| ARCHETYPE ID | openEHR-EHR-CLUSTER.exam-fetus.v1 |
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| Concept | Examination of the fetus |
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| Description | Examination cluster for describing a finding on physical examination of a fetus. |
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| Purpose | For recording findings on physical examination relating to the fetus while in the uterus. |
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| References | |
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| Copyright | copyright (c) 2010 openEHR Foundation |
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| Authors | Author name: Sam Heard
Organisation: Ocean Informatics, Australia
Email: sam.heard@oceaninformatics.com
Date originally authored: 19/04/2007
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| Other Details Language | Author name: Sam Heard
Organisation: Ocean Informatics, Australia
Email: sam.heard@oceaninformatics.com
Date originally authored: 19/04/2007
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| Other Details (Language Independent) | - References:
- MD5-CAM-1.0.1: 1D56F36C0F32C4A5D74F92289474005F
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| Keywords | foetus, fetal, foetal |
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| Lifecycle | AuthorDraft |
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| Language used | en |
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| Citeable Identifier | 1013.1.277 |
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| items | |
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| Normal statements | Normal statements: A group of statements about the normality of the examination. |
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| Normal statement | Normal statement: A specific statement of normality. |
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| Clinical description | Clinical description: Textural description of the part examined. |
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| Abdominal Findings | Abdominal Findings: Clinical findings on abdominal examination. |
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| Lie of the fetus | Lie of the fetus: The position of the fetus.
- at0.5::Longitudinal [The lie is along the line of the mother's spine.]
- at0.6::Transverse [The lie is perpendicular to the mother's spine.]
- at0.7::Oblique [The lie is oblique to the mother's spine.]
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| Presentation | Presentation: The presenting part of the fetus.
- at0.9::Cephalic [The head is the presenting part.]
- at0.10::Breech [The breech is the presenting part.]
- at0.11::Full breech [The breech is presenting with the legs flexed.]
- at0.12::Extended breech [The breech is the presenting part with the leg(s) extended.]
- at0.13::Shoulder [The shoulder is the presenting part.]
- at0.69::Footling breech [A fetal foot is extended and presenting.]
- at0.70::Face [The head is extended and the face is presenting.]
- at0.71::Cord [The umbilical cord is presenting.]
- at0.72::Compound [There is a compound presentation.]
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| Position | Position: The orientation of the denominator.
- at0.43::Right Occipito-transverse [The occiput is towards the right.]
- at0.44::Right Occipito-anterior [The occiput is towards the right and anterior.]
- at0.45::Right Occipito-posterior [The occiput is to the right and posterior.]
- at0.46::Occipito-anterior [The occiput is towards the symphasis.]
- at0.47::Occipito-posterior [The occiput is towards the sacrum.]
- at0.48::Left Occipito-transverse [The occiput is towards the left.]
- at0.49::Left Occipito-anterior [The occiput is to the left and symphasis.]
- at0.50::Left Occipito-posterior [The occiput is to the left and posterior.]
- at0.51::Right Sacro-transverse [The fetal sacrum is towards the right.]
- at0.52::Right Sacro-anterior [The fetal sacrum is towards the right and anterior.]
- at0.53::Right Sacro-posterior [The fetal sacrum is to the right and posterior.]
- at0.54::Sacro-Anterior [The fetal sacrum is towards the symphasis.]
- at0.55::Sacro-Posterior [The fetal sacrum is towards the sacrum.]
- at0.56::Left Sacro-transverse [The fetal sacrum is towards the left.]
- at0.57::Left Sacro-anterior [The fetal sacrum is to the left and symphasis.]
- at0.58::Left Sacro-posterior [The fetal sacrum is to the left and posterior.]
- at0.59::Right Mento-transverse [The fetal chin is towards the right.]
- at0.60::Right Mento-anterior [The fetal chin is towards the right and anterior.]
- at0.61::Right Mento-posterior [The fetal chin is to the right and posterior.]
- at0.62::Mento-Anterior [The fetal chin is towards the symphasis.]
- at0.63::Mento-Posterior [The fetal chin is towards the sacrum.]
