Maternity Care

The Maternity Summary Form or Management Plan group together all the likely entries needed for managing all aspects of antenatal, investigations and postnatal consultations.

To add a maternity consultation:

  1. From Consultation Manager, select the patient required and start a consultation if required.

  2. Now, either:

    • From the Navigation Pane, right click on Maternity and select either Summary or Management Plan, or

    • Select Summary - Routine Checks - Maternity, or

    • Select Select Summary Form , double click on the Clinical Entities folder, double click on the folder of the routine check you are recording and then and then double click on the green file next to Maternity.

The advantage of the Management Plan over the Summary Form is the ease with which you can see previous entries in a category, both display exactly the same - Add screens for the different maternity data.

  • Maternity Management Plans - Display in a grid format, so the rows show different data entries, while each column represents a single encounter on one date:

    Select the heading to view and/or record maternity details.

    Where a symbol displays instead of an entry or value, hover over it and the details display in a Tooltip.

    Select the data type to record the relevant information

    Maternity Management Plans are defined over a period of 11 months rather than on a daily basis, so that a group of columns reflect one pregnancy, rather than a number of pregnancies.

    Remember - When you are re-visiting a Management Plan where you have previously entered data, rows which contain no data may be hidden. Select the blank box at the top left to restore all rows.

  • Maternity Summary Forms - Displays latest recorded information for each data type. Select the tab required to display and record the appropriate details.

    To make an entry, right click on the entry required and select Add, the relevant - Add screen displays.

Remember - If you are recording data, select OK to save, if you are not recording data, select Next to move to the next screen without recording a default entry, or Skip to to move straight to a specific -Add screen.

Maternity care screens consist of:

From here you can view and/or record:

  • Parity Status - The clinical term defaults to152..00 Parity status. Enter the Number of Births and Number of Miscarriages which display as Pn + x, for example, P1 + 2 = 1 birth and 2 miscarriages.
  • Blood Group - The clinical term defaults to 431..00 ABO blood grouping, the Blood Group defaults to None, update as appropriate.
  • Pregnancy Dates - The clinical term defaults to 1513.00 Last menstrual period - 1st day, complete details as appropriate. The Estimated Date of Delivery (EDD) automatically completes based on the LMP Date entered, update if required. Certainty relates to the LMP Date, update from the available list if required.
  • Ante-Natal Risk Factors - The clinical term defaults to 623.. 00 A/N care: obstetric risk, update from the available list if required, enter comments into Notes if appropriate.
  • Ante-Natal Social Factors - The clinical term defaults to 625.. 00 A/N care: social risk, update from the available list if required, enter comments into Notes if appropriate.
  • Ante-Natal Booking - The clinical term defaults to 62B..00 Delivery booking place, update from the available list of booking places if required. Enter a number in Weeks Gestation and then select from the available list in Type of Booking.
  • Maternity Care Plan - You can select from the options here providing they have been set up in Control Panel - File Maintenance first, see File Maintenance (Opens the Management Tools Help Centre) for details.

From here you can view and/or record:

Note - Pregnancy Dates are completed from the Pregnancy Start screens.

  • Ante-Natal Consultation - The clinical term defaults to 62N..00 Antenatal examinations update from the available list if required. Complete Weeks gestation as appropriate.

  • Ante-Natal Symptoms - Enter a clinical term and any comments as appropriate, see Finding a Read Code if required.

  • Weight - Record the patient's weight, see Adding a Weight for guidance if required.

  • BP - Record the patient's blood pressure reading, see Adding a Blood Pressure for guidance if required.

  • Urinalysis - Glucose - The clinical term defaults to 466..00 Urine test for glucose update from the available list if required. Select a Result Qualifier as appropriate.

  • Urinalysis - Protein - The clinical term defaults to 467..00 Urine protein test update from the available list if required. Select a Result Qualifier as appropriate.

  • Fundus/Fetal Examination - The clinical term defaults to 271..11 O/E - fundus size - obstetric update from the available list if required. Complete the following where appropriate:

    • Fundus enter the value required based on the Unit of Measure specified, the default is week.

    • Presentation select if appropriate.

    • Fetal heart heard tick if heard.

    • Fetal movement felt tick if felt.

  • Maternal pelvic examination - The clinical term defaults to 277.. 00 O/E - VE for pelvic assessment, enter any comments required.

  • Maternal breast examination - The clinical term defaults to 26.. 11 Breast examination, update from the available list if required, enter any comments required.

  • Maternity ultrasound scan - The clinical term defaults to 62G.. 00 Antenatal ultrasound scan. Complete the following:

    • Result Qualifier - Select as appropriate.

    • Estimated Size in weeks - Enter as appropriate.

