous VTE except a single event related
to major surgery
Complete risk assessment and update management plan as necessary
OHSS (first trimester only)
No risks identified
Transient risk factors:
Dehydration / hyperemesis
Current systemic infection
Long distance travel
Signature*
Date
M YD MMD Y Y
High risk
Requires antenatal prophylaxis with LMWH
Refer to Trust-nominated thrombosis in pregnancy expert team
Intermediate risk
Consider antenatal prophylaxis with LMWH
Seek Trust-nominated thrombosis in pregnancy expert
team for advice
Lower risk
Mobilisation and avoidance of dehydration
fewer than three risk factors
↓
↑
Age>35 years
Family history of unprovoked or oestrogen-
provoked VTE in first degree relative
Parity ≥3
BMI>30
Smoker
Gross varicose veins
Immobility e.g. paraplegia, PGP
Current pre-eclampsia
Four or more risk factors:
prophylaxis from first trimester
Three risk factors:
prophylaxis from 28 weeks
Single previous VTE related to major surgery
IVF/ART
Low risk thrombophilia
Multiple pregnancy
High risk Low risk If changed reason:
Lead Carers in Labour
Name Post Reason for change
From
Date/Time
To
Date/Time
Lead Professionals for antenatal care
Lead Professionals for intrapartum care
Care pathway for intrapartum care
Midwife
Midwife
Consultant
Consultant
Intended place of birth
Intrapartum venous thromboembolism (VTE) assessment -on admission
35
LISA MOLLOY
0 1 4 5 6 9 2 4 9 8
page
32
*** Re-weigh on admission if booking BMI >30
Insert additional sheets here and number 32.1. 32.2 etc
** Definitions
Normal CTG where all features are reassuring
Suspicious CTG where there is 1 non-reassuring feature AND
2 reassuring features
Pathological CTG where there is 1 abnormal feature OR
2 non-reassuring
Signature*
Date/Time
M YD M YD M Y
H M
M
H
Yes
No
Fetal
movements
Yes
No
Contractions
Yes
No
Membranes
intact
Yes
No
Vaginal
bleeding
Yes
No
Pain
Yes
No
Yes No
Signs of
infection
Vaginal
loss
Presenting history
Vaginal Examination
right
left
posterior
anterior
Membranes
intact
Liquor
light
meconium
none clear
thick
meconium
blood
stained
Presenting part
station
caput
Fetal heart rate after VE (bpm)
mouldingposition
External genitalia
Lie/Presentation
Show5ths palpable
already
ruptured
hindwater
leak
ruptured
during VE
Forewaters:
Pinard Doptone Monitor
position
length
consistency
dilatation
Cervix
Bladder
care
Void prior to
procedure
Catheter
required
Yes
No
Consent
Duration of assessment (mins)
Signature*
Date/Time
M YD M YD M Y
H M M
H
Contractions
No. / 10 min
Yes No
Strength
Regularity
Fetal heart
Pinard
Doptone
CTG
Accelerations
Decelerations
Duration of assessment (mins)
Rate (Twin 2) (bpm)
Maternal pulse (bpm)
General examination
Estimated
liquor
Normal
Oligohydramnios
Polyhydramnios
Normal
Small
(<10th customised centile)
Large
(>90th customised centile)
Estimated
growth status
Blood
pressure
MEOWS
score
Urine
Pulse
(bpm)
Lie
Position
Engagement
(5ths palpable)
Fundal
height (cm)
Presentation
/
Comments
Temperature
***Weight
on admission
Oedema
Resps
Manual handling
assessment
Tissue viability
assessment
Comments
**
Normal
**
Suspicious
**
Pathological
Baseline
Variability
Rate (bpm)
Initial assessment
Induction of labour
Yes No
Augmentation of labour
Yes No
Special
Features
Yes No
Medical
Factors
Obstetric
Factors
Yes
No
Social
Factors
Yes
No
Current gestation
W ks
D
+
Date Time
M YD M YD M Y
H M M
H
Where seen
Total number of reduced fetal movement visits
5 or less
6-10
11 or moreUnbookedAN Visits:
Swab count
(inc. number)
Swabs
correct
N/A
Yes
*
Signatures
Plans for labour
Birth plan discussed
Yes
Call buzzer/emergency buzzer discussed
Yes NA
Birth plan completed
Yes No
Transfer to obstetric unit discussed (if required)
Yes NA
Birth partners
Comments e.g. coping strategies, management of 3rd stage
36
Affix additional sheets here, and number them
page
33
* Signatures and initials must be listed on page b for identification
Name
Unit No/
NHS No
Management plan for birth
D M YD M Y
H MH M
Type of fetal heart monitoring
Intermittent auscultation
Pathway of care for labour
Low
risk
High
risk
Risk assessment - at the onset of labour
Continuous monitoring
To deal with special issues during labour and delivery, a personalised management plan can be initiated which outlines specific
treatment and care agreed between the care providers and the expectant mother and her birth partner. This can be amended as
her labour progresses to ensure that everyone involved in her care is aware of her individual circumstances. The management
plan should be reviewed at each hand over of care.
