Prenatal care record sheet

The core value of the prenatal care record sheet has never been a standardized document to deal with the prenatal check-up process, but a risk warning file covering the entire pregnancy cycle, which can directly provide a basis for diagnosis and treatment decisions and reduce pregnancy risks at critical moments.

I came across a particularly impressive case when I was rotating in the obstetrics clinic: Ms. Lin, a 32-year-old patient with gestational diabetes. During every prenatal check-up, she would record her pre- and post-meal blood sugar test at home, the length of exercise that day, and even what she had eaten the day before in the blank column of the record sheet. During the routine prenatal check-up at 37 weeks, fetal heart rate monitoring suddenly appeared frequently. Slowing down, the bedside doctor reviewed her previous three records and found that her postprandial blood sugar had been above 8.5mmol/L in the past week. She also noted twice that she had "lower abdominal tightness after dinner that lasted about 10 minutes." An emergency cesarean section was arranged on the spot. When the baby was born, the umbilical cord had already been twisted three times around the neck. If it were half a day later, the consequences would be disastrous. If the doctors at that time only had scattered data of half an hour for each prenatal check-up, it would take a lot of time just to identify the triggers, and they would not be able to grab so much golden time for treatment.

Maybe many pregnant mothers have not carefully read the record sheet in their hands until now. They feel that it is all professional content filled in by nurses and doctors, and they do not need to understand it. In fact, in the past few years, there have been two different practical directions in the use of this record sheet in the obstetrics circle. The traditional school advocates that doctors and nurses should take the lead in filling in the records. After all, ordinary people without medical background can easily label normal physiological reactions as abnormalities, and either fill in the wrong data to mislead their judgments, or scare themselves and increase anxiety. The more standardized and unified the content of the record sheet, the easier it is to quickly read it across hospitals and doctors. But in recent years, the call for "joint recording" has become louder and louder. After all, doctors and nurses can only see your status during the dozens of minutes during the prenatal check-up. Details such as your fetal movement pattern, dietary preferences, and even mood swings at home are the vast majority of your pregnancy status. I have also seen a pregnant mother write down her fetal heart rate 10 times per minute after eating spicy hot pot. The doctor directly adjusted her dietary taboos, which is much more efficient than asking her repeatedly for half a day.

Don't underestimate this thin booklet. There are really more signals hidden in it than you think. There is no need to stare at those test items full of English abbreviations. Just look at the growth curve of uterine height and abdominal circumference. It is much more useful than a single value. If there is no change in uterine height for two consecutive weeks, it is safer to go to the hospital directly for a checkup without waiting for the next prenatal check-up appointment. Do not hide the past medical history column. Whether it is a previous miscarriage, drug allergy or family genetic history, you must fill it in truthfully even if you feel embarrassed. I have really encountered pregnant mothers who concealed their abortion history. Placental adhesion occurred during delivery. The doctor was not prepared in advance, and she suffered a lot in vain. Also, it is best to buy a transparent document bag for your own record sheet. Each B-ultrasound report and blood routine report are posted on the back of the blank page in chronological order, which is better than crumpling it randomly in the bag. On the day you enter the delivery room, you hand over the neat record sheet, and the nurse does not have to look for data for a long time. All you save is your time.

It's quite interesting to say that many public maternal and child health hospitals are now changing the record sheet templates that were densely packed with professional grids, adding blank areas for pregnant mothers to take notes, and even supporting electronic mini programs. After measuring blood sugar and counting fetal movements at home, you can fill it out at home, and the data will be automatically synchronized to the doctor in charge of the bed, saving a lot of time and effort in running back and forth. Of course, some people think that the electronic version is not as reliable as the paper version. If there is a problem with the system, it will be troublesome to lose the data. Each has its own reasons, as long as it is convenient for you to use.

After all, this record sheet is not just a cold medical document. When you flip through it, you can also see your own trajectory over the past ten months: from the excitement of seeing the fetal heartbeat and fetal bud for the first time, to the relief every time you pass the test of glucose tolerance and major ovarian abnormalities. Those random notes such as "I want to eat something sour today" and "The baby kicked me three times today" will be a special souvenir when your child grows up and looks through it, isn't it? Oh, by the way, one last reminder, this record sheet is a legally binding medical document. Before signing your name, it is best to take a look at it to see if there are any discrepancies with your actual situation. If you have any questions, ask for corrections on the spot. Don’t just sign it in a haphazard manner. There is no harm in it.