The maternity record – how to learn to understand it

If you have landed on this article, you have probably already received it from your gynecologist: your maternity record. This document will accompany you in the coming months and document the course of your entire pregnancy. The maternity record consists of 16 pages, which contain numerous abbreviations and medical terms. Don't worry: no one expects you to know what oligohydramnios is or what BPD stands for. ;) To ensure you understand more than just "train station" when flipping through your maternity record, we will explain the most important entries page by page in this article. Of course, you can always ask your attending doctor or gynecologist if you have any questions.

But what is actually the purpose of the maternity record?

Did you know that the maternity record is the most frequently issued document in Germany after the driver's license and ID card? After your gynecologist confirms your pregnancy, they usually give you the maternity record during your next visit. From now on, all results of the are documented there. Any potential risk factors for the pregnant woman are also recorded. After the birth, the examination findings of the newborn and the follow-up examination of the mother are noted in the maternity record.

It is advisable to always keep your maternity record with you during your pregnancy. This way, in an emergency, the attending doctor can respond quickly and correctly. But even after the birth, you should not dispose of the document. In the event of another pregnancy, it provides important information, which is why no new maternity record is created, but the second pregnancy is documented in the same booklet.

By the way, you are not obligated to show your passport to anyone. Authorities or your employer are also not allowed to request to see it.

What information is listed in the maternity record?

Page 1: Medical contact information and upcoming examination appointments

• Contact details of your treating gynecologist, delivery clinic, and/or the midwife assisting with your care

• Space to enter the dates of the upcoming check-up appointments

Page 2: Laboratory Tests and Rubella Protection

• Your own contact details

• Blood type affiliation : This information is intended for quick reference in case of emergency for the attending physician.

• Antibody search test : The test examines nonspecific antibody reactions, which are often associated with blood group characteristics (Rhesus factor intolerance). If the antibody screening test is negative, no further measures are necessary. If antibodies are detected, additional blood tests or, in some cases, special ultrasound examinations should be performed.

• Rubella antibody test : Such antibodies are either produced through vaccination or a previous infection and thus indicate whether you have sufficient protection against rubella infection. If you contract rubella during pregnancy, it can lead to severe physical and mental impairments in your child. If you are not sufficiently immune, a follow-up test will be conducted at a later date to rule out an infection (see page 3).

Page 3: Examination for Infections

• Chlamydia Chlamydia are bacteria that are usually transmitted through sexual intercourse and do not always cause symptoms. During your pregnancy, however, they can cause premature rupture of membranes and be transmitted to your baby during birth. Therefore, the infection must be treated with antibiotics again during pregnancy and also at the time of delivery.

• LSR : (Lues screening test, also called syphilis): If left untreated, the pathogen can harm the embryo. The mother's passport only records that the examination took place, not the result.

• Antibody Search Test Control This check-up is performed between the 24th and 27th week of pregnancy, even if no antibodies were found during the first test.

• Rubella antibody test control : This control test will only be conducted if you were not sufficiently immune to rubella during the first test.

• Detection of HBs antigen from serum (Hepatitis B): If the test for hepatitis B is positive, your child will be vaccinated immediately after birth.

Page 4: Information about previous pregnancies

• These details about any previous pregnancies provide your doctor with information to assess the current pregnancy, the possible course of delivery, or potential risks:

  • Spontaneous birth (vaginal birth without surgery)

  • Section (Caesarean section)

  • Abort (miscarriage)

  • Abruptio (abortion)

  • EU (Extrauterine pregnancy: Ectopic pregnancy or ectopic pregnancy)

• Documentation of what and on which topics you were informed about, for example nutrition, risks, or childbirth preparation

  • This also notes whether a HIV test was carried out. The test is only performed at your request and, like the LSR, the result is not entered into the mother’s pass.

Page 5: Medical history and general findings/Initial preventive examination

• Pregnant : Previous pregnancies

  Para : Births

• This information about your general health and any pre-existing conditions (mental and physical) is used to assess whether there is an increased risk for you or your baby.

