How should I structure prenatal intake and history?

Prenatal intake is the foundation of the antenatal record, so it has to be comprehensive: demographics, obstetric history (gravidity/parity, prior pregnancies and outcomes, prior modes of delivery), medical history, surgical history, family history, medications and allergies, social history (support, housing, intimate-partner violence screen), mental-health history and current screen, current pregnancy details (LMP, EDD, dating), vital signs, and risk-screening relevant to your scope of practice and the model of care. Build a templated PDF that prompts each section, fill in at the booking visit, sign and date. The clinical content and the risk thresholds are your professional responsibility under your scope and the model of care; the PDF discipline keeps the intake comprehensive and consistent.

What goes into a templated antenatal visit note?

A templated antenatal note covers visit week, presenting concerns or questions from the woman, vital signs, fundal height (after the appropriate gestation), fetal heart rate, any tests reviewed or ordered, the discussion (counselling, plan, danger signs, next visit), and signature. As a templated PDF, completing the same fields visit after visit keeps the record comparable across the pregnancy and means nothing is missed. Plot the fundal height and fetal growth trend rather than reading isolated values; isolated measurements are noisy and the trajectory is the signal. As a PDF craft, keep the template short enough that completion at the visit is realistic, and update the template as your practice guidelines evolve.

How do I produce a useful birth plan?

A useful birth plan is shorter than people expect: a one-page document covering what the woman wants for environment (mobility, lighting, who is present, music), pain management preferences (intermittent vs continuous monitoring where applicable, hydrotherapy, pharmacological), preferences around interventions and decision-making, planned location of birth, immediate-after-birth preferences (skin-to-skin, cord clamping timing, vitamin K and eye prophylaxis per local rules), feeding intention, and contact details for the support team. Pair it with a short clinical-context section that summarises the antenatal-record points the on-call team will want to see at a glance. Sign and date, deliver a copy to the woman and the planned-care setting, and revise as preferences and clinical picture evolve. The clinical content and counselling are yours; the PDF discipline is keeping the plan plain, signed, and portable.

How do I document an intrapartum record?

Intrapartum documentation is chronological — labour onset, observations through the stages (maternal vitals, fetal heart rate per the model of monitoring used, contractions, cervical assessment where performed, fluids, medication, position, any interventions and the indication for each), birth time, third stage management, immediate maternal and newborn assessment, and any complications and responses. As a PDF, capture on a partograph-style template where appropriate, then sign and archive. The clinical content and the monitoring approach are your professional responsibility under your model of care and applicable guidelines; the PDF workflow makes the record complete, signed, and retained.

What should postpartum and newborn records contain?

Postpartum and newborn records carry the assessment from birth through the postnatal weeks. For the mother: vital signs, lochia, fundus, perineum, breasts and feeding, mood (with appropriate screening), urinary and bowel function, pain, contraception discussion, and danger-sign counselling. For the newborn: feeding, weight trend, voiding and stooling, jaundice screening, cord, screening tests per local rule (newborn metabolic screen, hearing, congenital heart screening), and immunisations. Use templated PDFs per postnatal visit, signed and dated, and track in the per-client record so the trajectory across visits is visible. The clinical content and the screening rules are set by your scope and local guidance; the PDF discipline is templating and retention.

How do I write a referral or consult letter to OB / hospital?

A referral letter from a midwife to an obstetric provider or hospital should state the reason for referral up front in one line, then the relevant antenatal-record points (gestation, dating, prior history, current concerns, vitals, recent observations), what you have done and what you are asking the receiving provider to do, and your contact details. Keep it focused — the receiving provider may have minutes to read it before assessing the woman. As a PDF, build a templated referral letter, fill in the per-case detail, sign and date, send via your secure channel, and retain a copy in the per-client record. A clear, complete referral is what supports continuity of care at handover.

How do I keep a HIPAA-conscious per-client episode record?

A midwifery episode contains protected health information across many visits, so distribution and storage matter. Three practical disciplines: (1) deliver client documents via a HIPAA-appropriate channel (portal, secure messaging, or encrypted email — not plain email); (2) process files in tools that do not upload to third parties — local-only is the simplest privacy posture; (3) retain the per-client episode record per your regulator and your practice policy, and avoid working copies on staff devices. Confirm any third-party tool you use is appropriate for PHI, and where you must email, password-protect the PDF and share the password out of band.

