Additional Information

In terms of telephone (or if applicable video) contact the solution must:

• Have the ability to capture all telephone calls (or if applicable video calls) or attendances to any maternity unit. These must be summarised and recorded as part of the record, to include the full risk assessment, all relevant history, and appropriate recommendations.

• Present the calls and attendances as part of a whole maternity record.

• Be able to capture informal requests for the woman to re-attend so that those that do not attend can be followed up.

• Enable every interaction to be reviewed on transfer.

• Ensure that all interactions are captured and displayed in chronological order.

Additional Information

This is related to DCB3066 record standard.

The solution must capture the following data for all inpatients:

• Log and display any antenatal or postnatal admission and discharges, together with the reason for admission and gestation. This must include capturing the named midwife and consultant.

ANTENATAL: including but not exclusively:

• Referral information, booking details and subsequent antenatal visits, both in a hospital and community environment.

• Ultrasound and blood results.

• Details of antenatal complications.

• Previous individual pregnancies and relevant antenatal history/complications (including the ability to automatically copy data which is known to be true regarding previous pregnancies and deliveries, into the existing pregnancy record).

• Date, place and pregnancy outcome.

• Labour/birth details, including gestation, mode of birth, complications.

• Infant details, live/stillbirth, sex, weight, clinical condition or complications.

• Termination of pregnancy details, including gestation, type, management.

• First / second trimester pregnancy loss details, including gestation, type, any medical or surgical management

• Previous postnatal history/complications.

• Antenatal anaesthetic clinic visits and preferences/plans made.

• Screening for diabetes and pre-eclampsia, mental health and safeguarding including the woman's status at appropriate times during the pregnancy as locally defined.

• The outcome of screening assessments and risk assessments should automatically suggest or place the woman on an appropriate Trust definable pathway.

• Screening – flags throughout i.e. MRSA, GBS, BBI. Including screening for fetal growth restriction.

• Public health data collection during the course of the pregnancy - issuing of public health advice on smoking cessation and healthy eating (as per Saving babies lives v3) (including whether the woman was given advice, was offered referral and if this was accepted or declined). Whether a referral to the smoking cessation unit was completed and the results of a carbon monoxide test. The functionality must include electronic notification of any referral to appropriate services. This may include the partner or other household members. For smoking the full smoking cessation information and details of quit support and NRT information needs to be captured in line with the Tobacco SDCS submission requirements.

• Conversations recorded on Breast feeding at set gestations, safe sleeping at set gestations, routine enquiry at each contact, fetal movements at set gestations, birth plans at set gestations, contraception after delivery

• Vaccinations

• Female Genital Mutilation (FGM) assessment in line with local and national guidelines including alert triggers for women and female neonates, the output of a dataset and a referral if the woman is under 18 years of age.

• the woman's preferences for care (personal care and support plans) and birth including place of birth, and a labour care plan to be recorded and updated. Risk assessments must be able to be conducted on the selected place of birth.

• Sufficient data to allow for the closure of the pregnancy where antenatal care is provided by the Trust if the woman chooses or is recommended to birth in another hospital. A reason for notes closure should be recorded as a mandatory field.

• Clinical noting of all examinations and referrals including those relevant to generic care (e.g. dietician) and those which are specific to maternity.

• The solution will calculate estimated delivery date (EDD) from ultrasound information or last period and allow the use of this date as the formal Estimated Delivery Date.

• family history, social history, medical history and surgical history must all be captured, this should include lived gender, BMI, ethnicity, complex risk factors, alcohol and lifestyle choices (e.g. drug use). There should be the option to update and reassess these factors as the pregnancy continues.

• COVID-19 and MRSA assessments and risk assessments must be captured.

INTRAPARTUM: including but not exclusively:

• Admission, maternity specific VTE, risk assessments, COVID-19 and MRSA assessment. This should include any previous results.

• Interactive partogram with the ability to record observations, results of examinations etc. Observations recorded on the partogram must be available to other parts of the woman’s record (e.g. a maternity early warning score chart and fluid balance). This must be automatically populated with any observations and assessments undertaken while in labour.

• Fetal monitoring – CTG and Intermittent auscultation; including person and grade assessing CTG / IA, the interpretation of the parameters (using National guidelines) and the classification and any subsequent plan and actions.

• Fetal blood sampling in labour; including date, time, method, clinician performing procedure and results. This must support the NICE guidance for repeating sampling at defined intervals depending on results. This must include cord blood pH, pCO2, pO2, lactate and base excess on venous & arterial sampling.

• Induction reason and method including OP Induction of Labour (IOL), type of onset of labour, augmentation reason and method, rupture of membranes including type, colour of liquor from outset of rupture of membranes, intrapartum and at birth, type of maternal monitoring in labour, monitoring of uterine contractions.

• Mode of birth and indication for instrumental and / or caesarean birth and other interventions during birth.

• Record the times of birth of the neonate and the placenta

• Any complications in labour, birth or in the immediate postnatal period for example perineal trauma and blood loss. For blood loss the solution must be able to automatically accumulate blood loss recorded to capture primary and secondary blood loss and the method of the assessment.

• Medication including analgesia, any maternal mediation must feed to the neonate's record to include magnesium sulphate and steroids.

