Documentation in labour among midwives in Madonna university teaching hospital elele, rivers state, Nigeria

Abstract

Background: Documentation is a fundamental and vital communication tool among healthcare professionals. It is an essential part of midwifery that has clinical and legal implications for the client and midwife as well as the health care institution. This study assessed the knowledge, practice of and factors influencing documentation in labour among nurses in Madonna University Teaching Hospital, Elele Rivers State. Methods: This is a descriptive cross sectional study with a sample size of 102 nurses selected using purposive sampling technique. The instrument for data collection was structured questionnaire. Data collected were analysed using simple percentage and frequency table. Results: The findings of the study showed that midwives had good knowledge of documentation in labour, but their practices were poor. Factors influencing documentation includes; time, the attitude of the midwives (terming documentation to be unnecessary), and few number of midwives working in a shift. Conclusions: It was recommended that, the consequences of not documenting in labour should be emphasized and penalty is given to midwives who do not document properly. More staff should be assigned to client and the shift adjusted to shorter hours to prevent fatigue and tediousness.