Documentation/Maternity
Module guide · Clinical
Maternity
One pregnancy's full path: register it, track prenatal visits and scans, run the labor partograph, record the delivery, register the newborn, and screen for postpartum complications, all on one record.
What this module is for
Limited to physicians, OB/GYNs, midwives, nurses, admins and directors — the clinical staff who deliver maternity care.
Who uses it
OB/GYNs and midwives lead care and staff the labor/delivery actions. Nurses log visits, partograph readings, and postpartum assessments. Admins and directors see the unit-wide dashboard and worklists.
Where to find it
Open Maternity from the sidebar. Four screens: a dashboard, Pregnancies, an individual Pregnancy record (7 tabs), and Newborn Worklists.
- 1
Register
Capture GTPAL history, LMP, care team, blood type/Rh, and initial risk level.
- 2
Track the pregnancy
Log prenatal visits, ultrasounds, and fetal monitoring as the pregnancy progresses.
- 3
Labor & delivery
Start labor, run the partograph, record the delivery, and register each newborn.
- 4
Postpartum follow-up
Assess recovery and screen for postpartum depression; newborn tasks are tracked until complete.
A few terms you'll see throughout
Dashboard
Census, delivery-quality indicators, and a clinical alerts panel surfacing anything needing attention right now.
Clinical alerts (only shown when their count is above zero)
| Field | What it means |
|---|---|
| Rh-Negative — RhIG Needed, GBS-Positive (Intrapartum Prophylaxis) | Amber; pregnancies needing an intervention before or during labor. |
| Elevated BP, Tachysystole, Arrest of Labor, High-Risk PPD, Abnormal Biophysical Profile | Red; the most urgent flags, click through to the pregnancy. |
| Fetal Growth Restriction, Short Cervix | Amber; ultrasound-derived preterm/growth risk flags. |
Stat tiles
| Field | What it means |
|---|---|
| Active Pregnancies, High-Risk, In Labor Now | High-Risk is highlighted red when above zero. |
| Deliveries Today, Deliveries This Month, Newborns in NICU | NICU count is highlighted red when above zero. |
| Cesarean Rate, PPH Rate, Avg APGAR-5, Avg Blood Loss, PPD Cases (This Month) | PPH (Postpartum Hemorrhage) Rate and PPD Cases are highlighted red when above zero. |
| Pending Screening Results, Pending Notifications, Pending MFM Referrals | MFM = Maternal-Fetal Medicine specialist referral. |
A "Deliveries by Method" chart, a "Due Soon (Next 7 Days)" list, and a "Currently In Labor" table (with stage, hours in labor, and tachysystole/arrest flags) round out the page.
Registering a pregnancy
Search existing pregnancies, filter to High-Risk or Due Soon, and register a new one.
Register Pregnancy form
| Field | What it means |
|---|---|
| Patient* | |
| Gravida* | Total pregnancies including this one; minimum 1. |
| Para, Abortus, Living, Preterm | Rest of the GTPAL history. |
| LMP (Last Menstrual Period)* | Defaults today; used to calculate the EDD. |
| OB/GYN* | |
| Midwife | Optional. |
| Blood Type, Rh Factor | |
| Risk Level, High-risk pregnancy | Low/Moderate/High/Very High, plus an independent high-risk checkbox. |
| ICD-10 Code, Notes |
Active — ongoing pregnancy
Delivered — baby born, pregnancy record complete
Ectopic / Molar / Stillbirth — adverse outcome
Terminated / Miscarried — pregnancy ended early
Saving opens the new pregnancy's record directly, ready for its first prenatal visit.
Prenatal care
A pregnancy's record has 7 tabs; Overview, Prenatal Visits, Ultrasounds and Fetal Monitoring cover the antenatal period.