Signed *
Obstetrician
aware
Management plan
Risk factor /
Special features
Date/time
37
LISA MOLLOY
0 1 4 5 6 9 2 4 9 8
page
34
* Signatures must be listed on page b for identification
Name
Unit No/
NHS No
Date/
Time
Notes Signed*
D M YD M Y
H MH M
38
LISA MOLLOY
0 1 4 5 6 9 2 4 9 8
Date/
Time
Notes Signed*
D M YD M Y
H MH M
page
35
* Signatures must be listed on page b for identification
Name
Unit No/
NHS No
39
0 1 4 5 6 9 2 4 9 8
LISA MOLLOY
* Signatures must be listed on page b for identification
Name
Unit No/
NHS No
page
36
Date/
Time
Notes Signed*
D M YD M Y
H MH M
40
0 1 4 5 6 9 2 4 9 8
LISA MOLLOY
Date/
Time
Notes Signed*
D M YD M Y
H MH M
* Signatures must be listed on page b for identification
Name
Unit No/
NHS No
page
37
41
0 1 4 5 6 9 2 4 9 8
LISA MOLLOY
Date/
Time
Notes Signed*
D M YD M Y
H MH M
Insert additional sheets here and number 38.1. 38.2 etc
page
38
* Signatures must be listed on page b for identification
Name
Unit No/
NHS No
42
0 1 4 5 6 9 2 4 9 8
LISA MOLLOY
* Signatures must be listed on page b for identification
page
39
Name
Unit No/
NHS No
Discussed with mother
Signed *
Discussed with mother
Signed *
Discussed with mother
Signed *
Discussed with mother
Signed *
Discussed with mother
Signed *
Discussed with mother
Signed *
Discussed with mother
Signed *
Discussed with mother
Signed *
Discussed with mother
Signed *
Discussed with mother
Discussed with mother
Discussed with mother
Signed *
Signed *
Signed *
Date/
Time
Indication
Procedures
(e.g. analgesia, epidural anaesthetic, fetal blood sampling, operative delivery, episiotomy,
cannulation, delayed cord clamping, 3rd stage management)
Procedure Benefits and risks
Care provider should sign
following discussion with mother
D M YD M YD M Y
D M YD
D
D
M
M
M
Y
Y
Y
D
D
D
M
M
M
Y
Y
Y
D M YD M YD M Y
D M YD M YD M Y
D M YD M YD M Y
D M YD M YD M Y
D M YD M YD M Y
D M YD M YD M Y
D M YD M YD M Y
D M YD M YD M Y
Consent
Yes
No
Consent
Yes
No
Consent
Yes
No
Consent
Yes
No
Consent
Yes
No
Consent
Yes
No
Consent
Yes
No
Consent
Yes
No
Consent
Yes
No
Consent
Yes
No
Consent
Yes
No
Consent
Yes
No
H MH M
H MH M
H MH M
H MH M
H MH M
H MH M
H MH M
H MH M
H MH M
H MH M
H MH M
H MH M
43
0 1 4 5 6 9 2 4 9 8
LISA MOLLOY
page
40
Onset date and times:
Labour
D M YD M Y H MH M
Significant risk factors
Medications Allergies
Maternal Preferences
Age BP at booking
Current gestation
(weeks + days)
+
Prev. pregnancies
(>24 wks + <24 wks)
+
Antenatal risks present
Management plan initiated
Yes
No
Name Unit no.
Affix additional sheets here
Hrs
1
2
3
4
5
6
7
8
9
10
11
12
Date
Time
Hrs
P G B
Mins
Maternal Pulse
(bpm)
60 70 80 90 100 110 120 130 140 150 160 170 180
K
Fifths
palpable
per
abdomen
Liquor
Urine
P = protein
G = glucose
K = ketones
B = blood
Fetal Heart Rate
(bpm)
X
Temp
(
o
c)
I = intact
C = clear
M = meconium
B = blood
60 70 80 90 100 110 120 130 140 150 160 170 180
BPResps
MEOWS score onset
of labour
Booking BMI
SGA or FGR on scan
Maternal
activity-
posture/
pressure
area care
Yes
No
44
Intrapartum Action plans
Birth Action Plans
Paediatrician to be present Seniority :
Name Unit no.
page
41
Blood
group
Haemoglobin
(g/L)
Group
& save
Cross
match
units
Antibodies
present
Date
taken
D M YD M YD M Y
Rupture of
membranes
*If contractions exceed 4:10 min, stop or reduce oxytocin and reassess in line with local protocol
Active 2nd stage
D M YD M Y H MH M
D M YD M Y H MH M
Signature
Fluids
in
Fluids
out
Drugs
dosage
Position
Moulding
Caput
W = weak
M = moderate
S = strong
R = regular
I = irregular
Contractions
No. / 10 min
Total fluids in/out
(List on page 31
for identification)
