Prenatal care record sheet

The core essence of the prenatal care record sheet is a tripartite linked medical document with medical traceability attributes, clinical decision-making reference value, and personalized service anchor for pregnant women. It is by no means a formal form-filling task, but the most practical "safety navigation manual" throughout the entire pregnancy and delivery period.

Last week, I followed the director of the obstetrics department during the ward rounds and met a 38-week pregnant mother with her second child. Her hands were shaking while she was sitting in the clinic. Last week, her feet began to swell so much that she couldn't wear size 42 men's slippers. She thought it was a normal reaction in the third trimester. But if director Gao hadn't looked through her nursing records and saw that the urine routines at 34 and 36 weeks were weakly positive for proteinuria, she opened an emergency room and was hospitalized on the spot. If it took a few more days, she might have developed severe preeclampsia, which is risky for both adults and children.

There are actually two different ideas in the industry regarding the design of this record sheet.

Most public systems tend to use standardized templates, and the required fields are very stuck: vital signs for each prenatal check-up, uterine height and abdominal circumference, fetal heart rate, fetal position, key indicators of urine and blood routine, fetal movement count, and complication risk assessment. If you fill in one less item, you will not be able to get a prenatal check-up pass stamp. Call it rigid. If you have to transfer to another hospital in an emergency, doctors from other hospitals can take it and scan it. In 10 seconds, they can figure out the basic situation of your entire pregnancy without missing any key information. The shortcomings are also obvious. They are all objective indicators. Whether the pregnant mother has not slept well in the past half month, whether she feels like crying every now and then, and whether she has conflicts with her family. There is not enough space to write about it. For many emotional problems, you can only rely on doctor consultation and luck.

Private obstetrics and gynecology institutions have a lot of ideas. In addition to the required medical indicators, they will also add a lot of personalized modules: what you ate today, how many hours you slept, whether you had sex, how many prenatal checkups your partner went with this week, and even "happy things this week" and "anxiety points this week" have blanks for you to fill in. I have seen a record sheet from a private institution before, and even attached stickers on each page. If the fetal movement is normal, there will be a small sun, and if it is uncomfortable, there will be a small rain cloud. It is not stressful for pregnant mothers to fill it out. But here’s the problem. If you want to transfer to a large public hospital to give birth midway, the doctors will not recognize the personalized content at all, and it will take a long time to find the core indicators, which will delay things.

I have been in the obstetrics department for almost 7 years, and the most interesting record sheet I have ever seen was that of a post-95s girl who was pregnant with twins. During each prenatal check-up, she would post a small silhouette of the day's B-ultrasound screenshot in the blank space, and would also make casual notes, "I drank iced milk tea today, and my two babies moved all morning." "I had an argument with my husband yesterday and cried for half an hour, and the fetal movement was a little less." Later, when she was undergoing fetal heart monitoring at 37 weeks, the baby's fetal heart rate suddenly soared to 170. Just as the doctor was about to arrange an emergency B-ultrasound, she turned to the same record from last week and said that she had just eaten spicy Chongqing hot pot at noon. It was the same as last time. The doctor observed it for another 20 minutes and it dropped down. She avoided an unnecessary emergency examination.

Oh, by the way, many pregnant mothers think that this record sheet is for the doctor to fill out and has nothing to do with them. When they take it home, they stuff it in a drawer and worry if they can’t find it during the next prenatal check-up. Really not. Last year, I met a little girl who was 32 weeks pregnant. She had a cold and fever for three days but didn't take it seriously. She didn't tell the doctor. During the prenatal check-up, the doctor checked the fetal movement count she filled in at home and found that the fetal movements during those three days were one-third less than usual. They quickly arranged for NST. Fortunately, it was a transient hypoxia and she recovered after three days of oxygen inhalation. If she hadn't filled in those lines of numbers carefully, something might have happened.

There is still a hotly debated topic right now, which is whether to replace all records with electronic records. People who support it say how convenient it is. It can be adjusted at any time in the mobile phone and will not be lost. The system can also automatically warn you. For example, if you have less fetal movement for three consecutive days, a reminder will appear directly. The reasons for the objections are also very real: many pregnant mothers have to go to work during the day, and it is already midnight when they think of filling out the form. How can they have time to fill in the form on their mobile phones for half a day? There are also many elderly people who accompany prenatal check-ups and do not know how to operate the hospital's small procedures. They cannot produce the records when they arrive at the clinic, which is troublesome. Our hospital is now taking care of both ends. Paper documents are issued and electronic files are updated simultaneously. You can fill in whichever you want. At present, it seems that there are still many people who take paper documents. They say they can be touched in their bags and are practical.

To be honest, whether this record sheet is paper or electronic, whether it is a standardized template or a fancy personalized version, the core is never to complete the hospital's assessment tasks, but to provide guidance for you and your baby. Don’t fill it out too seriously, and don’t take it seriously. Even if you draw a crooked smiley face in the blank space and note that you are very happy today after eating a cake you have wanted to eat for a long time, it is meaningful - after all, your emotions are the most important part of prenatal care.