Tuesday, July 26, 2011

Documentation for student midwives: how to write up an abdominal palpation

I have just spent some time with midwifery students. One of the things I have found is a general lack of confidence with documentation. In all my years as a midwifery educator, this has probably been one of the most common themes, and continues to be an issue into practice as registered midwives. So here is the first of several posts that will talk about basic midwifery documentation.

Abdominal palpation
I write up an abdominal palpation in the way I actually carry it out. I start with the reason for carrying out abdominal palpation and briefly write about any particular information I gave mum and that she gave her consent.
  • General observations about the mother's health eg has she been feeling any abdominal tightenings or pain?
  • General observations about baby's health ie what has been the pattern of fetal movements?
  • General observations about the abdomen eg are there any scars and what is the significance for pregnancy?
  • Fundus - is it at the level you would expect for the baby's gestation? If not, by measuring the fundus (by inspection or using tape measure), what size do you think the uterus is?
  • What is the lie? If there are more than one baby, this may be difficult so you need to document what you feel and your "impression" of what you felt, acknowledging if you're not sure.
  • What is the presentation?
  • Where is the baby's back?
  • Some people actually document what position they think baby is lying in. I have to admit I do not. Whilst I might be pretty sure, I always wait until I have confirmed the position by vaginal examination, if I ever get to that stage.
  • Engagement of the presenting part. So if I can feel 4/5th of the head above the brim, I document that - there is no need to write not engage because that is evident. However, if the head is sitting at 3/5th engaged, just at the brim, I confirm that it is not engaged.
  • Whilst we know that listening to the fetal heart in pregnancy is of no use, I have to admit I still do it. I document the heart rate, as well as how I heard it ie with a pinard or doppler.
I complete my documentation with the information I share with the woman and any action plan I have developed with her.

Example of documentation
Visited Lisa at home for her 36 week ante natal check up. Lisa is in good health and happy with how everything is going. She is feeling Braxton Hicks contractions at times but no regular contractions. Baby has been moving a lot, especially first thing in the morning and late at night, at least 10 movements every 12 hours.

Carried out abdominal palpation to check growth of baby with Lisa's permission.
Abdomen - healthy with linea nigra
Fundus = dates (fundal height = 37 cm)
Singleton - Longitudinal lie
Cephalic presentation
Back on the left and anterior, ?LOA
Head not engaged - 3/5th palpable
Fetal heart heard with pinard - 140 beats per minute

Discussed findings with Lisa - baby is growing well and lying in a good position ready for when Lisa goes into labour in a few weeks' time.
Plan: for routine ante natal visit at home in 2 weeks on 9th August 10.00 hours. Lisa has been advised to contact me if she has any concerns about the baby's movements - if she feels less than usual or none at all.

What do you think of this example of documentation. Have I forgotten anything? How would you do it - is there anything you would write differently?

Image: '240 - Checking In'


Matt Mason said...

Hi Sarah,
Can't say that I would do anything differently, particularly as I am not a midwife. However, I would make sure that I have included a date and time of the report and ensured I have signed it with by designation. This allows me to construct a timeline if I need to in the future and if the record is a shared record differentiates my entries from another person's.

Sarah Stewart said...

Thanks, Matt...very basic stuff that I've left out...thanks for pointing it out :)

Anonymous said...

Hi Sarah

Thanks for sharing
Can you share documentation for birth of baby and placenta