Record and Report of Delivery

Record and Report of Delivery

• Always documenting and reporting is crucial since it is often used for statistical analyses and obstetrical research. So it is important to carefully record facts and figures. The document includes:
• Mother's Chart Recording,
• Presentation, fetal position, membrane rupture timing, and liquor amnii color.
• Normal delivery is the type of delivery. normal delivery involving an episiotomy, vacuum extraction, use of forceps, or cesarean section, etc.
• Observed delivery day and time,
• Use of local, epidural, or general anaesthetic.
• When was the placenta delivered, and how long later was the baby born?
• If there are any indications of incompleteness in the placenta, membrane, cord anomalies, etc., an inquiry and inspection are required to determine whether or not the placenta was retained.
• Amount of blood loss measured in milliliters; if more than 500 milliliters are lost, the condition is known as PPH. Blood loss should be measured as clotted, soaked, and blood-in-telespad.
• If there is a tear or laceration in the cervix or perineum, the condition of the tear and its depth should be noted.
• If non-absorbable thread is used for skin sutures, the number of sutures should be tallied and recorded together with any episiotomy wounds and sutures.
• Any prescription or drug given to a mother during labor should be meticulously recorded, including the name, dose, route, timing, and proper providing staff signature.
• The chart should indicate where the mother and child were transferred to after delivery, such as a postnatal ward, NICU, or a baby care facility.
• Any unusual condition or complication during labor and its management should be properly recorded, or the presence of an ANM should be clearly and specifically noted.
• Mother's vital signs (temperature, pulse, respiration, and blood pressure) following birth. It displays the mother's normal and atypical conditions. Every four hours, these vital signs should be recorded. Whether the mother has voided or not after birth, the volume of urine voided and the amount of time after delivery should be noted since the voiding time after delivery can be used to assess urine retention.
• After delivery, fundal height has to be measured and accurately recorded. the placenta's mass, color, and any anomalies.
• if the third stage of labor is actively managed while being induced with oxytocin. It needs to be properly documented.

Record of Baby's Chart

• Sex of the baby: male or female
• APGAR score
• Baby's weight, height, head circumference, chest circumference and if needed abdomen circumference should be taken and recorded.
• Temperature, pulse (Heart rate) and respiration of baby: Any congenital abnormalities and birth injuries of baby e.g. hare lip, cleft palate, spina bifida, Erb's paralysis etc.
• Any medication given for baby: medicine name, dose, route, time and drug given by should be recorded e.g. inj. Vitamin K 1 amp IM
• Any abnormal condition: Cord rounded around neck.
• Any resuscitation measure done to baby e.g. oxygenation, suction, endotracheal tube insertion etc.
• Transfer of baby from labour room e.g. pediatric baby unit, neonatal care unit, incubator ward, pediatric intensive care unit, neonatal intensive care unit.

Recording of Information and Data in Relation to the Antenatal Care

Antenatal cards are used by antenatal clinics and hospitals and contain all the patient's information, including blood type, gravida, para, preterm births, abortions, live children, LMP EDD, antenatal visits, TT 1st, TT 2nd, and more. It also includes all the patient's data, such as vital signs, physical exam results, results of abdominal and pelvic exams, results of urinalysis, etc. This card is used during the antenatal period, typically 12 weeks or later.

The following details must also be recorded during prenatal care:

Antenatal Visits

There should be a minimum of four antenatal visits for every pregnant woman. It should be made clear that this is only a minimum requirement and that additional visits might be required based on the woman's needs and condition. The following is a recommended schedule for prenatal visits.

• Timing of the First Visit/Registration - The first visit or registration of a pregnant woman for ANC should take place as soon as the pregnancy is suspected. Every woman in the reproductive age group should be encouraged to visit her health provider if she believes she is pregnant. Ideally, the first visit should take place within 12 weeks.
• Second Visit - Between 14 and 26 weeks.
• Third Visit - Between 28 and 34 weeks.
• Fourth Visit - Between 36 weeks and term.