PDF for midwives: birth plans, prenatal…

6 min read

By ScoutMyTool Editorial Team · Last updated: 2026-05-28

Midwifery is care-and-paperwork across a long episode — booking visit, antenatal visits across weeks, the birth, postnatal visits stretching for weeks beyond — and the document workflow has to keep the record continuous. I have watched practices produce excellent care while the paperwork sat in three places, the birth plan was typed in Word and never seen by the on-call team, the postnatal notes were free-text and inconsistent. This guide is the PDF workflow that holds the episode together: how to structure the prenatal intake, template the antenatal note, build an actually-useful birth plan, document intrapartum chronologically, capture postpartum and newborn assessments, and write a referral letter that supports continuity at handover. The clinical content is yours; the PDF discipline is everything else.

The documents a midwifery episode runs on

Document	Use	PDF need
Prenatal intake + history	Booking visit; risk screening	Structured; comprehensive; signed
Antenatal visit notes	Per-visit measurements + plan	Templated; comparable; dated
Birth plan	Individualised preferences + clinical context	Plain language; signed; portable
Intrapartum record	Labour timeline + interventions	Chronological; complete; archived
Postpartum + newborn records	Mother and baby assessments	Structured; signed; followed up
Referral / consult letter	Transfer to OB or hospital	Clear; complete; tracked
Per-client episode record	Pregnancy → postpartum continuity	Organised; searchable; retained

Step by step — running a midwifery episode on PDF

Templated prenatal intake. Fill PDF the booking-visit intake; risk-screen per your scope; sign.
Antenatal visit note per visit. Templated; plot trends; sign.
Birth plan one-pager. Plain language; signed; portable.
Intrapartum record chronological. Partograph-style template; complete; archived.
Postnatal + newborn assessments templated. Mother + baby; signed and dated.
Referral letter on a template. Reason + relevant points + ask; Sign PDF.
Deliver PHI HIPAA-appropriate. Portal or secure messaging — see password-protect a PDF on Mac for email exceptions.
Archive per client episode. Merge PDF the episode pack; OCR scans; retain per regulator.

Pitfalls that compromise continuity of care

Birth plan that never reaches the on-call team. Deliver to the planned care setting in advance.
Antenatal notes free-text and inconsistent. Use a template; values cannot be compared otherwise.
Single-value tracking. Plot fundal height + growth trajectory.
Intrapartum record reconstructed after the fact. Document chronologically as you go.
Postpartum notes free-text and inconsistent. Templates per visit.
Plain-email PHI delivery. Portal or password + out-of-band code.
Cloud-upload PDF tool for PHI workflow. Use locally-processing tools only.

PDF for dietitians: parallel structured-note discipline.
PDF for physical therapists: episode-of-care patterns.
PDF for pharmacists: parallel PHI-conscious clinical workflow.
Fillable patient forms: building intake forms.
Password-protect a PDF on Mac: PHI in transit.
Fill PDF: intake + visit templates.
Sign PDF: birth plans + referrals.
All ScoutMyTool PDF tools: the full toolkit.

