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For reference previous obstetrics record overview - GP system capability summary.

Logical model for obstetrics related data

 

NameDescription
Pregnancypregnancy record
  • Date of Last Menstrual Period : Date
 
  • Gestational Age (by scan) : Duration
 
  • Gestational Age (by LMP) : Duration
 
  • LMP Uncertain flag
 
  • Estimated Date of Confinement (by scan) : Date
 
  • Estimated Date of Confinement (by LMP) : Date
 
  • Pregnancy Number
 
  • Typical Menstrual Cycle Length : Duration
 
  • Menstrual Cycle Length Irregular
 
  • Managing clinician
 
  • IVF pregnancy
 
  
Pregnancy Outcome 
  • Outcome : CodeableConcept
Live Birth/Miscarriage/Termination/Ectopic Pregnancy/Still Birth/IUFD/Hydatidiform mole
  • Gestational Age
 
  • Notes
 
  • Complications
e.g. Gestational Diabetes, Hypertension, Pre-Eclampsia, Renal Disease
  • Labour Stage 1 Length : Duration
 
  • Labour Stage 2 Length : Duration
 
  • Labour Stage 3 Length : Duration
 
  • Delivery Method
 Normal Vaginal/Breech Vaginal/Rotation Forceps/Forceps/Vacuum Extraction/Elective Caesarean Section/Emergency Caesarean Section
  • Onset
Spontaneous/ARM/Vaginal Prostaglandin
  • Augmentation
Syntocinon
  • Analgesia
 
  • Perineum
Intact/Episiotomy/1st degree tear/2nd degree tear/3rd degree tear/4th degree tear
  • Blood Loss : Range/CodeableConcept
 
  • Placenta
Spontaneous/Episiotomy/Retained/Manual Removal
  • Administered Anti-D Immunoglobulin
 
  • Baby Name
 
  • Baby Sex
 
  • Birth Weight
 
  • Apgar 1
 
  • Apgar 5
 
  • Feeding
 

 

 

NameDescription
Antenatal Record 
  • Date of Visit
 
  • Weight
 
  • Blood Pressure
 
  • Oedema (Finding)
 
  • Urine Protein
 
  • Urine Glucose
 
  • Urine Other
 
  • Size Calculated (weeks)
 
  • Size Clinical (weeks)
 
  • Fundal Height (cm)
 
  • Foetal Heart Rate Heard
 
  • Foetal Heart Rate (bpm)
 
  • Foetal Movement
 
  • Presentation
Unknown/Cephalic/Breech/Transverse/Oblique
  • Position
LOT/ROT/LOA/ROA/LOP/ROP/OA/OP/LST/RST/LSA/RSA/LSP/RSP/SA/SP
  • Engagement
Unknown/Not Engaged/(0/5)/(1/5)/(2/5)/(3/5)/(4/5)/(5/5)
  • Visit Comments
 

 

 

NameDescription
Pregnancy Panel 
  • Collection Date
 
  • Hb
 
  • Blood Group
 
  • Antibody Screen
 
  • Urine M/C/S
 
  • Rubella Immunity: Condition
 
  • Syphylis Serology
 
  • Hepatitis B Serology
 
  • Hepatitis C Serology
 
  • HIV Serology
 
  • CMV Serology
 
  • Diabetes Screening
 
  • Glucose Tolerance Test
 
  • Group B Strep
 
  • Diagnostic Imaging
 
  • Other Diagnostic investigations
 
  • No labels