Components of Ante Natal Check-up

History Taking

A detailed history of the woman needs to be taken and documented to:

• Validate the pregnancy (first visit only).
• Determine whether there were any issues with a prior pregnancy or confinement that could have an impact on the current one.
• Identify any existing medical, surgical, or obstetric conditions that might make the current pregnancy more difficult. Using the menstrual cycle to estimate the due date.
• Ask her about the heartburn, constipation, nausea, and increased frequency of urination.
• Inquire about any signs of problems.
• Fever.
• Continual vomiting.
• Unusual vaginal bleeding or itching.
• Palpitations, fatigue easily.
• At rest or after light exertion, breathlessness.
• Bodily edema in general and facial puffiness.
• Severe headache and eyesight haze pee passing more slowly and experiencing burning during micturition.
• Uterine bleeding little or nonexistent fetal activity. Watery fluid leaking through the vagina (P/V).
• Inquire about her prior pregnancies or obstetric history and make a note of it.
• Ask and note how many pregnancies have already occurred. Verify that all of the births were live births and ask whether there were any stillbirths, abortions, or children who died.
• Find out the time and result of each occurrence, as well as the birth weight, if it is known. Check to see whether there were any unfavorable perinatal outcomes (which occur between 7 days before and 28 days after birth).
• Identify and document any obstetric issues and events that occurred during the previous pregnancies, such as: recurrent early abortion; post-abortion complications; hypertension; pre-eclampsia; eclampsia; ante-partum hemorrhage (APH); breech or transverse presentation; obstructed labor, including dystocia; perineal injuries/tears; excessive bleeding after delivery; and puerperal seps.
• Find out if the mother has undergone any obstetric procedures, including as caesarean sections, tool deliveries, vaginal or breech deliveries, or manual placenta removal.
• For a history of blood transfusions, inquire and make a note.
• Past and present medical histories of any systemic illnesses: Diabetes, chronic cough, blood in the sputum, protracted fever (tuberculosis), renal illness, convulsions (epilepsy), attacks of dyspnea or asthma, jaundice, and malaria are all symptoms of high blood pressure (hypertension). There are other diseases, such as HIV/AIDS, STIs, and reproductive tract infections (RTI). family history of chronic disease.
• History of using addictive or dangerous drugs - Chews, smokes, or consumes alcohol. Visual Inspection general assessment Edema, jaundice, pallor, pulse, and respiratory rate weight, blood pressure, and examining the breast.

Abdominal Examination

• Auscultation of the Fetal Heart Sounds.
• Inspection of scars/any other relevant abdominal findings.
• Measurement of fundal height.
• Determination of fetal lie and presentation by fundal palpation, lateral palpation and pelvic grips.

Laboratory Investigations

• Urine Pregnancy test.
• Blood investigations for Hemoglobin estimation and blood grouping including Rh factor.
• Urine test to assess the presence of sugar and proteins.
• Rapid test for malaria and syphilis, TORCH etc.

Interventions

• Iron Folic Acid (IFA) supplementation along with counseling about the necessity of taking IFA and the dangers associated with anemia
• Administration of TT injection two doses of TT injection for prevention of maternal and neonatal tetanus (tetanus of the newborn). ed Perinatal Death Surveillance and Response)

MPDSR (Maternal and Perinatal Death Surveillance and Response)

A key strategy for raising the standard of care for maternal and neonatal health is Maternal and Perinatal Death Surveillance and Response (MPDSR). In order to put a stop to unnecessary maternal and newborn mortality, MPDSR is also essential for informing advocacy, policy, planning, service delivery, and accountability. The use of tailored evidence-based therapies to address the underlying causes of maternal mortality is made easier by the MPDSR approach. As a result, it becomes a crucial tactic for achieving:

• SDG 3.1 by 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births
• SDG 3.2 by 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births
• SDG 3.8 by 2030 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all.

MPDSR Nepal

Over the past 20 years, Nepal has made considerable strides in lowering maternal and perinatal mortality. Despite advancements, maternal mortality remains a significant public health issue and one of the leading causes of death among women of reproductive age in Nepal. In Nepal, it was estimated that 1500 women died in 2015 as a result of pregnancy, childbirth, and the puerperium (WHO 2015). The maternal mortality ratio only tells half of the tale, despite the fact that it is obviously necessary to keep track of this. It is crucial to comprehend the reasons for the rise in maternal mortality over the previous ten years and to take the appropriate precautions to stop further increases.