FAQ

How should I structure prenatal intake and history?: Prenatal intake is the foundation of the antenatal record, so it has to be comprehensive: demographics, obstetric history (gravidity/parity, prior pregnancies and outcomes, prior modes of delivery), medical history, surgical history, family history, medications and allergies, social history (support, housing, intimate-partner violence screen), mental-health history and current screen, current pregnancy details (LMP, EDD, dating), vital signs, and risk-screening relevant to your scope of practice and the model of care. Build a templated PDF that prompts each section, fill in at the booking visit, sign and date. The clinical content and the risk thresholds are your professional responsibility under your scope and the model of care; the PDF discipline keeps the intake comprehensive and consistent.
What goes into a templated antenatal visit note?: A templated antenatal note covers visit week, presenting concerns or questions from the woman, vital signs, fundal height (after the appropriate gestation), fetal heart rate, any tests reviewed or ordered, the discussion (counselling, plan, danger signs, next visit), and signature. As a templated PDF, completing the same fields visit after visit keeps the record comparable across the pregnancy and means nothing is missed. Plot the fundal height and fetal growth trend rather than reading isolated values; isolated measurements are noisy and the trajectory is the signal. As a PDF craft, keep the template short enough that completion at the visit is realistic, and update the template as your practice guidelines evolve.
How do I produce a useful birth plan?: A useful birth plan is shorter than people expect: a one-page document covering what the woman wants for environment (mobility, lighting, who is present, music), pain management preferences (intermittent vs continuous monitoring where applicable, hydrotherapy, pharmacological), preferences around interventions and decision-making, planned location of birth, immediate-after-birth preferences (skin-to-skin, cord clamping timing, vitamin K and eye prophylaxis per local rules), feeding intention, and contact details for the support team. Pair it with a short clinical-context section that summarises the antenatal-record points the on-call team will want to see at a glance. Sign and date, deliver a copy to the woman and the planned-care setting, and revise as preferences and clinical picture evolve. The clinical content and counselling are yours; the PDF discipline is keeping the plan plain, signed, and portable.
How do I document an intrapartum record?: Intrapartum documentation is chronological — labour onset, observations through the stages (maternal vitals, fetal heart rate per the model of monitoring used, contractions, cervical assessment where performed, fluids, medication, position, any interventions and the indication for each), birth time, third stage management, immediate maternal and newborn assessment, and any complications and responses. As a PDF, capture on a partograph-style template where appropriate, then sign and archive. The clinical content and the monitoring approach are your professional responsibility under your model of care and applicable guidelines; the PDF workflow makes the record complete, signed, and retained.
What should postpartum and newborn records contain?: Postpartum and newborn records carry the assessment from birth through the postnatal weeks. For the mother: vital signs, lochia, fundus, perineum, breasts and feeding, mood (with appropriate screening), urinary and bowel function, pain, contraception discussion, and danger-sign counselling. For the newborn: feeding, weight trend, voiding and stooling, jaundice screening, cord, screening tests per local rule (newborn metabolic screen, hearing, congenital heart screening), and immunisations. Use templated PDFs per postnatal visit, signed and dated, and track in the per-client record so the trajectory across visits is visible. The clinical content and the screening rules are set by your scope and local guidance; the PDF discipline is templating and retention.
How do I write a referral or consult letter to OB / hospital?: A referral letter from a midwife to an obstetric provider or hospital should state the reason for referral up front in one line, then the relevant antenatal-record points (gestation, dating, prior history, current concerns, vitals, recent observations), what you have done and what you are asking the receiving provider to do, and your contact details. Keep it focused — the receiving provider may have minutes to read it before assessing the woman. As a PDF, build a templated referral letter, fill in the per-case detail, sign and date, send via your secure channel, and retain a copy in the per-client record. A clear, complete referral is what supports continuity of care at handover.
How do I keep a HIPAA-conscious per-client episode record?: A midwifery episode contains protected health information across many visits, so distribution and storage matter. Three practical disciplines: (1) deliver client documents via a HIPAA-appropriate channel (portal, secure messaging, or encrypted email — not plain email); (2) process files in tools that do not upload to third parties — local-only is the simplest privacy posture; (3) retain the per-client episode record per your regulator and your practice policy, and avoid working copies on staff devices. Confirm any third-party tool you use is appropriate for PHI, and where you must email, password-protect the PDF and share the password out of band.

Citations

Wikipedia — “Midwifery,” the profession and scope of practice. en.wikipedia.org/wiki/Midwifery
Wikipedia — “Prenatal care,” the antenatal-visit framework the visit notes support. en.wikipedia.org/wiki/Prenatal_care
Wikipedia — “Partograph,” the labour-monitoring chart referenced for intrapartum documentation. en.wikipedia.org/wiki/Partograph

Run a midwifery episode on PDF — without uploading client data

Template intake, antenatal notes, birth plans, intrapartum and postnatal records — fill, sign, archive, and protect in transit entirely in your browser with ScoutMyTool. Client files never leave your machine.

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PDF for midwives: birth plans, prenatal records, and postpartum notes

Introduction

The documents a midwifery episode runs on

Step by step — running a midwifery episode on PDF

Pitfalls that compromise continuity of care

Related reading and tools

FAQ

Citations

Run a midwifery episode on PDF — without uploading client data