Station
Cervical dilatation
X
2
-3
3
-1
4
0
5
+1
6
+2
7 8 9 10
-2
10
high
2 3 4 5 6 7 8 9 1010
Oxytocin
rate*
or pool
temp
o
45
page
42
** Caesarean section classification:
1. Immediate threat to the life of the mother or fetus.
2. Maternal or fetal compromise, not immediately life-threatening.
3. No maternal or fetal compromise but needs early delivery. 4. Delivery timed to suit woman or staff.
Name
Unit No/
NHS No
Indication
Suspected fetal compromise Failure to progress
Pre-delivery findings
dilatation
moulding
Bloodstained
Not performed
Fetal heart
Delivery decision made by
Designation/ Grade Name of Consultant
Yes No Yes No
Consultant aware
Consultant present
Procedure
Caesarean
Classification **
Ventouse
Other
Forceps
General anaesthetic
(eg allergic reaction, difficult intubation, O
2
for 4hrs post op, dural tap observed)
Assisted delivery
Thick meconium
Light meconium
Clear
None
Decelerations
Accelerations
Variability
Baseline
CTG performed
Normal
FBS result
Suspicious
Pathological
Predelivery FBS
Liquor
caput
position
station
length
consistency
Cervix position
Vaginal examination
Position
Lie
Presentation
Abdominal
palpation
Anaesthetic/Analgesia
SpinalPudendalPerineal infiltrationEpiduralNone
Alerts/Comments
Operative details
Caesarean section
Antepartum haemorrhage
Breech
Multiple
pregnancy
Other
Presenting part
Pre-delivery bladder care
Bladder emptied
Time
Yes No
Indwelling catheter
Yes No
Maternal request
Decision time
Type of instrument used
Time instrument applied
Rotation
Number of pulls
Time instrument applied
Liquor
Time baby delivered
Placenta delivered
Duration of application
minutes
Position at delivery
Change of instrument (Type)
Cord pH
Venue for procedure
MM
Pre delivery swabs/
instruments correct (inc. no)
H H M M
H H M M
H H M M
Decision time
Time arrived in theatre
Time of knife to skin
Time of knife to uterus
Type of uterine incision
Liquor
Time baby delivered
Placenta delivered
Tubes and ovaries
Skin closed
Cord pH
Time out of theatre
Decision to delivery time
minutes
Prophylactic antibiotics given
Yes No
M
M
H H M M
Post delivery swabs/
instruments correct (inc. no)
Signatures
Signatures
Yes No
Episiotomy performed
Pre delivery swabs/
instruments correct (inc. no)
Post delivery swabs/
instruments correct (inc. no)
Signatures
Signatures
H H M M
H H M M
H H M M
H H M M
H H M M
H H M M
Verbal Written
Informed consent obtained for
Verbal Written
caesarean section
Informed consent obtained for
assisted delivery
Engagement
(5ths palpable)
46
0 1 4 5 6 9 2 4 9 8
LISA MOLLOY
page
43
* Signatures must be listed on page b for identification
Signature*
Date/Time
D M YD M YD M Y
H H M M
Staff present
Others
Paediatrician
Surgeon
Midwives
Assistant
Anaesthetist
ODP
Time called Time arrived
Time in recovery
minutes
M M M
Estimated blood loss
Closure and sutures
Details - including surgeon’s name and signature
mls
Post-delivery instructions
Yes No
Anti-embolic stockings
Antibiotics
Analgesia
Draw any abrasions / marks and position of instruments
Comments
Drains
Yes No
Urinary catheter
Sutures for removal
Suggest for VBAC next time
Vaginal pack in situ
Follow up required
Vaginal pack removed
Anti-coagulation therapy
Epidural catheter removed
Name
Unit No/
NHS No
47
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LISA MOLLOY
Name
Unit No/
NHS No
page
44
** Descriptions:
3a =Less than 50 % of external anal sphincter (EAS) thickness torn.
3b=More than 50 % of EAS thickness torn 3c= Internal anal sphincter (IAS) torn.
4th=Injury to perineum involving the EAS and IAS and anal epithelium
Comments / Actions
Immediate Postnatal Observations
Date/Time Temp
Pulse
(bpm)
BP Uterus
Lochia /
Blood loss
Perineum Urine Pain Signature *
Wound /
Drains
Resps
O
2
Saturation
If further observations required commence Trust MEOWS chart
Vaginal delivery pack
Pre delivery
swab count
(inc. no)
Signatures*
Third Stage
Physiological
Management
Active (CCT)
Manual removal
of placenta
OxytocinSyntometrine Ergometrine
Measured
Blood loss (ml)
Further
action
Dosage & time given
Membranes
Apparently complete
Incomplete
Apparently complete
Placenta
Incomplete
Ragged
Cord
Estimated
Total
Sent for histology
No. of vessels
Comments
Consent
obtained
Yes
Haemobate Misoprostol
Drugs
Delayed cord clamping-duration >5 mins<5 mins
Comments
Perineum
Trauma **
Labial
Cervical
Repair required
Vaginal pack in situ
Antibiotics
Laxatives
No
Yes
Catheterised
Hygiene
Diet, including fibre
Extent of trauma
Type of repair
Pelvic floor exercises
Post repair
Advice given
Indication for
episiotomy
Pain relief
1
°
3b
°
3c
°
4
°
Vaginal
Episiotomy
2
°
3 a
°
PV examination
Discussed
with mother
Consent
obtained
Tampon removed
Indwelling
For postnatal consultant review
Venue for repair
(room/theatre)
Details of repair
Repair by
Anaesthetic
Spinal
Pudendal
Local
Epidural None
Lignocaine (mls)
Suture material
Comment
Pre-repair
Start date
and time
Swab count
Signature*
Signature*
Finish date and time:
Signature*
Signature*
Count performed by:
Count by:
Needle
count
(inc. no)
Haemostasis
Analgesia
Swab count
Needle count
(inc. no)
PR performed
GA
PR examination
If declined, reason
No trauma identified
If PR declined,
reason
Tampon inserted
Technique (post vaginal wall, muscle, skin, labia)
Post natal review
Epidural catheter removed
D M YD M YD M Y H H M
M
Yes
N/A
No
Post delivery
swab count
(inc. no)
Signatures*
Tranexamic
acid
48
0 1 4 5 6 9 2 4 9 8
LISA MOLLOY
Name
Unit No/
NHS No
* Signatures must be listed on page b for identification
page
45
At beginning of pregnancy
Post-partum haemorrhage
Shoulder dystocia
Theatre (WHO checklist)
Third/ Fourth degree tear
Meconium
Incident form
Indication
Other:
Smoking/Tobacco use
Bloods
Maternal position
at delivery
Place of birth
Maternal complications
Length of labour
Proforma checklist
Rupture of membranes
Pain relief
Birth Summary - Mother
Maternal blood taken
Or attach computer
printout, if available
Cord blood taken
No
No
Yes
Yes N/A
Yes
Number
Number
Yes N/A
Comments
Baby 1 Baby 2
Delivered by
Midwife at
delivery
Others present
Birth
Attendants
Onset of est. labour
Date Time
Length (hrs/mins)
Fully dilated
1st stage
/
Head delivered
Baby delivered
Duration
of labour
2nd stage
3rd stage
/
/
/
Pushing commenced
/
Duration
Spontaneous
Date
Artificial
Time
Indication
hrs /mins
None
H
2
O
TENS
Entonox
Narcotics
Pudendal
Spinal
Complementary therapies:
Combined
spinal/epidural
Epidural
Twin 2
delivered
End of third stage
Signature*
D M YD M YD M Y H H M
M
Date/Time
At end of pregnancy
Yes
Received antenatal
smoking cessation services
Declined
Normal
Vaginal breech
Ventouse
Forceps
1.