Overview tab
| Field | What it means |
|---|---|
| GTPAL & dating | Gravida/Para/Abortus/Living, LMP, EDD, ultrasound-corrected EDD, days until due. |
| Labs | Blood type, Rh factor, GBS, GBS prophylaxis, GDM, HIV, HBsAg, NIPT, each editable inline as results come in. |
| Mark RhIG Given | One-click action for Rh-negative mothers, once given it's locked in. |
Prenatal Visits — Add Visit form
| Field | What it means |
|---|---|
| Visit Date, Gestational Weeks* | |
| Weight, Systolic/Diastolic BP, Fetal Heart Rate, Cervical Dilation | BP shown bold red with a warning if systolic ≥140 or diastolic ≥90, the preeclampsia threshold. |
| Performed By* |
Ultrasounds & Fetal Monitoring
| Field | What it means |
|---|---|
| Ultrasound report | Scan type, EFW (Estimated Fetal Weight) and percentile, AFI (Amniotic Fluid Index), cervical length, BPP (Biophysical Profile) score, impression and recommendations. Flagged red if EFW percentile <10, BPP ≤6, or cervical length <25mm. Reports are drafted, then finalized. |
| Fetal monitoring record | NST/CST/intrapartum EFM type, FHR baseline, NST result, NICHD category (I/II/III), tachysystole flag. Category III or a non-reactive NST are flagged red. |
Labor
Start labor to open the partograph, then track stage, interventions, and any emergencies through to completion.
Start Labor / ongoing actions
| Field | What it means |
|---|---|
| Start Labor | Labor onset time and attending OB, required; optional induced-labor flag. |
| Advance Stage | Moves through Latent → Active → 2nd Stage (Pushing) → 3rd Stage (Placenta) → 4th Stage (Recovery), confirmed each time. |
| Record ROM, Epidural, Oxytocin, GBS Prophylaxis | Rupture of membranes (type + fluid color), anesthesia with a pre-procedure pain score, oxytocin augmentation dose, and intrapartum antibiotic prophylaxis. |
| Log Emergency | Free-text record of an emergency event during labor. |
| Complete Labor | Closes out the labor record with total duration. |
A partograph chart plots cervical dilation and fetal heart rate against time from logged readings (dilation, FHR, maternal BP).
Tachysystole and Arrest of Labor
Delivery & newborns
Record the delivery once the baby is born, then register each newborn and work through their initial care checklist.
Record Delivery form
| Field | What it means |
|---|---|
| Delivery Date, Gestational Weeks* | |
| Delivery Method* | 9 methods: Spontaneous/Induced Vaginal, Elective/Emergency Cesarean, Vacuum- or Forceps-Assisted, VBAC, Water Birth, Home Birth Transfer. |
| APGAR 1/5/10 min, Estimated Blood Loss | A red banner flags Postpartum Hemorrhage if it occurred. |
| Attending Staff* |
Register Newborn & care checklist
| Field | What it means |
|---|---|
| Last Name, Date of Birth, Gender, Weight (grams)* | |
| APGAR 1/5 min | |
| Vitamin K, Eye Prophylaxis, Hep B Vaccine | One-time preventive actions, each disappears once given. |
| Record Screen, Record Bilirubin | Newborn metabolic screen result, and jaundice bilirubin readings with the baby's age in hours. |
| File Birth Cert | Records the certificate number once filed. |
A newborn needing intensive care shows a red NICU badge on its card.
Postpartum
Recovery assessments after delivery, including depression screening.
Add Assessment form
| Field | What it means |
|---|---|
| Assessed At, Assessed By* | |
| EPDS Score (0-30) | Edinburgh Postnatal Depression Scale; 10-12 flags amber "PPD Risk", 13+ flags red "High-Risk PPD". |
| Systolic/Diastolic BP, Fundal Height | |
| Lochia Type, Lochia Amount | Stage (Rubra/Serosa/Alba) and amount (Scant to Heavy) of postpartum discharge. |
Newborn worklists
Unit-wide, cross-patient views of newborn census and pending required tasks.
Five tabs: Recent Births (last 90 days), Active NICU, and three pending-task queues — Pending Hep B, Pending Newborn Screen, and Pending Birth Certificate — each listing every newborn still missing that task, regardless of which pregnancy record they came from.
Good practices
Update labs as results come in
Don't skip the partograph
Screen every postpartum patient for depression