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Midwife

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Midwife Delivery Note

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Finished note

Example — generated by Notat from a sample visit

Presenting concern:
Follow-up for heavy menstrual bleeding over several cycles, with fatigue. No severe pelvic pain or pregnancy concern reported.

Assessment:
Abnormal uterine bleeding requiring routine investigation.

Plan:
Discussed symptom diary, relevant blood tests, and follow-up after results. Urgent review advised for severe pain, dizziness, or very heavy bleeding.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

symptoms

Bleeding: Heavy menstrual bleeding over several cycles

Associated symptom: Fatigue

denials of symptoms

Denies: Red flags: No severe pelvic pain or pregnancy concern reported

Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.

plan

Investigation: Symptom diary and blood tests discussed

Safety-netting: Follow-up triggers and urgent return precautions were documented as part of the plan.

history of present illness

Visit focus: The main concern, timeline, and functional impact were identified from the conversation.

Template

Midwife Delivery Note

Patient Identification:
[Patient name], [age], [gravida/parity], [gestational age], presenting for delivery.

Labor and Delivery Details:
(hyphenated list)
- Date and time of admission: [date/time]
- Date and time of delivery: [date/time]
- Onset of labor: [spontaneous/induced]
- Membrane status: [intact/ruptured, time of rupture]
- Type of delivery: [vaginal/assisted/C-section]
- Presentation: [cephalic/breech/other]
- Duration of labor: [hours]
- Analgesia/anesthesia: [type, dose]
- Episiotomy: [performed/not performed, type]
- Perineal status: [intact/tear, degree]
- Complications: [if any]

Delivery Outcome:
(hyphenated list)
- Infant sex: [male/female]
- Birth weight: [grams]
- Apgar scores: [1 min: #, 5 min: #]
- Cord status: [clamped/cut, cord blood collected]
- Placenta: [delivered intact, abnormalities]
- Neonatal complications: [if any]
- Maternal complications: [if any]

Assessment & Plan:
(hyphenated list)
- Maternal status: [stable/unstable, concerns]
- Neonatal status: [stable/unstable, concerns]
- Postpartum care: [monitoring, medications, breastfeeding support]
- Counselling: [postpartum instructions, warning signs]
- Referrals: [if needed]
- Follow up: [timing, location]
- Return precautions: [signs/symptoms to watch for]

Shared by

PN

Dr. Priya Nair

Pediatrician, Singapore

How it works in Notat

Add this template to your library, record the visit as usual, and Notat drafts the note in this exact structure from the extracted clinical facts. You review, edit, and sign.

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