2.
None
Spontaneous
Induced
Labour onset Delivery
Indication
3.
4.
Augmented
(See page 16 for
classifications)
Baby 2Baby 1
Caesarean:
One to one care achieved
Yes If no, reason why
Third Stage
Placenta Apparently complete
Comments
Total blood loss (ml)
Membranes Apparently complete
Incomplete
Ragged
Incomplete
49
Name
Unit No/
NHS No
page
46
* Signatures must be listed on page b for identification
Birth
order
Date of Birth Time Sex (g) Centile NHS Number
Congenital
Anomaly
Apgars
Unit Number
Mode of
Delivery
Outcome
Birth
weight
Apgar Score
<100
>100
absent
Heart rate
(bpm)
weak cry
good
strong cry
absent
Respiratory
effort
some
flexion of
extremities
limp
Muscle tone
some
motion
cry
no
response
Reflex
irritability
body pink,
limbs blue
pink
blue /
pale
Colour
0 1 2
Baby 1
Total
Plans for Transfer after Birth
Mother
Date and time of transfer Signature *Transfer to:
Birth Summary - Baby
1 5
Head circumference (HC, cm)
Temperature (
o
C) / route
Identification / security labels
Baby 1 Baby 2
Initial Examination
1
2
well
flexed
Name
Resuscitation
IPPV : Face mask
ETT
Cardiac massage
Intubated
Age intubated (mins)
Drugs
Grade
Resuscitation
discussed with parents
Baby 1
Yes No
pH
Base excess
/deficit
Other
Cord Gases
Contact & Feeding
Skin-to-skin
Time
Baby 1 Baby 2
Yes
Offered
Accepted
No Comments
Type of feed
Breast
Formula
Feed offered
Method
Time feed started
Duration of feed
Time
5
Baby 2
1
10
10
Baby 1
Baby 2
Arterial
5
1
10
Baby 2
Yes No
Venous Arterial
Venous
None Basic Advanced
Level
None Basic Advanced
Physical examination at birth
completed as per Trust guideline
T- Piece
Administered
Route
Requires
further dose
Baby 1 Baby 2
Vitamin K
Yes
Yes
No
Consent obtained
Yes
Yes No
Yes No
No
No
H H M M
Baby(ies)
Declined
Handover
to - (name)
Handover of care tool (as per trust guideline)
Yes
Handover
to - (name)
N/A
Yes
Comments
D M YD M YD M Y
D M YD M YD M Y
D M YD M YD M Y
H H M M
H H M M
Signature*
Duration (mins) Duration (mins)
Handover of care tool (as per trust guideline)
N/A
Yes No
Declined
OR attach computer printout if available
Baby Details
Number of babies
Time from birth to onset of regular respirations Baby 1 Baby 2
mins mins
Neonatal Comments/Risks
Prolonged rupture of membranes
Meconium present at birth
Shoulder Dystocia
Traumatic/difficult delivery
Risk of hypoglycaemia
Rhesus Negative
NEWS chart commenced
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Key to abbreviations
NEWS = Newborn Early Warning System
50
Name
Unit No/
NHS No
* Signatures must be listed on page b for identification
POSTNATAL
If you have one or more risk factors for any of the conditions below, it does not necessarily mean that you will develop a problem.
These are merely prompts for your carers to initiate further investigations, treatment or referral. Should you have concerns about
any of these risks, contact your midwife.
17 18 19 20
Psychological well being
1 3 4
Hypertensive disorders
Key to risk
5 8 9 11
Infection
2 6 7 12 13 14 15 16
Urinary urgency or incontinence
Faecal urgency or incontinence
10
1
Age > 35
13
High temperature / unwell
2
Para > 3
14
3
BMI > 30
15
Episiotomy / 2nd degree tear
4 16
3rd / 4th degree tear
5
Pregnancy induced hypertension / Pre-eclampsia
17
No spontaneous urinary void > 3 hours
6
Prolonged rupture of membranes
18
Single catheter drainage > 500 ml
7
19
Indwelling catheter > 24 hours
8
Pushing > 1.5 hours
20
Lack of support
9
Ventouse or forceps
21
10
Caesarean section
22
11
Incomplete placenta or membranes
23
12
Baby weight > 90th centile
24
Excessive blood loss
Antenatal anti-coagulation therapy
Thrombophilia
Smoker
2 4 9
Abnormal bleeding
11
23 24
12 13 14 15 16 21 22
None identified at delivery
Mother alerts
Part of the assessment at each postnatal contact is to identify any additional needs you may have. The alerts below can be used by your
care team to help identify your risk of developing problems. The aim is to monitor your health and to check that you are well and
progressing normally after the birth. The management of any problems or special features can be documented on page 48.
