Record keeping – Understanding how your pregnancy is documented
In this article:
- Your maternity (handheld) notes
- Who can see the notes?
- What’s in the handheld notes?
- Storage of maternity notes
- Importance of your own notes
- The Red Book
- Spotlight Issues
Your maternity (handheld) notes
After you complete your booking appointment with your midwife, you will be given a set of maternity notes, commonly known as your “handheld notes”. These notes act as a central place to document your care and progress through your pregnancy. During your antenatal journey, you may have appointments in various settings (e.g. hospitals or family practices) and with many different healthcare professionals including doctors, midwives and sonographers. You should bring your notes with you to all of your antenatal appointments. Every appointment and every ultrasound scan will be documented in these notes. This allows any healthcare professional that comes into contact with you to have a full overview of your pregnancy health, and therefore provide you with a high standard of individual care.
Take good care of your handheld notes as there is no copy! Try to keep them with you as much as possible e.g. when you are at work, shopping or even on holiday. In an emergency situation these notes will be provide key information to the professionals looking after you. You also need to bring them with you when you go into labour.
Who can see the notes?
Any healthcare professional that is involved in your antenatal care. Importantly, you have access to the exact same information as your doctors and midwives. If you don’t understand anything documented, do not forget to ask at any antenatal appointment.
What’s in the handheld notes?
Each hospital will have different formats of the handheld notes, but in general all should contain:
Booking appointment details:
- Demographics: name, address, ethnic origin, religious beliefs, language
- Your past medical history: any illnesses that may affect your pregnancy
- Information regarding any previous pregnancies
- Results of screening blood tests, e.g. your Rhesus status
Information about the pregnancy:
- Ultrasound scans and growth charts for your baby
- Checks at antenatal appointments: blood pressure, urine dip results, the height of your growing bump and position of baby, your weight and body max index (BMI)
- Any attendances to the antenatal ward, maternity triage or day care unit for complications arising in your pregnancy
- Plans for the safe delivery of your baby
Details of your labour
Importantly all of the events of your labour and delivery, whether vaginal or caesarean section, are carefully documented in your maternity notes. This will be used during your labour to allow handover of relevant information between the teams of people looking after you and your baby. The progress of your labour, delivery and any complications are also valuable information for when it comes to planning the safe birth of any future babies.
Storage of maternity notes
Once you have delivered your baby and are going home, the notes will become part of your permanent maternity record. These are usually stored at the hospital responsible for your care for many years. In future pregnancies these notes may be examined again to see whether any additional care needs to be provided antenatally and what type of delivery you should aim for at which gestation. Even if you move to another area, the notes can be made available to the new team looking after you.
Importance of your own notes
It is important to write down any questions you may have regarding any aspect of your pregnancy health so that these can be addressed at your next appointment. There may also be a section for you to fill in with your midwife regarding your choices for labour and delivery of your baby. These may include pain relief and setting of delivery.
The Red Book
This is the personal child health record (PCHR). This nearly always has a red cover and is therefore known as the “red book”. It is usually given to you before you go home with your new baby. This will contain all of the information about the health of your baby for the first 2 years, much like your antenatal notes contained information about your pregnancy health.
You will be offered regular health reviews and also vaccinations for your baby until they are 2 years old. This is to ensure that your baby’s development is on track. This may be done by paediatricians (doctors for children), at the GP surgery or by midwives. Like your maternity notes, it is a good idea to take the red book to every check-up of your baby. Again, you can also add your own information to the book, for example, any accidents or illnesses of your baby. There will also be a “milestones” section in the book where you can record when your baby first crawled, talked or walked for the first time.
- Your “handheld notes” act as a central place to document your care and progress through your pregnancy. Every appointment and every ultrasound scan will be documented in these notes.
- You should bring your notes with you to all of your antenatal appointments, as well as appointments with doctors, midwives and sonographers.
- In an emergency situation these notes will be provide key information to the professionals looking after you. You also need to bring them with you when you go into labour.
- Importantly all of the events of your labour and delivery, whether vaginal or caesarean section, are carefully documented in your notes.