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Medical Notes & Abbreviations
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Medical Notes
If you can just draw your attention away from that fine specimen above....ahem......at Birth Choices we very much believe that every woman should have the chance to go through her medical notes after her birth as part of the normal process. Whether you had a fantastic birth or one you'd rather try to forget, we think it's incredibly important that at some point you get the opportunity to sit down with a midwife or other medical professional of your choice and go through everything that happened during your birth.
Your medical notes, or 'patient records' are a hard-copy record of all the medical aspects of your care throughout your pregnancy & birth. They will detail every event that occured & all the action taken and by whom.
It's easy to get hold of your medical notes - you just call the hospital switchboard where your baby was born, or where your midwives are based if you had a home birth & ask to be put through to 'patient records' or 'medical records'. You will then be sent a form to fill out & sign before being posted a copy of all the notes connected to your birth. The hospital must reply to your written request within 40 days - some people like to send their request via recorded delivery so they can keep track of the date they sent it.
If you apply for your notes within 6 weeks of giving birth, you should not be charged for a copy to be sent. Any time after that though will incur a charge of between £30 - £50, depending on where you live.
You do not have to give a reason why you would like to see or obtain a copy of your notes.
If the 6 weeks has passed & you did not want to pay for a copy of your notes, you can always arrange an appointment to go into the hospital where they are kept to view them free-of-charge. You may wish to do this in the company of a medical professional, such as a midwife, or you may wish to view them on your own or with a friend or partner. There is no obligation in law to have a member of staff present when you view your notes. You may take a pen and paper with you to make some of your own notes and often there will be an opportunity to ask for photocopies to be made of individual pages for a small charge.
Obtaining a copy of your notes soon after your birth means that if, in the future, you wished to complain about an aspect of your care, you already have your notes in your possession, and can proceed when you feel the time is right. Most women don't wish to pursue a complaint straight after their birth - they can often feel relieved that the whole event is 'over' and they become pre-occupied with caring for their newborn baby. However, as the months roll by, some women may feel that a complaint will bring 'closure' to any issues they have surrounding their birth so they can move on.
Even if you do not wish to make a complaint, we believe that understanding the events of your birth is a very healthy process to go through. In order to help with this, we've put together a list of medical abbreviations below which may help you decipher a copy of your medical notes.
Abbreviations
This list is not definitive or exhaustive - it represents just some of the abbreviations you may come across in your notes.
A/F - artificial feeding - bottle feeding
AFP - alpha feto protein – a blood screening test to detect some abnormalities in the baby
A/N - antenatal
ANC - antenatal clinic
APH - antepartum haemorrhage-severe bleeding in pregnancy
ARM - artificial rupture of membranes –also known as having your ‘waters' broken
BBA - born before arrival(at hospital) - a baby born in a car / ambulance / Tesco carpark / unplanned homebirth etc..
B/F - breast feeding
BPD - bi-parietal diameter –the circumference of baby's head
BP - blood pressure
Br - Breech baby - baby is bum first/down instead of its head
CCT - controlled cord traction-used with a managed third stage to remove the placenta after birth
Cehp - baby is head first/head down
CPD - cephalo pelvic disproportion - when the baby's head is too big to fit through the mothers pelvis
CRL - crown rump length - the measurement from the top of the baby's head to it's bum
CTG – cardiotocograph - used for continuous monitoring or for assessment during pregnancy
Cx - cervix
D & C - dilation & curettage - a surgical procedure done under general anaesthetic, some times used after a miscarriage if baby is not naturally expelled from the uterus.