    • EDD date - Enter the estimated delivery date based on the scan.

  • Blood Group - The clinical term defaults to 431..00 ABO blood grouping, the Blood Group defaults to None, update as appropriate.

  • Blood group antibodies - The clinical term defaults to 43...00 Immunology, update from the available list if required. Select the appropriate Result Qualifier.

  • Alpha fetoprotein - The clinical term defaults to 44B..00 Serum alpha-feto protein, update from the available list if required. In Weeks enter the weeks of gestation and then select the appropriate Result Qualifier.

  • Amniocentesis - The clinical term defaults to 62F..00 Anenatal amniocentesis, update from the available list if required. Select the appropriate Result Qualifier.

  • Haemoglobin - The clinical term defaults to 423..00 Haemoglobin estimation, update from the available list if required. Enter the Value and select the appropriate Result Qualifier.

  • Iron Studies - The clinical term defaults to 42R..00 Serum iron tests, update from the available list if required. Enter the Value and select the Result Qualifier where appropriate.

  • Rubella Test - The clinical term defaults to 4JR0.00 Rubella screening test, update from the available list if required. Select the Result Qualifier.

  • Ante-natal blood tests - The clinical term defaults to 62W..00 Antenatal blood tests, update from the available list if required. Enter the Value and select the Result Qualifier where appropriate.

  • Urinalysis - Glucose - The clinical term defaults to 466..00 Urine test for glucose update from the available list if required. Select a Result Qualifier as appropriate.

  • Urinalysis - Protein - The clinical term defaults to 467..00 Urine protein test update from the available list if required. Select a Result Qualifier as appropriate.

After the baby is born:

  • Delivery Details - Mother - Enter the Date of Delivery, the clinical term defaults to 63...00 Birth details, update from the available list as required and enter any comments as appropriate.

  • Gestation at Birth - The clinical term defaults to 635..00 Maturity of baby, update from the available list as required. In Weeks enter the number of weeks at delivery and enter any comments required.

  • Stages of labour - The clinical term defaults to 632..00 Length of labour, update from the available list as required. In Duration, enter the details of the three stages as appropriate.

  • Placenta - The clinical term defaults to 63D.. 00 Placental details update from the available list as required and enter any comments required.

  • Episiotomy - The clinical term defaults to L34.. 00 Trauma to perineum and vulva during delivery update from the available list as required. Tick Episiotomy and Sutures to remove, if relevant and enter a Tear Stage. Enter any comments required.

  • Perineal Tear - The clinical term defaults to L34.. 00 Trauma to perineum and vulva during delivery update from the available list as required. Tick Episiotomy and Sutures to remove, if relevant and enter a Tear Stage. Enter any comments required.

  • Sutures - The clinical term defaults to L34.. 00 Trauma to perineum and vulva during delivery update from the available list as required. Tick Episiotomy and Sutures to remove, if relevant and enter a Tear Stage. Enter any comments required.

  • Infant details - The clinical term defaults to 63...00 Birth details, update from the available list as required and complete the following:

    • Date of birth.

    • Sex.

    • Birth weight, ensure the Unit of measure is correct.

    • Apgar at 1 minute.
    • Apgar at 5 minutes.
    • Outcome.
    • Notes - Enter any comments required.

  • Feeding (Summary Form only) - The clinical term defaults to 62P..00 Infant feeding method, update from the available list as appropriate. In Type of Feeding, select from the available list.

  • Postnatal visit - The clinical term defaults to 62R..00 Postnatal visits, update from the available list as appropriate. Complete the following:

    • Date of Visit

    • Seen by

    • Days post-natal

    • Management Plan - If you are adding more than one visit, select Another to add the next visit.

    Summary Form - If you are adding more than one visit, use a separate Add to record each visit.

  • Post Natal Examination - The clinical term defaults to 62S..00 Maternal P/N 6 week exam, update from the available list as appropriate, and enter Weeks post-natal as appropriate. This is usually the date of last service.

  • Post-natal Symptoms - Enter a clinical term and any comments as appropriate, see Finding a Read Code if required.

  • Weight - Record the patient's weight, see Adding a Weight for guidance if required.

  • BP - Record the patient's blood pressure reading, see Adding a Blood Pressure for guidance if required.

  • Maternal Breast Examination - The clinical term defaults to 26B..00 O/E - general breast exam, update from the available list as appropriate. Enter any comments required.

  • Maternal Pelvic Examination - The clinical term defaults to 277.. 00 VE for pelvic assessment. Enter any comments required.

  • Cervical Cytology - Enter details of any smear taken as part of the postnatal exam, see Adding Cervical Cytology for details if required.

  • CS Claim Due Date - No longer used

Note - To print this topic select Print in the top right corner and follow the on-screen prompts.