Postnatal venous thromboembolism (VTE) assessment
- to be completed immediately after birth.
Yes
Anyone requiring antenatal LMWH
Any previous VTE
High-risk thrombophilia
Low-risk thrombophilia + family history
Any surgical procedure in the puerperium except
immediate repair of the perineum
Caesarean section in labour
Medical Co-morbidites e.g. cancer, heart failure, active SLE, IBD
or inflammatory polyarthropathy; nephrotic syndrome, type I DM
with nephropathy, sickle cell disease, current IVDU
Lower risk
Early mobilisation and avoidance of dehydration
Fewer than 2 risk factors
2 or more risk factors
High risk
At least 6 weeks postnatal prophylactic LMWH
Intermediate risk
At least 10 days’ postnatal prophylactic LMWH
Note: if persisting or > 3 risk factors, consider extending
thromboprophylaxis with LMWH
↑
↑
No risks identified
Update Management Plan as required.
Signature*
Date
M Y
D MMD Y Y
Age>35 years
Smoker
Elective caesarean section
Gross varicose veins
Low-risk thrombophilia
Family hisory of VTE
Prolonged labour (>24 hours)
Multiple pregnancy
Preterm delivery in this pregnancy (<37 weeks)
Stillbirth in this pregnancy
Immobility, e.g. paraplegia, PGP, long distance travel
Current pre-eclampsia
Mid cavity rotational or operative delivery
PPH > 1 litre or blood transfusion
Current systemic infection
Parity
>
3
BMI
>
30
Readmissio
n
or prolonged admission (
>
3 days) in the puerperium
BMI
>
40
Current mental health problems
Family history of severe perinatal mental health
Previous mental heath problems
page
47
51
Risk factor /
Special features
Date/time Management plan Signed *Referred to
Management plan
Name
Unit No/
NHS No
* Signatures must be listed on page b for identification
To deal with special issues after your birth, a personalised management plan will outline specific treatment and care agreed
between you and your care providers, including specialists. The aim is to keep you well, and to ensure that everyone involved in
your care is aware of your individual circumstances. If any special issues have been identified from the alerts on page 47, which
require further consideration they will be recorded below. This plan will be updated and amended to reflect your changing needs.
D M YD M Y
H MH M
page
48
52
Medications Allergies
Key points (i.e. specific antenatal/intrapartum/postnatal events)
Date Time Amount (ml)1st urinary void
First postnatal assessment
To be completed prior to: leaving a home birth, early transfer home, or on admission to postnatal ward.
Orientation to ward
Explanation of ward routine and layout (if applicable)
Date Time Signature*
Security
system
Ward
layout
Visiting
details
Introductions
Information
leaflets
Expected date
of discharge
Meals/
drinks
Call
system
No Yes Comments/ActionsAre there any concerns about the following:
Temperature, pulse, respirations and
blood pressure
Infection, fever, chills, headache, visual disturbances
A
Abdominal tenderness, subinvolution
UterusC
Clots, offensive smell, return to heavy loss
Vaginal lossD
DVT, redness, swelling, pain, varicose veins, cramps
Legs
E
Pain on passing urine, leakage, urgency
Bladder
Constipation, haemorrhoids, leakage, urgency
BowelsG
Suture removal, healing, infection
Wound
H
Soreness, bruising, swelling, sutures, infection
Perineum
Headache, backache, abdominal
Pain
Feeling down, low in mood, worried or anxious
Mental health and wellbeing
L
Unable to sleep, restless sleep, extreme tiredness
Fatigue
K
Postnatal exercises
Pelvic floor, abdominal, legs, deep breathing, relaxation
M
Tissue viability assessment completedN
Redness, pain, cracked, sore, bruised nipples
Breasts and nipples
B
Where seen
Date
Time
D
M
MD Y Y H H M M
D
M
MD Y Y H H M M
MEOWS chart commenced
No Yes
Risk of developing a pressure ulcer
page
49
Name
Unit No/
NHS No
* Signatures must be listed on page b for identification
F
I
J
Special features
Last Hb and Date
Y YMD D M
Para
+
Blood group
+-
Booking BMIBooking B/P Age
Management plan initiated
Yes
Key to risk reviewed (page 47)
Yes
Infant feeding method
Signature*
Date/Time
M Y
D M YD M Y
HH M M
53
Name
Unit No/
NHS No
* Signatures must be listed on page b for identification
page
50
Date/
Time
Notes Signed*
D M Y
D
M Y
H MH M
54
Name
Unit No/
NHS No
* Signatures must be listed on page b for identification
page
51
Date/
Time
Notes Signed*
D M YD M Y
H MH M
You may find it helpful to discuss aspects of your pregnancy, birth and postnatal experience with your care givers. This can take
place at any time and your midwife may wish to record the details below.
Reflections on birth experience
(Completed during the postnatal period, at appropriate times)
Pregnancy
Birth
Postnatal
Details Signature*/Date/Time
55
56
Assessment Overview
Midwifery
Candidate’s Name: __________________________________________________
Note to Candidate:
Complete a midwifery antenatal assessment including observations and
urinalysis of the woman.
An observation chart is provided and must be completed within the station.
