I attended my first labour where the Mum chose to give birth standing up in my second year and it caused me problems.
Not for anything to do with physical care or the woman's choice to stand up; in fact, it was the best thing ever.
Mum was standing up leaning on the bed, and I had warm towels, a pillow to catch the baby on if we needed somewhere to put him temporarily, and the birth pack with cord clamps, sterile bowls, etc. My notes were balanced on a trolley.
The baby was born with a seismic roar from Mum. It sounded like a mountain giving birth.
I'll always remember how in control this mother was. She gave me this blissful, calm 'Thanks Ellie, I've got this' smile as I passed her baby boy to her through her legs, and I was in awe.
The problem was, I'd done no documentation at all.
Slippery gloves, fast pushing, my biro falling down the gap between the bed and the wall had all made me feel like it was impossible to document, and I should be just caring for the woman in question.
My mentor thought this was hilarious, and luckily she'd got down all the important times.
From this, I clearly remember that 'part student midwife, part octopus' feeling that you get when learning how to document, especially during the second stage of labour or emergencies.
You get a completely different 'part midwife, part octopus' feeling when you're qualified and have seen ten different clients that day, but that topic's for another post!
This post is on the basics.
Documentation is important for a few good reasons. Communication of essential facts and history of women's care to other professionals is one. Audit, which means looking at care in detail and picking up on either good or poor patterns of outcomes is another.
The third reason can feel like the black dog in the room watching you. Many midwives say this is the major downside of 'the best job in the world': the possibility of litigation.
Poor documentation can mean the end of a career, despite the actual care being good (one reason we should think carefully before judging any healthcare professional being accused in the news).
As the medical malpractice lawyers are so keen on saying:
‘If you didn’t document it, it didn’t happen.’
I’ve written before about the unachievable aspects of UK midwifery documentation, you can see the blog post here.
But I don't want to be gloomy.
Only 0.2% of midwives will ever get sanctions on their practice from the Nursing and Midwifery Council, and this means excellent documentation and practice are being achieved in very challenging circumstances.
So here are my top 10 tips for learning excellent documentation, while still keeping care women centred.
1. Have a system to make documentation as fun as possible to get right
I know, you’re thinking “Ellie, that’s bonkers” (I’m reminded here of that episode of ‘Yes Minister’ where one of the Home Office employees came up with a new slogan to promote government: ‘Red Tape Can Be Fun!’)
What I mean is – get a good couple of pens that you enjoy writing with. To fulfill most trusts guidelines, you’ll need at least one red pen, and as many black as you can get into your pocket (as they will walk 🙂 ).
I also like those stamps (no affiliation) which have your name, PIN number and designation: 'Registered Midwife' on them – you have to sign every entry into notes that you make, and print your full name at least once on every page, so why not do it with a stamp that you can use with a satisfying ‘kathump!’ every time?
2. Write out the date in full on every page
Instead of ‘1/11/2015’ write ‘Ist November 2015’
Because you’re taking your time over writing the date, you’re far less likely to get it wrong. It’s also very clear for auditors or other readers, as standalone numbers can be misinterpreted.
3. I’m one to talk here, but perfect your handwriting
I have a friend who’s a homebirth midwife whose writing is a work of art – honestly, I could get her to write ‘antenatal check’ on a bit of metal and wear it on my wrist as a bracelet.
Whereas my own handwriting, as my old colleagues will tell you, is something akin to a spider who’s been tap dancing in ink...
Unclear writing is a waste of time because if you can’t read it, it doesn’t meet the purposes of documentation . Practice writing fast and clearly.
4. Learn how to write out a really good history, and do this for every client that enters your care
This should include gravida (how many pregnancies a woman has had), parity (how many births) Hb (which is blood iron count), blood type, medical and obstetric history, and allergies. This was a lightbulb moment for me as a student as it prompted me to find information.
I used to do this even if I just saw a client for half an hour, or was taking over for a lunch break – it means that even when you’re knackered you don’t miss anything. You can see an example of the kind of information you should include in this here.
Get your mentor to show you what they do documentation wise when they first meet a client, and try over your three years training to work out a system whereby you assimilate all the client’s information routinely.
There’s always going to be a time when you can't do this - birth in the car park anyone? But if you do get a chance, do it for every client as it’s a rock solid way of showing in your documentation that you have the facts, and of minimising your chances of missing anything.
