Maternity Record Book Smriti Mani
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1MATERNITY RECORD BOOK2
3MATERNITY RECORD BOOK A PRACTICAL RECORD BOOK OF OBSTETRICS
SECOND EDITION
Smriti Mani MA (Phil) BEd, MSc Nursing, M Phil in Nursing (Speciality Obstetrics and Obstetrical Nursing) Principal College of Nursing Medical College and Hospital Kolkata, West Bengal, India
4
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© 2012, Jaypee Brothers Medical Publishers
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This book has been published in good faith that the contents provided by the author contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the author specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the author. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device.
Maternity Record Book
First Edition: 2009
Second Edition: 2012
9789350259917
Printed at
5Preface to the Second Edition
There are many demands made on the Maternity Record Book as the maintenance of records are compulsory by all nursing students. First, to provide high quality and patient focused care afterwards student nurses must be prepared from the training period properly.
Next, to compare the care delivered with agreed standards is the objective of continuing to improve the process of fill-up the record book. Last but not the least, there is a responsibility to disseminate new ideas and information through the filling-up of the record book.
In the second edition, the accessory portion of record book is deleted. The book is made less voluminous to make it handy. The writing portion is also curtailed as per student's convenience. Hope it will be helpful for students and instructors to strive for excellence in the field of midwifery aspect of their professional life.
Smriti Mani6
7Preface to the First Edition
It is well known that midwives are women's first choice for a skilled attendant at birth. They should be each country's first choice to lead in care for childbearing women. Many other professions contribute value skills to assist women with particular needs as and when necessary; but the midwife is there throughout. So, the midwife's contribution to maternity and public health is very much significant. Health promotion during pregnancy contributes to healthy lifestyles. A midwife is responsible to provide all information to a pregnant woman regarding birth process. A well-informed woman will enter the birth process with confidence. A confident new mother physically fit and active after the experience of birth, is far less likely to suffer anxiety and depression. A healthy and mentally prepared mother will feed and care for her baby properly, increasing the chance of normal, healthy life for both. A happy and enthusiastic mother will join in her life within the community helping others and spreading knowledge about good practices. A midwife cannot create this precious being but she can provide the care, support and security needed to nurture this precious being and the woman during the whole childbearing period. This healthy experience in a cyclical way will lead to other women for healthy practices and healthy families representing the wealth of nations. Midwives not only provide care, support, security and promote healthy lifestyle during antenatal period but also help to prevent maternal and neonatal deaths during delivery and postnatal period which is the basics and the aim of quality midwifery practice. A midwife will provide comprehensive care to mother and baby and take care of family planning also.
Being a teacher in midwifery for many years, I felt the need for a comprehensive practical record book for students of midwifery. A trained midwife must be prepared as a competent, skillful and up-to-date knowledgeable nurse during the training period. In order to meet such a need, the requirement of a nursing student in handling a woman skillfully in pregnancy, labour and postpartum period is important. This casebook is prepared in such a way that if a student fills it up each time to record the cases, he/she will learn automatically regarding assessment, diagnosis and management of a woman. Hope that this book will benefit all levels of student of midwifery training programme like BSc Nursing, Post-Basic BSc, MSc (IGNOU) and specially nursing practitioners as a practical record book.
Smriti Mani8
9Acknowledgements
Being constantly insisted by the students of BSc (Hons) Nursing and MSc, it was ultimately decided to prepare a comprehensive maternity record book to guide the students properly in recording their clinical experiences in the field of midwifery. So, I wish to acknowledge students’ inspiration first for the work.
In preparing this practical record book, I utilized the knowledge of existing casebooks for midwives by Molly Babu, Shobha Gusain, Anita Das and Annamma Jacob and IGNOU books by different authors. I acknowledge and express my gratitude to all of them including publishers.
An expression of cordial thanks to Shri Jitendar P Vij (Chairman and Managing Director), Mr Tarun Duneja (Director-Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India and Mr Indrajit Upadhyaya of Kolkata Branch for their constant encouragement, support and reminder without which this record book could have never been finished in time.
Above all, I felt God Almighty's grace which made this work possible.
10Instructions for Filling Up the Casebook
Students are instructed to carry the casebook to the clinical field during their clinical posting to antenatal OPD/ward, labour room, postnatal ward, nursery, PP unit and OT. Students will fill up the casebook by putting a tick mark (✓) or writing in the blank space by a word or by a sentence only. The example copy is a comprehensive one. There is no need to copy everything from the example copy. For example, you may write only “ND with epi” instead of normal delivery with episiotomy done. Students can modify their findings as per their convenience with the help of their instructors and adopt a brief recording system also wherever it is applicable. It is also given in the example by putting ‘or’ and ‘you may write’. There is no need to waste extra time to fill it up. So, students are instructed to fill it up while they are taking history, doing assessment and making nursing diagnosis for the clients or immediately after conduction of delivery, etc. Then only this book will be a useful learning guide as well as a record book for the students.
11MATERNITY RECORD BOOK For Clinical Experiences
12ESSENTIAL REQUIREMENTS OF CLINICAL PRACTICE AS PER INDIAN NURSING COUNCIL SYLLABUS
S. No.
Title of Requirement
Total Requirement for Basic BSc Nursing
Total Requirement for Post-Basic BSc Nursing
Total Requirement for IGNOU BSc Nursing
Total Requirement for MSc Nursing
1.
Antenatal Examinations Performed
30
20
10 (high-risk screening-3)
20
2.
Normal Deliveries Conducted
20
10
2 (1 only assessment)
20 (using partograph)
3.
Vaginal Examinations Performed
5
5
1
20
4.
Episiotomies and Suturing Performed
5
5
1
10
5.
Neonatal Resuscitations
5
5
1
5
6.
Caesarean Sections Assisted
2
2
1
2
7.
Abnormal Deliveries Witnessed/Assisted: Forceps/ Ventouse/ Twins/ Others
5
5
-
5
8.
ND Witnessed
50
30
-
30
9.
Postnatal Mothers and Neonates Nursed
20
15
2
20
10.
Assisted with MTP/DE/Any Other Surgical Procedure
1
1
-
1
11.
IUD Insertions
5
5
-
5
12.
FP Counselling
2
2
-
5
13.
Assisted/Observation: Permanent FP Methods
[Tubectomy, NSV, Vasectomy]
1
1
-
1
14.
Newborn Examination
5
5
2
5
15.
Observation of High-Risk Newborn
1
1
-
5
16.
Case Presentation
1
1
-
2
17.
Case Study
2
2
1
2
18.
Health Education
2
2
4
1
*The number of cases is not mentioned in INC syllabus (2011), the number is taken arbitrarily to keep a balance with the Basic BSc Course.
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