Scenario
Lisa Molloy has presented today with raised blood pressure in the antenatal clinic
based in the General Practitioner Midwifery Clinic.
Lisa is gravida 1 para 0, her pregnancy has been low risk and she is currently 36
weeks gestation.
You need to complete maternal observations; blood pressure, temperature, pulse
rate, respiratory rate, oxygen saturation levels, urinalysis and calculating a Modified
Early Obstetric Warning Score (MEOWS).
Assume it is TODAY and it is 10:30
This documentation is for your use and is not marked by the examiners.
57
click to sign
signature
click to edit
click to sign
signature
click to edit
Planning Overview
Midwifery
Candidate’s Name: __________________________________________________
Note to Candidate:
Document to NMC standards
Your examiner will retain all documentation at the end of the station
Scenario
Lisa Molloy has been seen in the antenatal clinic and has raised blood pressure. You
are referring her to be seen in the Antenatal Day Assessment Unit for review. Lisa is
gravida 1 para 0, her pregnancy has been low risk and is currently 36 weeks
gestation.
Based on your midwifery assessment of Lisa Molloy, please produce a midwifery
care plan for the next 4 hours to communicate to the midwifery team using the
national SBAR method of communication:
S – Situation
B – Background
A – Action
R – Recommendations
Complete all sections of the care plan.
Assume it is TODAY and it is 11:30
58
Planning Candidate Documentation
Midwifery
Patient Details:
Name: Lisa Molloy
Hospital Number: 0145692498
Address: 41 Almond Close, Tatterell, LL12 TBU
Date of birth: 01/01/1996
Midwifery Care Plan
Situation
Background
59
click to sign
signature
click to edit
Planning Candidate Documentation
Midwifery
Assessment
Recommendations
PRINT NAME:
Midwife signature:
Date:
60
click to sign
signature
click to edit
Implementation Overview
Midwifery
Candidate’s Name: __________________________________________________
Note to Candidate:
Talk to the woman
Please verbalise what you are doing and why
Read out the chart and explain what you are checking/giving/not giving and why
Complete all the required drug administration checks
Complete the documentation and use the correct codes
The correct codes are on the chart and on the drug trolley
Check and complete the last page of the chart
You have 15 minutes to complete this station, including the required
documentation
Please proceed to administer and document the woman’s 14:00 medications in a
safe and professional manner
Scenario
Lisa Molloy has been admitted to the Antenatal Day Assessment Unit with raised
blood pressure. She is gravida 1, para 0, her pregnancy has been low risk and she is
currently 36 weeks gestation. Lisa has been seen by the consultant and medications
have been prescribed.
Please administer and document Lisa’s 14:00 medications in a safe and professional
manner.
Complete all sections of the documentation.
Assume it is TODAY and it is 14:00
61
Prescription Chart for:
LISA MOLLOY
FEMALE
HOSPITAL NUMBER:
DATE OF BIRTH:
ADDRESS:
0145692498
01/01/1996
41 ALMOND CLOSE
TATTERELL, LL12 TBU
ADMISSION DATE & TIME:
TODAY 10:30
WARD:
ANTENATAL DAY
ASSESSMENT UNIT
KNOWN ALLERGIES OR SENSITIVITIES
TYPE OF REACTION
PENICILLIN
ANAPHYLAXIS
Signature:
Dr A.Kumar
Date:
TODAY
INFORMATION FOR PRESCRIBERS:
INFORMATION FOR NURSES ADMINISTERING MEDICATIONS:
USE BLOCK CAPITALS.
RECORD TIME, DATE AND SIGN WHEN MEDICATION IS
ADMINISTERED OR OMITTED AND USE THE FOLLOWING
CODES IF A MEDICATION IS NOT ADMINISTERED.
SIGN AND DATE AND INCLUDE BLEEP
NUMBER.
SIGN AND DATE ALLERGIES BOX- IF NONE-
WRITE "NONE KNOWN".
1. PATIENT NOT ON
WARD.
6. ILLEGIBLE/INCOMPLETE
PRESCRIPTION OR WRONGLY
PRESCRIBED MEDICATION.
RECORD DETAILS OF ALLERGY.
2. OMITTED FOR A
CLINICAL REASON
7.NIL BY MOUTH
DIFFERENT DOSES OF THE SAME
MEDICATION MUST BE PRESCRIBED ON
SEPARATE LINES.
3. MEDICINE IS NOT
AVAILABLE.
8. NO IV ACCESS
CANCEL BY PUTTING LINE ACROSS THE
PRESCRIPTION AND SIGN AND DATE.
4. PATIENT REFUSED
MEDICATION.
9. OTHER REASON- PLEASE
DOCUMENT
INDICATE START AND FINISH DATE.
5. NAUSEA OR VOMITING.
* IF MEDICATIONS ARE NOT ADMINISTERED PLEASE DOCUMENT ON THE LAST PAGE OF THE DRUG
CHART.
Does the patient have any
documented Allergies?
YES
NO
Please check the chart before administering
medications.
WARD
CONSULTANT
HEIGHT
5 FOOT 2 INCHES (1.57 m)
ANTENATAL DAY ASSESSMENT UNIT
MR JONES
WEIGHT
10 STONE 3 POUNDS (65 kg)
BMI = 23
ANY Special Dietary requirements?
