Accurate records are important

Accurate records are important

Keep complete and neat antenatal records

Accurate records are important

Each pregnant woman has a hand-held paper record (the antenatal card or maternity case record) which she carries with her and can give to the clinic staff at each visit. This contains the orderly and accurate record of her antenatal care. It immediately shows healthcare staff the most important information about the woman and her pregnancy.

During booking you need to record:

  • the mother’s personal details,
  • duration of pregnancy,
  • obstetric history,
  • examination details (including breast exam and upper arm circumference),
  • results of screening HIV, syphilis, proteinuria and glycosuria
  • results of screening HIV, syphilis, proteinuria and glycosuria
  • PAP smear (cervical smear for cytology)
  • haemoglobin level, and
  • blood group.

The Department of Health has increased antenatal care visits from five to eight. The visits now take place at 14, 20, 26, 30, 34, 36, 38 and 40 weeks. The visit at 32 weeks falls away.

Remember to complete the antenatal record at each visit with the observations and management, level of care required, and plans for delivery. Plot the symphysis-fundal height on the fetal growth curve and record the findings of ultrasound scans.

Having all this information recorded in a simple, easy way helps staff give appropriate care. It also provides a written checklist to make sure that all aspects of pregnancy care are met.

What common mistakes have you seen in the hand-held record?

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