Obstetrics

Basic history and complaint analysis helps defining main patient problems. Parity, preterm, abortions history is important. Medical, family, and social history is relevant. Detailed obstetric history is captured in a tabular format including delivery/abortion, gestation, and mode of delivery, baby gender, baby weight, purperium, and general remarks of each event.

Antenatal follow up visits data are registered in a tabular format, including date of visit, gestation in weeks, fundal level, baby presentation, fetal heart rate, maternal blood pressure, edema, Hb, urinalysis, weight, medications, and remarks for each visit. Detailed mother examination includes general, abdominal, and pelvic examination. Finally identifying risk factors and giving instructions.

Delivery Record

One of the main components of Obstetric Module; Delivery Record is designed to help clinicians assess female patients in labor. With pre-natal assessment; general maternal examination, abdominal examination to evaluate fetal gestation, presentation, liquor volume, contractions…etc.

Vaginal examination; using speculum and digital methods. Assessment of different maternal, fetal, and labor risk factors. Fetal condition assessment; evaluating viability, heart rate, decelerations, molding, and caput. Labor progress using graphical partogram presentation.

Maternal condition monitoring; uterine contractions, blood pressure, and pulse rate. Assisted delivery (forceps/vacuum) management, Caesarean section management. And finally Labor summary with different stages outcomes and notes.