YES
NO
If YES please specify
ONCE ONLY AND STAT DOSES
Date
Time
due
Drug name
Dose
Route
Prescribers signature & bleep
Given by
Time given
TODAY
14:00
LABETALOL
HYDROCHLORIDE
100 mg
PO
Dr P Smith, 3459
62
Prescription Chart for:
LISA MOLLOY
FEMALE
HOSPITAL NUMBER:
DATE OF BIRTH:
ADDRESS:
0145692498
01/01/1996
41 ALMOND CLOSE
TATTERELL, LL12 TBU
ADMISSION DATE & TIME:
TODAY 10:30
WARD:
ANTENATAL DAY
ASSESSMENT UNIT
Does the patient have any
documented Allergies?
YES
NO
Please check the chart before administering
medications.
PRESCRIBED OXYGEN THERAPY:
Date
Time
Prescribers
signature &
bleep
Target
oxygen
saturation
Therapy
instructions
Device
Flow
Time started
& signature
Time discontinued
& signature
PRN (AS REQUIRED MEDICATIONS):
Date
Drug
Dose
Route
Instructions
Prescriber
signature & bleep
Given by
Time given
TODAY
PARACETAMOL
1 g
PO
6 HOURLY
Dr P Smith, 3459
ANTIMICROBIALS:
1. DRUG
Date and signature for administering
medications. Code for non-
administration.
DATE
DOSE
FREQUENCY
ROUTE
DURATION
TIME
Start date
Finish date
Prescriber signature & bleep
2. DRUG
Date and signature for administering
medications. Code for non-
administration.
DATE
DOSE
FREQUENCY
ROUTE
DURATION
TIME
Start date
Finish date
Prescriber signature & bleep
3. DRUG
Date and signature for
administering medications. Code
for non-administration.
DATE
DOSE
FREQUENCY
ROUTE
DURATION
TIME
Start date
Finish date
63
Prescription Chart for:
LISA MOLLOY
FEMALE
HOSPITAL NUMBER:
DATE OF BIRTH:
ADDRESS:
0145692498
01/01/1996
41 ALMOND CLOSE
TATTERELL, LL12 TBU
ADMISSION DATE & TIME:
TODAY 10:30
WARD:
ANTENATAL DAY
ASSESSMENT UNIT
Prescriber signature & bleep
Does the patient have any
documented Allergies?
YES
NO
Please check the chart before administering
medications.
REGULAR MEDICATIONS:
1. DRUG
FERROUS SULPHATE
Date and signature for
administering medications.
Code for non-administration.
DATE
DOSE
FREQUENCY
ROUTE
DURATION
TIME
TOMORROW
200 mg
ONCE DAILY
PO
6 WEEKS
Start date
TOMORROW
14:00
Finish date
+6 WEEKS
Prescriber signature & bleep
Dr P Smith, 3459
2. DRUG
LABETALOL HYDROCHLORIDE
Date and signature for
administering medications.
Code for non-administration.
DATE
DOSE
FREQUENCY
ROUTE
DURATION
TIME
TODAY
TODAY
100 mg
TWICE A DAY
PO
7 DAYS
08:00
1. J EVANS
Start date
TODAY
Finish date
+7 DAYS
20:00
Prescriber signature & bleep
Dr P Smith, 3459
3. DRUG
Date and signature for
administering medications.
Code for non-administration.
DATE
DOSE
FREQUENCY
ROUTE
DURATION
TIME
Start date
Finish date
Prescriber signature & bleep
INTRAVENOUS FLUID THERAPY:
Date
Fluid
Volume
Rate/time
Prescriber
signature
& bleep
Batch
number
Commenced
@
Given
by
Checked
by
Finished
@
64
Prescription Chart for:
LISA MOLLOY
FEMALE
HOSPITAL NUMBER:
DATE OF BIRTH:
ADDRESS:
0145692498
01/01/1996
41 ALMOND CLOSE
TATTERELL, LL12 TBU
ADMISSION DATE & TIME:
TODAY 10:30
WARD:
ANTENATAL DAY
ASSESSMENT UNIT
Does the patient have any
documented Allergies?
YES
NO
Please check the chart before administering
medications.
DRUGS NOT ADMINISTERED:
DATE
TIME
DRUG
REASON
NAME AND SIGNATURE
TODAY
08:00
LABETALOL
HYDROCHLORIDE
PATIENT NOT ON
WARD
J EVANS
Jamie Evans RM
65
Evaluation Overview
Midwifery
Candidate’s Name: __________________________________________________
Note to Candidate:
This document must be completed in BLUE pen
At this station you should have access to your Assessment, Planning and
Implementation documentation. If not, please ask the examiner for it
Please note; there is a total of 3 pages to this document
Document to NMC standards
The examiner will retain all documentation at the end of the station
Scenario
Lisa Molloy was seen in the antenatal clinic in the community and was referred to
the Antenatal Assessment Unit with raised blood pressure.
Lisa has been transferred to the Antenatal Ward and following investigations she
was diagnosed with pregnancy induced hypertension. The fetal monitoring was
within normal limits and was a reassuring trace throughout the time Lisa was
monitored. Lisa is feeling spontaneous fetal movements, has been prescribed
antihypertensive medication and is now being transferred home. She is now 36
weeks +3 days gestation.
You are now working on the Antenatal Ward and you need to complete a transfer
of care letter to ensure that the community midwife has a full and accurate
account of Lisa’s history and ongoing care needs.
Complete all sections of the documentation.
Assume it is TODAY and it is 17:00
66
Transfer of Care Letter
Patient Details:
Name: Lisa Molloy
Hospital Number: 0145692498
Address: 41 Almond Close, Tatterell, LL12 TBU
Date of birth: 01/01/1996
Clearly describe the reason for the initial admission and subsequent
diagnosis
Date of admission
Situation
Background
67
Assessment
Recommendations
Plan of care and future appointments
Document allergies and associated reactions
68
Identified/potential areas for parent education
What are the actual or potential problems that may risk or complicate current
pregnancy?
