Document Labor and Delivery Details

You can provide information on the maternal labor, delivery, and birth history of a baby in the Labor and delivery section on the Pregnancy/Birth History template.

1. Open NextGen® Enterprise EHR.
2. Open a patient's record, and then open an encounter.
3. On Top Toolbar, select Templates .
   The Select Template window opens.
4. Open the Intake template.
5. Click the Birth History link.
   The Pregnancy/Birth History template opens.
6. In the Labor and delivery section, select the type of delivery from the list.
   The Reason field appears.
7. Enter the reason for the delivery.
   

8. To indicate the type of labor, select Spontaneous or Induced.
9. Click the arrow next to the Time of birth field to enter the time on the Time Entry template, or click to select the time of birth from the clock.
   The birth time is entered in the Hours, Minutes, and Seconds fields.
10. Click Hours of labor, and then type the labor hours using the numeric keypad.
11. Enter the gestational age at birth in the Wks and days fields.
    If the gestational age is below 37 weeks, the Premature checkbox is automatically selected.
12. Enter the birth weight, and then click Save.
    Note: You can enter the length within the 0 – 172.51 cm or 0 – 67.92 in range, and head circumference within the 25.4 – 76.17 cm or 10.00 – 29.99 in range. A message appears if the value entered is not within the range.
13. Select the Multiple birth option.
    If you select Yes, the Birth order and Number of births in the multiple birth fields appear. Do the following:
14. Enter the birth order of the newborn.
15. Enter the number of births in the multiple birth using the numeric keypad.
16. Select one of the following options with respect to the weight of the baby:
    • SGA: Small
    • AGA: Appropriate
    • LGA: Large
17. To indicate the spontaneous or artificial rupture of membranes, select SROM or AROM.
18. Enter the Apgar score regarding the health of the newborn, taken after one, five, and ten minutes.
19. Select Meconium.
    If you select Yes, the Intubated field appears, where you can select the appropriate option.
20. Select Maternal fever. If you select Yes, the Birth Hx Fevr Dtl template opens. Do the following:
    1. Select the relevant options for the maternal fever details.
    2. Click OK.
    Note: A Detail button appears on the Pregnancy/Birth History template adjacent to the fields for which you provide additional information.
21. Select the Resuscitation option.
    If you select Yes, the Birth Hx Resusc template opens. Do the following:

    

    1. Select the relevant options for the resuscitation details.
    2. Click OK.