=Dates - this means the size of the uterus is equal to the number of weeks pregnant
DIC - disseminated intravascular coagulation - a rare but severe clotting disorder
DNA - did not attend
D & V - diarrhoea & vomiting
DVT - deep vein thrombosis - a clot - usually in the leg, occasionally in the arm
EBM - expressed breast milk
ECV - external cephalic version - used to try and abdominally turn a breech baby head down in late pregnancy
EDD - estimated date of delivery
ERPC - evacuation of retained products of conception - a surgical procedure done under general anaesthetic, used if there are any small bits of placenta or membranes left inside after birth
EUA - examination under anaesthetic
EPU - early pregnancy unit
FBC - full blood count
FBS - fetal blood sampling-used if there are signs that the baby is becoming distressed in labour, a small blood sample is taken from the top of the baby's head
FHHR - fetal heart heard & regular, also seen as FHH - fetal heart heard
FMF - fetal movements felt
F/U - follow up
Gravida - the number of times a woman has been pregnant
GTT - glucose tolerance test-used to assess for gestational diabetes in the presence of other symptoms
GUM - genitary urinary medicine
Hb - haemoglobin
HCG - human chorionic gonadotrophin-a pregnancy hormone
HELLP - haemolysis & elevated liver enzymes & low platelets - a serious disorder , different from pre-eclampsia, but can follow on from it
HVS - high vaginal swabIM - intra muscular injection
IMW - independent midwife
IOL - induction of labour
IUCD - intra uterine contraceptive device - known as a coil
IUD - intra uterine death - when the baby has died before birth
IUGR - intra uterine growth retardation - a baby who is not growing as it should
IUI - intra uterine insemination – a fertility treatment
IVF - in vitro fertilization - a fertility treatment
IVI - intravenous infusion - fluids and/or drugs given via a drip
LBW - low birth weight
LFTs - liver function tests-a blood test
LMP - last menstrual period
LOA - left occipito anterior - baby lying to your left with it's back to your front
Long lie - the baby is lying vertically inside your uterus, parallel to your spine (normal )
LSA - left sacro anterior- baby lying to your left with it's bum to your front(breech)
LSCS - lower segment caesarean section
MROP - manual removal of placenta-a procedure to remove a placenta that is stuck
MSU - midstream specimen of urine
Multip - a woman who has had at least one previous baby/birth
NAD - no abnormalities detected
N/A - not applicable
NND - neonatal death - a baby that dies soon after birth
NTD - neural tube defect-spina bifida
OA - occipito anterior - position baby is in before birth (it's back towards your front)
O/E - on examination
O/P - on palpation-when a health care professional feels your belly to assess baby
OP - occipito posterior- position baby is in before birth (it's back to your back)Para - the number of times a woman has given birth
PE - Pulmonary Embolism-a blood clot on the lung
PIH - pregnancy induced hypertension-high blood pressure in pregnancy
pH - degree of acidity/alkalinity
PKU - phenylketonuria – a metabolic disorder that newborns are screened for via the ‘heel prick test around 5/6 days old
PM - post mortem
P/N - post natal
POP - persistent occipito posterior (position)-baby has it's back to your back before birth and stays that way
PPH - post partum haemorrhage
PR - per rectum-via the anus
PROM - premature rupture of membranes-waters breaking before 37 weeks
Primip - a woman having a first pregnancy
PT - prothrombin time-the time it takes your blood to clot
PTT - partial prothrombin time
PV - per vaginum-via the vagina
RBC - red blood count
RDS - respiratory distress syndrome-difficulty breathing
Rh – rhesus - concens your blood group
ROA(L)(P) - right occipito anterior (lateral)(posterior) (position) - baby lying on your right with it's back to your front
RSA (L)(P) - right sacro anterior (lateral)(posterior) (position)-baby lying to your right with it's bum to your front (breech)
SROM - spontaneous rupture of membranes-your ‘waters' break naturally
SB - stillbirth
S/B - seen by
SBR - serum bilirubin-a blood test that measures jaundice
SCBU - special care baby unit
SID - sudden infant death
SOM - supervisor of midwives
SROM - spontaneous rupture of membranes
STD - sexually transmitted disease
SVD - spontaneous vaginal delivery
TOP - termination of pregnancy
TORCH - toxoplasmosis, rubella, cytomegalovirus, herpes –an ante natal blood screening test, usually done at booking
TTO - to take out
TPR - temperature, pulse, respiration
Us & Es - urea & electrolytes - measured by blood tests
USS - ultrasound scan
UTI - urinary tract infectionVBAC - vaginal birth after a previous caesarean section
VE - vaginal examination
Vx - vertex – the head
VTE - venous thromboembolism - a clot
WBC - white blood count-a blood test that is a measurement of white blood cells in your blood, high levels can indicate infection