midwifery-assessment-report

Assessment & Findings Report — Midwifery

Assess pregnant and postnatal women and newborn babies and write a defensible findings report as a midwife. The deliverable is a structured assessment report with findings, evidence and recommendations. This skill is written for a midwife working with pregnant and postnatal women and newborn babies in a maternity unit, birth centre and community clinics.

When to use

• You are a midwife preparing, delivering or reviewing this part of your work in a maternity unit, birth centre and community clinics.
• You need a defensible, repeatable approach that produces a structured assessment report with findings, evidence and recommendations.
• A colleague, auditor or client asks how this was done and what evidence supports it.

Key Concepts

Term	Meaning
Postnatal	the period after birth
Continuity of carer	care from the same midwife or small team
Fundal height	measurement used to track baby growth in pregnancy

Workflow

1. Step 1 - Review the intake record and antenatal records so the assessment builds on verified information, not assumptions
2. Step 2 - Carry out the assessment using CTG monitors, following the recognised method for a maternity unit, birth centre and community clinics
3. Step 3 - Compare findings against the benchmarks behind antenatal appointment attendance and note where evidence is strong, weak or missing
4. Step 4 - Draft the report: findings first, then interpretation, then recommendations in priority order
5. Step 5 - Check the draft for accuracy and for fetal distress escalated late; have it reviewed where the profession's standards require a second sign-off

Profession-Specific Components

Component	Details for Midwifery
Core documentation	antenatal records; birth records; postnatal checks; feeding support notes
Core tools & equipment	CTG monitors; birthing pools; resuscitation equipment for newborns; ultrasound dopplers
People involved	pregnant and postnatal women and newborn babies; the midwife; colleagues and other services in a maternity unit, birth centre and community clinics
Primary record	antenatal records — keep it current, dated and attributable

Output Format

Context: [Situation in a maternity unit, birth centre and community clinics] | Objective: [What this must achieve] | Audience: [pregnant and postnatal women and newborn babies and other stakeholders]

The finished output is a structured assessment report with findings, evidence and recommendations, structured as:

1. Summary of position and evidence
2. Detail, following the workflow above
3. Decisions, actions, owners and dates
4. Review point and escalation route

Action Plan

1. Immediate: Confirm scope, consent and the evidence available in antenatal records.
2. Short-term: Complete the workflow steps and record outcomes against antenatal appointment attendance.
3. Medium-term: Review results, close actions, and update local procedures in a maternity unit, birth centre and community clinics.

Success Metrics

Metric	Target	Method
antenatal appointment attendance	Agree a local target and track the trend	Measured from antenatal records and reviewed on a set cycle
breastfeeding support rates	Agree a local target and track the trend	Measured from antenatal records and reviewed on a set cycle
postnatal visit timeliness	Agree a local target and track the trend	Measured from antenatal records and reviewed on a set cycle
birth experience feedback	Agree a local target and track the trend	Measured from antenatal records and reviewed on a set cycle

Guardrails & Quality Checks

• Never let this happen: fetal distress escalated late.
• Never let this happen: postnatal depression unrecognised.
• Never let this happen: newborn feeding problems missed.
• Work only within the competence and authority of a midwife; escalate or refer anything beyond it.
• Record facts and observations, not speculation, and keep records confidential to a maternity unit, birth centre and community clinics's rules.
• Verify names, dates, figures and measurements twice before anything is issued or signed off.
• Use only real, verified information from the case in hand — never invent results, credentials or evidence.

Example (illustrative)

A midwife in a maternity unit, birth centre and community clinics applies this workflow for pregnant and postnatal women and newborn babies: they open antenatal records, work through the five steps using CTG monitors, and close by recording the outcome against antenatal appointment attendance and agreeing the next review date. (Illustrative example only — replace with the real details of the case in hand.)