Quality of Documentation of Delivery Notes by Midwives in Benghazi Medical Center

Abstract

Introduction: Midwives play a significant role as health professionals in the labor ward. It is crucial that all delivery information is documented and accurate. The aim of this audit was to evaluate the accuracy and completeness of the newborn and delivery notes recorded by the midwives in the labor room at Benghazi Medical Center (BMC).

Method: A retrospective audit of 189 newborn and delivery notes of women delivered vaginally at BMC were randomly chosen during a nine month period in 2015. Data was described statistically by the use of percentages. For medico-legal purposes the standard was set at 100%.

Result: The highest documentation rate was for vitamin K dispensed to the newborn, gender, birth weight, date of delivery, newborn status, time of delivery, and perineum status (100%, 96%, 95%, 94%, 92%, 90%, 87% respectively). Zero recording rate for the Apgar score, congenital malformations, any resuscitations of newborns by the neonatologist, gestational age, the duration of all stages of labor, and tear stitch notes.

Conclusion: Compared to the set standard, numerous sections from both newborn and delivery note were inefficiently completed or omitted. Balance all points mentioned in both recommendation and action plan is suggested.