Page 6: Notable Findings During Pregnancy

• Documentation of special findings during pregnancy, such as high blood pressure, bleeding, premature labor, or psychological stress:

  • Abuse : Taking medication and smoking or drug use

  • Placenta praevia : Placenta (Mother cake) sits in front of the cervix and obstructs the birth canal

  • Hydramnios : Excessive amniotic fluid production may indicate possible malformations or supply disturbances (for example, in cases of diabetes or infections of the pregnant woman) of the unborn child.

  • Oligohydramnios : Too little amniotic fluid, may indicate a possible growth delay of the fetus

  • Placenta insufficiency : The placenta cannot adequately nourish your baby; in this case, close medical supervision is necessary.

  • Cervical insufficiency : Shortening or inadequate closure of the cervix ( Cervix ), there is a risk of miscarriage or premature birth under certain circumstances

  • Indirect Coombs test positive The indirect Coombs test is an antibody screening test and can detect Rhesus incompatibility. If it is positive, it means that the mother has developed antibodies in a previous pregnancy, and treatment is necessary to prevent harm to the fetus, for example through prophylactic administration of Rhesus factor antibodies.

  • Hypertension : High blood pressure

  • Hypotonia : Low blood pressure

• Estimated Delivery Date

  • Calculated due date (based on the first day of your last menstrual period)

Pages 7 and 8: Pregnancy Chart

The pregnancy chart is an overview of your pregnancy progress. The results of your prenatal check-ups are recorded in the observation sheet:

• Your data

  • Pregnancy week

  • Fundus position : Height of the uterus

  • Payment Fluid retention in the tissue

  • Varicose veins: Varicose veins

  • Weight

  • RR : Blood pressure

  • Hb : Iron level

  • Bacteriological findings

  • Results of the vaginal palpation examination

• Your child's data

  • Kindslage

    (SL = head circumference, BEL = breech presentation, QL = transverse lie)

  • Heartbeat

  • Children's movement

Page 9: Additions to pages 5 to 8

• Additions to the risk catalogs on pages 5 and 6 (for example, measures taken)

• Entry if inpatient treatment in the hospital took place during pregnancy

• Cardiotocographic findings: The cardiotocograph provides information about your baby's heart activity and your uterus's readiness for contractions.

Pages 10 to 12: Ultrasound Examinations

The results of the three are entered here, for example whether the fetus has implanted in the uterus as expected, whether there are multiples, or if there are any malformations or abnormalities.

• FS : Fruit sac diameter (indicates an intact pregnancy early on)

• SSL : Length of your baby from crown to rump

• BPD : Head circumference of your baby

• FOD/KU : Head circumference of your baby

• ATD : Your baby's abdominal circumference

• APD/AU : Your baby's waist circumference

• FL : Length of your baby's thigh bone

Page 13: Standard Curves for Fetal Growth Progression

The measurements taken during the ultrasound examinations are plotted on the graphs. This allows the measurements to be compared with average values to check whether your baby's growth is proceeding normally.

Page 14: Further Ultrasound Examinations

If during one of your inspections there are any abnormalities that require further investigations, the results will be recorded here.

Pages 15 and 16: Final Examination/Epicrisis

Under Summary (griechisch „assessment“, „decision“) refers to the overall evaluation of the medical history (although pregnancy is, of course, not a disease). In the maternity record, it includes the following areas:

• Pregnancy : Brief summary of the pregnancy course

• Birth : Your child's measurement data

  • Apgar score The Apgar score is determined once at five minutes and once at ten minutes after birth and assesses your baby's vital functions based on parameters such as breathing, heart rate, reflexes, skin coloration, and muscle tone. Each parameter is awarded 0 to 2 points, and the Apgar score is based on the total of the individual assessments.

• Postpartum : Abnormalities in the postpartum period, both in you and your baby

• 2. Examination after childbirth : Results of the examination six to eight weeks after birth (from you and your child)

From page 17: Documentation of another pregnancy

In case you have a second child, pages 1 to 16 will now be repeated so that the second pregnancy can be documented there. This way, your doctor can view the values from your first pregnancy if they have any implications for the second.

We hope we could shed some light on the world of medical terminology and abbreviations for you, so that in the future, when flipping through your maternity record, you won't have a thousand question marks in your head! Of course, you should never hesitate to ask your gynecologist or midwife if you have questions about specific entries. :)