Clinical Record Forms

Labour Record

2021 updates:

• Previously the first page of Labour: First Stage, it is now a one-page form of its own.

• Previous caesarean section and chlamydia and gonorrhea results have been added to the history section, and public health bloodwork has been made consistent with the OPR.

• Gestational age has been added.

Non-randomized trials have shown potential benefits of the use of the partogram (pictoral overview of progress, ease of recording, auditing of care, training of clinicians, and transferring of care), however high-quality evidence is not available. The Cochrane Systematic Review concludes that the decision to use a partogram should be locally determined, while the World Health Organization (WHO) recommends the use of the partogram and the CMO encourages its use. The AOM clinical record forms have historically included a partogram. As a result, the partogram recommended by the WHO has been included for those midwives who choose to use it; it does not distinguish between primiparous and multiparous clients.

Charting should be initiated on the partogram when the client is in active labour and 4 cm dilated.  

Alert and Action lines are printed on the partogram, 4 hours apart.  A client’s labour graph crossing the Alert line is a visual prompt to consider paying closer attention to the progress of the labour; crossing the Action line is a visual prompt to consider taking action to encourage the progress of the labour. Primiparous clients’ labour graphs will cross the Alert line more often than multiparous clients’ labour graphs.

The use of the partogram is more effective when a guideline is used to outline what a midwife might do in these two circumstances.  Practices may consider discussing and agreeing upon labour management actions that they would take specific to their community.

Practices may want to discuss what “screened for S&S (signs and symptoms) of infectious disease” refers to in their context.  This may change with outbreaks of infectious diseases, or may be different regionally.

Labour Notes

2021 updates:

• First and Second Stage of Labour pages have been amalgamated into one document called Labour Notes where all stages of labour can be charted.

• This form contains a distinct column for vital signs, making it easier to chart parturient heart rate throughout labour, and a column for contractions.

• Time of pushing, full dilation and backup midwife call and arrival can be filled in at the bottom of this form when it becomes relevant in the labour.

Immediate Postpartum/Third Stage/Labour Summary

No updates in 2021.

This form includes client position at time of birth and fetal position at birth, which is tracked in BORN.

If more room for charting is necessary, as in a postpartum hemorrhage, a Narrative Note and/or the Client Transfer Record may be used;

An area to assist in tracking the sterilization of instruments has been included.

Perineal Repair/Instrument Record/Departure

No updates in 2021.

An area to assist in tracking the sterilization of instruments has been added;

The departure section of the form can be used to document the midwives departing from the client’s home or the client departing from the birth centre or clinic. If the newborn departure time is different from the client departure time, it can be charted on page 2 of the Immediate Newborn Care and Summary form.

Immediate Newborn Care and Summary, and Newborn Narrative/ Informed Choice Discussions

No updates in 2021.

The form includes skin-to-skin and breastfeeding attempts fields – which are tracked in BORN.

A weight percentile for gestational age field assists in identifying SGA and LGA babies and implementing a pediatric consultation or a hypoglycemia protocol as necessary.  Some ancestry-specific birthweight charts have been developed or midwives may choose to use the basic Canadian birthweight charts as resources. BORN will be providing Canadian data to GROW (Gestation Related Optimal Weight) UK to develop customizable growth curves for pregnancy that are Canadian specific. These curves may offer further options for ancestry-specific normal birthweight assessments. This tool is not currently available. Midwives may refer to http://www.gestation.net/ or the BORN Bulletins for updates. Practices/birth centres may choose to:

• include a copy of the birthweight chart in each out of hospital birth package which would be reused;
• post the birthweight chart (especially for birth centres and practices that offer clinic births); or
• refer to the birthweight chart online.

It is expected that midwives will have documented any prenatal informed choice discussions about newborn medications on a prenatal narrative note and that the level of documentation will reflect the level of risk associated with the choice the client makes.  Any repeat ICDs should be charted on the Narrative section on page 2 of the form.

Additional detail on newborn exam or additional assessments can be charted on the Narrative section on page 2 of the form.

Newborn Summary and Postnatal Care (Page 1 and 2)

No updates in 2021.

Routine screening for hyperbilirubinemia may be charted on the first page.  Follow-up testing may be charted on the Narrative on the second page.