5. Learn the house rules
Every trust is different. Some will have different notes for different hospitals, some will have stickers for filling out vaginal examination information, some will have stamps for theatre that need to be filled out, on pain of being politely or not so politely reminded by your manager.
It’s all stuff to get used to, and it changes frequently.
One thing’s for sure: you’ll make a lot of mistakes, as we all do!
If I had a couple of weeks off for holiday time etc. I’d come back and specifically ask ‘what’s new with documentation’ as there’s always something!
6. Practice writing out the following examination bits of midwifery care until you can document them almost subconsciously
Basic observations (Blood pressure, temperature, pulse, respiration rate, per vaginum loss)
One book that can teach you to do this well is The Midwife's Labour and Birth Handbook, but you’ll also need to keep your eyes open for excellent documentation from certain midwives (you’ll soon learn which as their notes will be clear, without fluff, and they’ll be praised for their documentation often - work out what their format is, and steal their style!)
7. Check The Clock
During an emergency or, as I found, just as a baby is born are the hardest points of documentation. You either have to memorise the time of events - pushing, fetal heart rate every 5 minutes, birth of head, birth, placenta, etc. - or you have to try and note them down with gloves on between tasks.
(I had one colleague who told me she was always happy when she got some blood or show on her notes as it showed they were 'contemporaneous!')
Note taking when you also have to act is difficult - many midwives make notes on a bit of tissue to write up later, and then throw the tissue away. This is not seen as good practice by the NMC, and technically the tissue should be filled in the notes.
It'll become instinctual to look at the clock for crucial moments so that you can see what’s going on.
You may find saying out loud - ‘birth of head 10.02’ - will help the essentials stick in your mind.
Sometimes during an emergency, you genuinely won’t have time to document - in this case, hopefully, you have a colleague who will document for you, and that will be his or her role throughout.
Otherwise, you just have to do the best you can.
8. Learn Your Favourite Phrases
Every midwife documents differently - you need to have a formal, objective, clear way of writing that doesn’t use too many acronyms (as this can be confusing) and covers a heck of a collection of information succinctly.
There’ll be useful phrases which help you show what’s going on.
For example, one of mine was ‘welcomed into my care, introductions made, orientated to ward’ which is a short and objective way of me saying ‘I was welcoming and made sure this woman knew she could ask for things, and had access to drinking water and the facilities’.
You’ll also learn to avoid certain phrases as they aren’t objective enough for example ‘Hannah is well’ may be more accurately “Hannah says she feels well” or “Hannah’s observations are normal and she looks relaxed and well rested.”
9. If Something’s Not Right, Put In Your Plan
If you’re ever documenting something that’s not quite normal, you need to put in what you plan to do about it. Even if it’s ‘wait and recheck’. Showing that you realised something was wrong, but didn’t do anything about it is one of the main things to avoid when learning to document well. This is for legal reasons - but it’ll also prompt you to think about solutions carefully.
10. Be Ok With Getting It 'Wrong' From Time To Time!
Midwifery is hard, these days very difficult indeed. Often you will not have time to document or give care in the way you want to through no fault of your own.
I’ve woken up in the middle of the night thinking ‘I didn’t document that second PU (passed urine)!’ - you just have to do the very best you can and keep committed to learning how to do it faster and more accurately.
If you beat yourself up too much over it, this tends to perfectionist thinking.
I fear the concept of ‘perfectionism’ - I think it’s demoralising and dangerous. Also dehydrating, as it leads to prioritising documentation over having a drink of water even!
Have that drink of water, have that conversation with the woman instead of perfectly documenting the fourth normal blood pressure in the notes as well as on the MEWS chart, listen to your manager as they have your best interests at heart in terms of care and protecting you from litigation - but keep your balance if you can and forgive yourself for getting things wrong.
I suppose the most important documentation tips is, as always:
'It’s the care that will protect both your woman’s experience, and you as a professional.'
However good your documentation is, it’s the relationship and how you help your client and family feel that count most of all. The stuff that happens in real life, not on paper will always be the most important part of being a midwife.
Now I’d love to hear from you! Leave me a comment letting me know: what did you struggle with most in learning to document well? How did you overcome this?
Or, if you’re an aspiring midwife, what worries you most about learning documentation, and how do you plan to overcome this?
Much love for anyone working with childbearing women out there.