Labor and Delivery Record Profile

The Labor and Delivery Record (LDR) is a continuation of the Antepartum Record (APR). The LDR is not defined as an actual profile. Use the LDR information as background. To implement against this supplement, you will implement one or more of the content profiles.

The LDR provides comprehensive information regarding the course of labor and delivery to healthcare providers caring for both the mother and the newborn in the postpartum period. For example, in cases such as chorioamnionitis or birth trauma, if the postpartum nurse or the attending obstetrician were not present at the birth, the LDR would be crucial for risk identification and appropriate inpatient postpartum care. The pediatrician uses the information present in the LDR to develop the infant’s plan of care. The outpatient care is out of scope for this profile, as well as the newborn’s discharge summary from the birthing facility. In some settings, public health officials are interested in the labor, delivery and inpatient postpartum information as to better monitor the mother and child’s health, and develop quality improvement processes if necessary. Certain data present in the LDR is monitored anonymously as to conduct studies about population health. The public health aspect is out of scope for this profile as it is addressed in the Quality, Research and Public Health (QRPH) domain.

The information found in the LDR is important for continuation of care for the mother and the newborn, in both inpatient and outpatient settings, and should be available to all healthcare providers. Prior to discharge from the birthing facility, the mother receives a comprehensive assessment which provides the follow-up health care provider with the details of the labor and delivery, as well as a “snapshot” of the mother’s condition at discharge. The newborn’s status immediately following birth, while the newborn is still in the delivery room is also captured thus if any complications arise and the newborn is transferred to a specialized unit, this information is available. The typical workflow resulting in the collection of this information in a laboring patient is as follows:

1. Maternal demographic information is recorded or verified when the mother arrives at the birthing facility if the situation permits (i.e. the delivery is not immediate). 2. An Admission History and Physical Assessment is performed (or updated) if the situation permits (i.e. the delivery is not immediate). 3. Labor information is recorded. 4. The mother delivers. 5. A Labor and Delivery Summary (LDS) is produced. 6. Information is captured at the time of birth about the infant's delivery course and becomes part of the mother’s record. 7. Maternal post-partum information is recorded. 8. The mother leaves the birthing facility and a Maternal Discharge Summary (MDS) is produced. 9. The information about the mother and child can be shared seamlessly between the stakeholders.

The information collected varies according to the type of birthing facilities, their birthing practices and location, and also depends on the characteristics of mothers and newborns. The stakeholders are: attending physicians, resident physicians, medical students and staff, obstetrician-gynecologists, family physicians, covering physicians, nurse midwives, physicians’ assistants, nurse practitioners, pediatricians, healthcare administrators, social workers, , other medical specialists, researchers, patient safety and quality officers, billing specialists, pharmacists, laboratory personnel, and public health officials.

The information is uniform in terms of structure and content and the resulting documents can be shared between all the stakeholders. Also, this information may also be incorporated into a patient's personal health record (PHR). The LDR is kept at least until the age of majority, and the information could be collected by Social Services, as well as Public Health officials for epidemiological studies.

This year’s scope will be limited to the Labor and Delivery information, the information about the infant in the birth room, and the Maternal Discharge Summary. The resulting content profiles present in the LDR are:

1. The Labor and Delivery Admission History and Physical (LDHP) content profile which can point to the Antepartum Admission History and Physical content profile from the Antepartum Record. If there is no Antepartum Record a new document The Labor and Delivery Admission History and Physical will be created. 2. Labor and Delivery Summary (LDS) content profile containing a summary of the 0 labor and delivery course and the Newborn’s Birth Summary while in the birth room. 3. Maternal Discharge Summary (MDS) content profile representing the mother’s postpartum course up until her discharge from the birthing facility and the newborn’s status).