DOCUMENTATION - ANTENATAL-INTRANATAL-POSTNATAL CARE, TUBECTOMY, BIRTH REGISTRY, SURGERY & REFERRAL

DOCUMENTATION IN ANTENATAL CARE, INTRANATAL CARE, POSTNATAL CARE, TUBECTOMY, BIRTH REGISTRY, SURGERY AND REFERRAL

• Practice documentation is a systematic record of medical care, procedures, outcomes, and referrals maintained by the healthcare provider.

• In Ayurveda, systematic recording ensures continuity of care and reflects on Yuktivyapashraya Chikitsa.

• It helps in legal, academic, research, and administrative purposes.

• In obstetrics and gynecology, detailed documentation during the phases of pregnancy and delivery is crucial for maternal and neonatal safety.

ANTENATAL CARE DOCUMENTATION

• Definition: Antenatal care is the care of the pregnant woman before the onset of labor.

• Key Documentation Points:

  • Complete personal and obstetric history (Gravida, Para, Abortions, Living).

  • LMP (Last Menstrual Period) and EDD (Expected Date of Delivery).

  • Regular check-up entries including:

    • Blood Pressure

    • Weight

    • Fundal Height

    • Fetal Heart Sound (FHS)

    • Urine examination

    • Hemoglobin level

    • Ultrasound findings

  • Iron and folic acid supplementation.

  • Tetanus toxoid injections.

  • Dietary and lifestyle advice (Pathya-Apathya).

  • Any complications (like PIH, GDM, Anemia).

  • Advices on Garbhini Paricharya as per Ayurveda.

• Sanskrit Reference:

  • गर्भिण्या आहार विहारं च विशेषेण समाचरेत् ।
    गार्भिण्याश्च महीस्नेहः सदा कार्यो विशेषतः ॥
    (Aṣṭāṅgahṛdaya, Uttarasthana 2/8)

• Modern Guidelines: WHO recommends at least 8 antenatal visits for proper monitoring and timely interventions.

INTRANATAL CARE DOCUMENTATION

• Definition: Care provided during the process of labor and delivery.

• Key Documentation Points:

  • Admission details including onset and duration of labor pains.

  • Partograph maintenance (modern tool to monitor labor).

  • Cervical dilatation and effacement status.

  • Presentation and position of fetus.

  • Rupture of membranes – time, color, and odor of amniotic fluid.

  • Mode of delivery (Normal vaginal, Instrumental, Cesarean).

  • Any intervention or complication (e.g., PPH, cord prolapse).

  • Medications and fluids administered.

  • APGAR Score of newborn and time of birth.

• Sanskrit Reference:

  • प्रसवकाले विशेषेण योषिद्भिः स्यात् प्रसन्नधीः ।
    शान्तात्मा धर्मनिरतः कर्तव्यो बन्धुभिः सह ॥
    (Suśrutasaṁhitā, Śārīrasthāna 10/23)

• Modern Additions: Use of sterile delivery kits, CTG monitoring, and immediate neonatal care per NRP protocols.

POSTNATAL CARE DOCUMENTATION

• Definition: Care provided to the mother and the newborn after delivery for about 6 weeks.

• Key Documentation Points:

  • General health check-up of mother (bleeding, uterine involution, breast condition).

  • Lochia observation.

  • Monitoring for signs of postpartum hemorrhage or infection.

  • Counseling on breastfeeding, contraception, and nutrition.

  • Neonatal care – weight, feeding, urination, vaccination schedule.

  • Mother’s emotional health screening.

• Sanskrit Reference:

  • सूतिका सुतमुत्पाद्य सप्ताहं क्षीणमूत्रिणी ।
    शयीत सन्ततं तस्मात् काषायं दीपनं पिबेत् ॥
    (Aṣṭāṅgahṛdaya, Uttarasthana 2/40)

• Modern Guidelines: WHO recommends postnatal visits at 24 hours, 48-72 hours, 7-14 days, and 6 weeks.

TUBECTOMY DOCUMENTATION

• Definition: A permanent method of female sterilization by surgical ligation of fallopian tubes.

• Key Documentation Points:

  • Consent form signed after explaining procedure and risks.

  • Preoperative assessment and investigations.

  • Surgical notes:

    • Type (Mini-lap, Laparoscopic).

    • Side and technique used (Pomeroy, Irving).

  • Post-operative care and vitals monitoring.

  • Discharge summary including follow-up advice.

• Ayurvedic Correlation: Though not directly mentioned in Samhitas, sterilization falls under Apatkalika Karma (Emergency measures).

• Modern Insight: Part of National Family Welfare Programme in India, especially postpartum sterilization.

BIRTH REGISTRY DOCUMENTATION

• Definition: Legal and medical record of childbirth including details of both mother and newborn.

• Key Documentation Points:

  • Name of mother and father.

  • Date and time of delivery.

  • Sex of the baby.

  • Mode and place of delivery.

  • Name of attending obstetrician.

  • Weight and condition of baby at birth.

  • Entry in birth registry and issuance of birth certificate.

• Importance: Vital statistics, public health planning, proof of identity.

• Modern Law: Registration of Births and Deaths Act, 1969 mandates registration within 21 days.

SURGERY DOCUMENTATION

• Definition: Documentation related to operative procedures in obstetric and gynecologic practice.

• Key Documentation Points:

  • Indication for surgery.

  • Consent form and risk explanation.

  • Pre-operative investigations and anesthetic evaluation.

  • Operative notes:

    • Procedure done.

    • Instruments used.

    • Duration and complications.

  • Post-operative instructions and medications.

  • Histopathology if applicable.

  • Follow-up schedule.

• Common Gynaecological Surgeries: D&C, Myomectomy, Hysterectomy, Cystectomy.

• Sanskrit Context:

  • यत्र यत्र यथाकालं यथा युक्तं यथाबलम् ।
    कर्तव्यमेषां कर्मणां तत्र तत्र विशेषतः ॥
    (Suśrutasaṁhitā, Sūtrasthāna 1/23)

REFERRAL DOCUMENTATION

• Definition: Formal transfer of a patient from one level of care to another for specialized management.

• Key Documentation Points:

  • Reason for referral.

  • Summary of findings and treatment given.

  • Accompanied documents (lab reports, imaging).

  • Urgency and type of transport arranged.

  • Contact details of referred center.

• Importance: Ensures continuity of care and prompt management.

• Modern Additions: Use of referral slips, telemedicine documentation, digital records in HMIS.