• Persons present during the birth including their name and status. This must include (but not be limited to) the following: responsible midwife; senior personnel; names and roles of all present including health professionals, name, role and title of the person delivering the neonate, students, family members, birth supporters, doulas.

• The name of the supervising midwife where the birth is attended by a student.

• One to one care in established labour. This must include the ability to record a Trust definable reason where this does not take place. The solution must provide the capability to report on this data. This must capture whether it is Named, Buddy or Team of Midwives.

• Calculation of cervical scoring using the modified bishop’s score.

• Start date and times of all stages of labour and automatically calculate the duration of each stage of labour. It must also record the onset of active pushing in the second stage. This functionality must provide the capability to set mandatory fields, but also support the scenario where information is not known.

• Details of the third stage of labour including but not limited to the following information: method, state of placenta and membranes (and any abnormalities), number of vessels in the cord, oxytocin administered, estimated blood loss, any blood transfusion, record cord blood taken.

• Record maternal blood taken, cord blood gases and Stem cell collection.

• Indications for and outcomes of all invasive procedures including but not limited to: instrumental births, caesarean sections, manual removal of placenta, breech and vaginal breech birth, and Multiple births and perineal repair.

• Caesarean sections must be categorised in accordance with National guidelines. The solution must include the ability to record the procedure and other information using a Trust defined proforma.

• The condition of the perineum (with the ability to make multiple selections) including: all genital trauma including FGM, type and extent of trauma to be classified using RCOG guidelines, allow the user to document drawings of the tear.

• For any repair undertaken to the perineum to include: date and time of procedure, record of consent or refusal, venue for repair, technique, analgesia used, material used, name and status of personnel involved, supervising personnel, record of pre- and post-swab, instrument and needle count, incorporating the entry of two passwords in support of two-person check, if they are under supervision, including the name and status of the supervisor, record type and extent of trauma.

• The name and status of the clinician who makes a decision to offer caesarean or instrumental birth (include date and time of decision and must automatically calculate the decision to delivery interval).

• The type of pain relief provided (epidural, combined spinal/epidural, Remifentanil Patient Controlled Analgesia PCA) using Trust defined proformas. This must include: observations to be recorded at Trust definable regular intervals, monitor and manage a Trust defined target from request for an epidural/PCA to its administration, support to multiple requests and administrations.

• The presentation of the fetus (single/multiple) at birth and position of presentation.

• Method and outcome of birth - to include date and time of birth for all neonates.

• Actual place of birth including the unit, room number or theatre code to be recorded (using codes), including the reason for change if this is different from the intended place of delivery.

• This must also allow users to record the place of birth where it is outside the Trust including "home" or BBA (born before arrival).

• Record home births appropriately within the solution, i.e. without the need for an inpatient episode/time of decision taken to transfer in. For home births include the ability to populate full partogram and observations.

• Maternal and neonatal items must be kept separate so that multiple births can be entered sequentially (data which is relevant to all births should be ‘pulled forward’).

• Delayed cord clamping whether performed, reasons why not, length of time, allowing for lotus births where the cord is not cut at birth

• Include the ability to capture or scribe obstetric and neonatal emergencies as they occur.

POSTNATAL: ~ The type of neonatal resuscitation given, including the name and role of all staff involved.

• Capture postnatal observations, risk assessments, notes and plans at the bedside of both the woman and neonate (where necessary).

• The dosage, date and time of any drugs and who administered them.

• The ability to calculate the total of the Apgar score at Trust definable intervals for example 1, 5 and 10 minutes and elapsed time before onset of regular respirations.

• The sex of the neonate(s) and gestational age calculated from the agreed EDD or an estimate when the woman is unbooked. This must include the ability to record indeterminate sex.

• Initial Midwife examination following birth

• Measurements including the birth weight, head circumference and temperature of neonate/babies to be recorded. This might be recorded immediately at birth or at a later stage.

• First full examination of the new-born including head, face, eyes, musculoskeletal, cardiovascular, oxygenation saturation and central nervous solution (CNS).

• This functionality must also be available in the case of a home birth and provide alerts to ensure this is carried out within 72 hours.

• Further involvement by anaesthetists for women with complications such as bleeding, eclampsia and also in the transfer of the most seriously ill women to enhanced maternity care, high dependency and / or intensive care.

• This must provide the capability to prompt the user to complete the relevant Trust defined proformas, for example massive obstetric haemorrhage in line with the woman's journey.

• Women requiring high dependency care within the labour suite.

• Any neonatal complications including congenital abnormalities and dysmorphic features

• The actual method of feeding at intervals - at birth, within 24 hrs/48 hrs, on discharge from hospital, and on discharge from care by the community midwife.

• Whether skin to skin was initiated at birth and duration

• Whether vitamin K was given including dose, route, batch number, date and time, clinicians involved, or whether it was declined.

• If vitamin K is given orally, the solution must provide prompts for repeated doses at Trust defined time periods.

• The latest weight of neonate/babies at discharge from hospital.

• Where a woman experiences a traumatic birth, the solution must prompt for and record details of the duty of candour/debriefing.

• Any other specialist care provided e.g. ITU/cardiology.

• Capture date of discharge from Maternity Services to Health Visitor/GP/Trust.

• Capture COVID-19 and MRSA assessments.