If newborn screening for congenital heart defects using oxygen saturation is routine in the midwives’ community, it can be charted under the Notes section on the first page or on the Narrative section on the second page.

Tick boxes are included for routine newborn medication and tests for quick reference. Details regarding medication administration or tests may be charted on the birth records or on other forms such as the hearing screen form.

Client Summary and Postnatal Care (Page 1 and 2)

No updates in 2021.

The date and time of hospital admission and discharge is included for use (if relevant) to assist in BORN data entry.

Narrative Notes

No updates in 2021.

This can be used for any narrative that does not fit on the relevant record.

Assessment Record (Page 1 and 2)

2021 updates:

• A vitals section has been added in response to the new Fetal Health Surveillance (FHS) guideline and so that parturient heart rate can be more easily charted with the fetal heart rate.

• History of caesarean has been added.

• Urine has been removed as protein dips are no longer routine. If a urine dip is done because of the specific clinical situation, this can be charted in the narrative notes.

• Cervical effacement has been changed from “%” to “% or cm long”.

Some practice groups may choose to use this record to document early labour assessments or other in-person clinical assessments, for example assessment of prelabour rupture of membranes.

An area to assist in tracking the sterilization of instruments (i.e. a speculum) has been added.  If relevant, record the tracking #, sterilization log # and sterilization date.

Some FHR Assessment fields may not be relevant if the midwife is completing an assessment using auscultation.

Some fields from this form are repeated on the Labour Record.  When a client is in active labour on first assessment the midwife would skip the Assessment Record and start charting on the Labour Record.

Client Transfer Record and Client Transfer Record Narrative

No updates in 2021.

Some fields on this form may not be applicable depending on when the transport takes place.  
This form may be copied and used as a summary for the receiving hospital physician.
It is often difficult to chart during an emergency so page 2 of this form is entirely space for narrative to facilitate contemporaneous charting. There is a space at the bottom of page one to indicate if the form is filled out as a late entry (i.e. on arrival at hospital). If it is a late entry, ensure you include a rationale.

Newborn Transfer Record and Newborn Transfer Record Narrative

No updates in 2021.

This form may be copied and used as a summary for the receiving hospital physician;

It is often difficult to chart during an emergency so page 2 of this form is entirely space for narrative to facilitate contemporaneous charting. There is a space at the bottom of page one to indicate if the form is filled out as a late entry (i.e. on arrival at hospital).

Newborn Resuscitation Record (Page 1 and 2)

2021 updates:

• On the first page, the order of boxes has been slightly changed for clarity and some minor edits to wording have been made.

• In the legend, the option to document PPV bag type has been added (self inflating, flow inflating or T piece resuscitator).

• In the legend, “40% oxygen” has been replaced with “self inflating bag no reservoir. NRP used to say that a self inflating bag with oxygen without a reservoir provided 40% oxygen. However, the manufacturer now says that this is not an oxygen blender and cannot be reliably used in this way. Midwives may still use it as a middle oxygen option, but the AOM wished to be clear that this is not reliably provide 40% oxygen.

• Boxes have been added for orogastric tube insertion and intraosseous access.

• Updates have been made to follow NRP guidelines (e.g. removal of size 4.0 ETT, updated tip to lip, removal of Ringer’s Lactate from volume expansion); space has been provided for subsequent doses of epinephrine.

• Ordering, checkboxes and wording have been streamlined for clarity.

• A section at the bottom has been added for calling EMS and hospital and the space for names has been changed from “midwives” to “clinicians involved” to represent students, Birth Centre Aides, EMS or anyone else who might participate.

This form will be used infrequently so midwives may consider using it in skills drills to familiarize themselves with the format.

Prompts have been incorporated into the form to remind midwives of steps in resuscitation. Canadian guidelines are expected to change when the 7th edition of the NRP handbook is released. At that time the meconium section of this form may be removed or updated.

The ETT dose of epinephrine is from the Canadian Supplement to the NRP handbook. The dose differs slightly in comparison to the American dose.

Midwives may choose to document repeated attempts at intubation in the Narrative section or practices may choose to include duplicate copies of this form for extra charting.

Signature Page

No updates in 2021.

Everyone who provides care to the client should sign this form. This includes midwives, students and birth centre aides.

This form may be in the client file rather than in the birth package for home births. For births at the birth centre, it may also need to be in the birth record package so that birth centre aides can sign it.