As a result, Nepal has been working on several projects to find data that may be used to influence investments and interventions in maternal health.

Maternal death reviews were first implemented in 1990 at the only maternity hospital in the country, Paropakar Maternity and Women's Hospital in Kathmandu. The hospital implemented perinatal death review in 2003. In six hospitals, maternal and newborn mortality evaluations started in 2006. By 2014, 44 referral facilities were doing these reviews. Studies on maternal mortality and morbidity also started in 1998 in three areas and were expanded to eight districts in 2008-2009.

The Government of Nepal (GON) started a maternal and perinatal death surveillance and response system in 2014 in accordance with the recommendations of the Commission on Information and Accountability/World Health Organization (ColA/WHO). The system is based on lessons learned from the maternal mortality and morbidity study and MPDR implementation.

While facility-based reviews of maternal and perinatal deaths continue in 44 referral hospitals, the GoN, with support from the WHO and other partners has been implementing MPDSR in five districts, namely Banke, Dhading, Kailali, Kaski and Solukhumbu since 2016. In these districts, MPDSR is implemented at two levels: health facility and community. At the facility level, both maternal and perinatal deaths are reviewed The Ministry of Health of Nepal, with support from the WHO, UNICEF Nepal Health Sector Supon maternal deaths only Program/Department for International Development and other partners, has taken the lead and made a commitment to gradually scale up maternal and perinatal death surveillance and response to all community verbal autopsies are conducted for hospitals across the country by 2020 and ultimately expand to include community-based maternal death surveillance and response. A series of planning meetings are taking place with experts to finalize the training modules, review processes, and develop implementation guidelines, to name a few.

Referral Slip

The referral slip is a slip that includes information on the patient, the referring provider, referral details, a list of the procedures being referred, and any extra remarks the doctor wishes to provide. An efficient referral system maintains close communication between all levels of the healthcare system and aids in ensuring that patients receive the finest treatment near to where they live. Additionally, it aids in the efficient utilization of medical facilities and basic healthcare services.

It is crucial to have access to emergency obstetric care and to support prenatal and delivery care in primary facilities during pregnancy and childbirth. In pregnancy and childbirth, referrals can be made in a variety of ways. Depending on the involvement of the first line services, this can be categorized as institutional or self-referral, antenatal, delivery, or postnatal referral, and elective or emergency referral. However, there are a few widespread problems in the referral system that make it difficult for patients to get the right care at a referral facility. These problems include poor communication, inadequate transportation, and poorly documented referral flows. Various community-level interventions can be made in relation to educational initiatives to increase awareness of danger signs and promote the use of obstetric services, as well as to remove financial and geographic barriers through emergency loans and to enhance transportation and communication.

Verbal Autopsy

The history of verbal autopsy, which looks for likely reasons of death, extends back to London in the 17th century, when so-called death searchers conducted inquiries concerning deaths by going to the homes of persons who had passed away. Later, in the 19th century, Europe saw the end of this tradition as a result of the creation of contemporary systems for death registration. But later, in the 1950s and 1960s, Asia (Khanna and Narangwal in India, Companiganj in Bangladesh), and Africa adopted the practice. Physicians trained in this technique, as opposed to death searchers, were to determine the most likely causes of death through methodical interviews. Workers on the Narangwal project gave this novel method the moniker "verbal autopsy."

In a Verbal Autopsy, the next of kin or other caregivers are interviewed to determine the most likely cause of death. Due to the lack of a civil registration system, most deaths that happen at home in many nations go unrecorded. In these situations, verbal autopsies have been used to provide information on the distribution and trend of causes of death. Such data gives decision-makers access to information that is essential for public health planning, resource allocation, and the evaluation of intervention impact.

There are various uses of verbal autopsy, some of which are mentioned below:

• It offers details on the distribution of fatality causes.
• It is employed in the assessment of public health initiatives intended to lower the death toll from certain causes.
• It is used to identify variables linked to mortality (cultural, social and behavioral) Additionally, it is employed in the analysis of infectious disease outbreaks and risk factors for specific illnesses.