Documenting IA

Midwives are expected to complete records at the time or as soon as possible after an event, recording if the notes are written after the event [The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates; paragraph 10], such as when documenting details of a birth or perineal suturing.  

Midwives are expected to record in real time the fetal heart rate and any accelerations and/or decelerations heard, throughout labour. 

Inadequate and inaccurate record keeping has been highlighted as a recurring theme and contributing factor in sub-optimal care in confidential enquiries into stillbirths and infant deaths (e.g. MBRRACE-UK, 2017).

A case-note audit of 115 births that used IA at some point, in seven settings, found variation in the documenting of IA and in the completeness of documentation (in both paper and electronic notes).  The study identified several factors that contributed to the quality and completeness of documenting IA.  These were:

• The multitude of tasks required when caring for a woman during labour, especially in the second stage.
• Technical limitations of electronic notes/systems
• Poor internet connectivity
• Duplication of information or volume of information required
• Sub-optimal layout of birthing room

Think about what is recorded and how.