Overview or summary record of a pregnancy including the antenatal period, labour, birth and the immediate postnatal period.

Was the pregnancy a result of assisted reproductive technology?

True, if assisted reproduction was required to achieve the pregnancy.

Type of assisted reproductive technology used to achieve pregnancy.

Coding with a terminology is preferred, where possible.

Actual date of conception.

To be recorded only if the actual date of conception is known, not estimated or calculated. This usually occurs in situations where fertilisation is assisted, for example via IVF.

Estimated date of birth based on a known date of conception.

Most recent form of contraception used.

Date that the most recent form of contraception was ceased.

Details about the estimated date of birth (EDB) based upon the menstrual cycle.

An EDB based on cycle can only be calculated if both LNMP and cycle length are known to a degree of certainty that is clinically acceptable.

First day of last normal menstrual cycle (LNMP).

Certainty of LNMP as a reliable basis for calculation of EDB (Cycle).

Usual length of menstrual cycle.

Are the menstrual cycles irregular?

Record as True only if the cycles are irregular.

Narrative description of menstrual cycle or menstruation.

Estimated date of birth based on menstrual cycle.

Details about the estimated date of birth (EDB) based upon an ultrasound examination.

Date on which the ultrasound examination was performed.

Estimated gestation based on the ultrasound findings.

Possible variation from Estimated Gestation, recorded as a positive number of days.

For example, 7 days indicating EDB +/- 7 days.

Estimated date of birth based on ultrasound examination.

Details about the agreed estimated date of birth (EDB).

Estimated date of birth (EDB) on which all antenatal care and management is based.

As agreed by the care team, and after taking into consideration all available information regarding Date of Conception, EDB (Cycle) and EDB (Ultrasound).

Reason for selection of EDB (Agreed).

Model of antenatal care provided.

The Model of care type.

Coding with a terminology is preferred, where possible. For example, GP shared care, birth centre, private community midwife or midwifery group practice.

Reason or rationale for the selected type of antenatal care.

Date of commencement of the identified type of antenatal care.

Planned or intended physical location for birth.

Local standardisation of the value set is desired in preference to free text entry, so as to provide clinicians with a meaningful local list, including 'Home'. The value set may be modelled directly in a template or via inclusion of an external terminology reference set.

Number of fetuses identified in utero.

Outcome of the pregnancy as a whole.

Coding of the Pregnancy Outcome with a terminology is desirable, where possible. If individual fetuses have been identified, record this information using the 'Individual Outcome' data element. This data element is not to be recorded if 'Individual Outcome' is recorded.

Manner in which labour started.

Method of labour induction.

Coding of the 'Induction Method' with a terminology is desirable, where possible.

Reason for induction of labour.

Method of labour augmentation.

Coding of the 'Augmentation Method' with a terminology is desirable, where possible.

Method/s of analgesia used during labour.

Coding of the 'Type of Pain Relief' with a terminology is desirable, where possible.

Total duration of the first stage of labour.

Details about pregnancy complications or birth complications affecting the mother.

Identification of the complication.

Coding of the 'Complication' with a terminology is desirable, where possible. For example, post partum haemorrhage or pre-eclampsia.

Narrative description of the maternal complication.

Date of onset of complication, as assessed by a clinician.

If only a partial date is available, this is acceptable.

Information about an individual identified baby.

While most often these details are used to record information about birth of newborn, occasionally they are also useful to record delivery details for

Identification of the baby.

Identification might be by the name of the neonate or a label given to a fetus.

Sequential order of each baby in a multiple birth event.

For example, record '1' if this neonate is the first born of a multiple birth; record '4' if this neonate is the fourth born of a multiple birth.

Duration of second stage for the baby.

Method by which the baby was delivered.

Value set from AIHW.

Presenting part of the baby at birth or delivery.

Extension of the AIHW value set. The clinical context for recording this data element is only presentation at birth, not at any other phase of labour.

Outcome of the pregnancy for the identified baby.

Sex of the baby, as determined by observable physical characteristics.

Coding with a terminology is preferred, where possible. Indeterminate is to be used in the situation where is it not possible to tell if the sex is male or female.

Date and time of birth.

The category of the physical location where the birth occurred.

The actual physical location where the birth occurred.

For example, the name of an institution or an address.

Estimated gestational age of fetus or baby at birth or delivery, based on clinical examination and evaluation.

This data element is intended to record estimated gestation based on clinical findings on examination of the fetus/neonate and clinical assessment, not the calculated gestation based on the 'Agreed EDB'.

Weight of the fetus or baby at birth or delivery.

Narrative description of the birth or delivery.

For example, footling breech with cord presentation or uncomplicated vaginal birth.

Description of the fetus or baby at delivery.

For example, need for resuscitation.

The sum of the 5 scores for each Apgar component recorded at 1 minute after birth.

Can be derived direct from the Birth Record documentation, if present.

The sum of the 5 scores for each Apgar component recorded at 5 minutes after birth.

The sum of the 5 scores for each Apgar component recorded at 10 minutes after birth.

Details about complications affecting the baby.

Identification of the complication after birth.

Coding of the 'Complication' with a terminology is desirable, where possible. For example, neonatal hypoglycaemia or hypothermia.

Narrative description of complication.

Date and/or time of onset of the complication.

Total duration of the third stage of labour.

Total duration of all three stages of labour.

Narrative description about the condition of the perineum after birth, including injuries and repairs.

Estimation of maternal blood loss during birth and immediately post delivery.

Narrative description about feeding.

Narrative description about the whole of pregnancy.

The date this pregnancy summary was last updated.