Other members of the multidisciplinary team who need to be aware of Lisa’s
discharge
PRINT NAME:
Midwife signature:
Date:
69
Frequency of observations
DATE TIME
Ward:
Date :
Time :
>30 >30
21-30 21-30
11-20 11-20
0-10 0-10
95-100% 95-100%
<95% <95%
(L/min)
Urine
passed (Y/N) passed (Y/N)
protein ++ protein ++
protein >++ protein >++
Clear (C)
Pink (P)
Clear (C) Pink (P)
Green (G) Green (G)
Alert Alert
Voice Voice
Pain Pain
Unresponsive Unresponsive
0-1 0-1
2-3 2-3
Normal (N) Normal (N)
Heavy (H) Fresh
(F) Offensive
(O)
Heavy(H) Fresh(F)
Offensive (O)
NO (√) NO (√)
YES (√) YES (√)
Total Red Scores
Pain Score (no.)
Looks unwell
Neuro response
(√ )
Lochia
Total Amber Scores
Respirations
(write rate in
corresp. box)
Hospital No:
Systolic blood pressure
Administered O
2
(L/min.)
Diastolic blood pressure
Amniotic fluid
Saturations
if applicable
(write sats in
corresp. box)
Proteinuria
PROMPT - MODIFIED OBSTETRIC EARLY WARNING SCORE CHART
(FOR MATERNITY USE ONLY)
PRINT
Use identification label or :-
STATUS
Name:
DOB:
CONTACT DOCTOR FOR EARLY INTERVENTION IF WOMAN TRIGGERS ONE RED OR TWO AMBER SCORES AT ANY ONE TIME
FREQUENCY
(IN HRS)
SIGNED
Heart rate
Temp
.
.
39
38
37
36
35
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
50
130
120
110
100
90
80
70
60
50
40
170
160
150
140
130
120
110
100
90
80
70
60
50
40
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
50
130
120
110
100
90
80
70
60
50
40
170
160
150
140
130
120
110
100
90
80
70
60
50
40
39
38
37
36
35
70
01/01/1996
0145692498
LISA MOLLOY
Guidance for using Modified Obstetric Early Warning Score Chart
When should the Modified Obstetric Early Warning chart be used?
This chart has been designed to allow early recognition of deterioration using physiological parameters.
It should be used for any pregnant or postpartum woman requiring observations who:
- Is not in labour (partogram should be used in labour)
- Does not require maternal critical care (when a maternal critical chart should be used).
This chart should only be used for documenting maternal observations. Fetal well-being should be monitored in
accordance with specific care plans and documented in the mother’s hand held notes.
Guidance when completing the form
Frequency of observations: This should be completed when the chart is commenced by the doctor or midwife
caring for the woman. The frequency should be updated when there is a change in frequency of observations.
Respiratory Rate: Respiratory rate is the single most important parameter for early detection of deterioration and
should be measured at ALL monitoring events.
Oxygen Saturation (SpO
2
): This should be undertaken if: receiving oxygen, has a respiratory condition i.e.
suspected P.E, or if woman is triggering one red or two amber scores at time of observations. If oxygen is
prescribed, please write target saturation to left of saturation boxes.
Heart rate: Heart rate is the key parameter for early detection of critical illness. Tachycardia may be the only sign
of deterioration at an early stage and a tachycardic woman should be considered hypovolaemic until proven
otherwise.
Temperature: Temperature change may not necessarily be an effective measure of deterioration. A fall or rise in
temperature may indicate sepsis and a full sepsis screen and appropriate antibiotic therapy should be considered.
NB. Sepsis can be particularly difficult to recognise. A collapsed septic woman may exhibit all the signs and
symptoms of hypovolaemia. If there is no positive response from fluid resuscitation after 10 minutes, then a Sepsis
risk assessment should be conducted and appropriate actions taken e.g Sepsis Six including lactate should be
undertaken urgently. (UK Sepsis Trust)
Blood pressure:
Hypotension is a late sign of deterioration as it signifies decompensation and should be taken very seriously. The
physiological changes caused by pregnancy and childbirth can mean that early signs of impending collapse are not
easily recognised.
Hypertension – ALL pregnant women with a systolic blood pressure of 160mm/Hg or higher must be treated
urgently (MBRRACE 2016).
Neuro response: AVPU is a measure of consciousness and the best response of the following should be
documented:
A – Alert Alert and orientated
V – Voice Drowsy but answers to name or some kind of response when addressed
P – Pain Rousable with difficulty but makes a response when shaken or mild pain is inflicted (eg.
rubbing sternum, pinching ears)
U – Unresponsive No response to voice, shaking or pain
A fall in AVPU score should always be considered significant.
Urine output: Urine output is one of the few signs of end-organ perfusion. This chart only identifies if urine is
passed or not. Where indicated, a fluid balance chart should be used to document urine measurements in
conjunction with this chart.
Pain scores: pain assessments are often inadequate in hospital. Pain levels should be recorded as follows:
0 – No pain
1 – Mild pain
2 – Moderate pain
3 – Severe pain
Scoring and responding: All the scores for all parameters should be added up and documented at bottom of the
chart
THE DOCTOR SHOULD BE CONTACTED FOR EARLY INTERVENTION IF WOMAN TRIGGERS ONE RED OR TWO AMBER
SCORES AT ANY ONE TIME
71
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