- at0.64::Left Mento-transverse [The fetal chin is towards the left.]
- at0.65::Left Mento-anterior [The fetal chin is to the left and symphasis.]
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| Attitude | Attitude: The degree of flexion of the body.
- at0.33::Flexed [The fetus is fully flexed.]
- at0.34::Deflexed [The fetus is not flexed.]
- at0.35::Extended [The fetus is extended.]
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| Engagement | Engagement: Estimation of presenting part in relation to pelvic brim. |
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| Fifths | Fifths: The proportion of the presenting part which is felt above the pelvis.
- at0.23::Not engaged (0/5) [The head is not engaged in the pelvis.]
- at0.24::1/5 [About 20% of the head is inside the pelvis.]
- at0.25::2/5 [About 40% of the head is inside the pelvis.]
- at0.26::3/5 [About 60% of the head is inside the pelvis.]
- at0.27::4/5 [About 80% of the head is inside the pelvis.]
- at0.28::Fully engaged (5/5) [The head is inside the pelvis.]
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| Qualitative | Qualitative: Description of engagement of fetal head.
- at0.76::High and mobile [The presenting part is high and mobile.]
- at0.77::At pelvic brim [The presenting part is at the pelvic brim.]
- at0.78::Engaged [The presenting part in engaged in the pelvis.]
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| Size relative to gestation | Size relative to gestation: The apparent size of the baby relative to normal for gestation.
- at0.15::Small for dates [The size of the baby is smaller than expected for gestation.]
- at0.67::? small for dates [Possibly small for this gestation.]
- at0.16::Normal [The size of the baby is normal for gestation.]
- at0.68::? large for dates [Possibly larger than expected for this gestation.]
- at0.17::Large for dates [The size of the baby is larger than expected for gestation.]
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| Station | Station: Posiiton relative to the ischial spines (minus is above, 0 is at the spines and plus is below).
Property: Length
Units: -5.0..5.0 cm
Limit decimal places: 0 |
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| Estimated fetal weight | Estimated fetal weight: The estimated weight of the baby on examination.
Property: Mass
Units: - 0.0..20.0 kg
- 0.0..20000.0 gm
Limit decimal places: 0
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| Size | Size: Details of size of fetus.
Include:
openEHR-EHR-CLUSTER.physical_properties.v1 and specialisations |
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| Detail | Detail: More focused examination findings.
Include:
openEHR-EHR-CLUSTER.exam-generic.v1 and specialisations or
openEHR-EHR-CLUSTER.auscultation.v1 and specialisations or
openEHR-EHR-CLUSTER.inspection.v1 and specialisations or
openEHR-EHR-CLUSTER.palpation.v1 and specialisations or
openEHR-EHR-CLUSTER.percussion.v1 and specialisations or
openEHR-EHR-CLUSTER.physical_properties.v1 and specialisations |
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| Vaginal findings | Vaginal findings: Clinical findings on abdominal examination. |
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| Flexion | Flexion: Findings about fetal flexion on vaginal examination.
- at0.85::Flexed [The fetal attitude is flexed.]
- at0.86::Deflexed [The fetal attitude is deflexed.]
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| Caput | Caput: Findings related to caput. |
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| Moulding | Moulding: Findings related to moulding. |
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| Asynclitic | Asynclitic: Codes yet to be added. |
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| Position | Position: The orientation of the denominator.
- at0.43::Right Occipito-transverse [The occiput is towards the right.]
- at0.44::Right Occipito-anterior [The occiput is towards the right and anterior.]
- at0.45::Right Occipito-posterior [The occiput is to the right and posterior.]
- at0.46::Occipito-anterior [The occiput is towards the symphasis.]
- at0.47::Occipito-posterior [The occiput is towards the sacrum.]
- at0.48::Left Occipito-transverse [The occiput is towards the left.]
- at0.49::Left Occipito-anterior [The occiput is to the left and symphasis.]
- at0.50::Left Occipito-posterior [The occiput is to the left and posterior.]
- at0.51::Right Sacro-transverse [The fetal sacrum is towards the right.]
- at0.52::Right Sacro-anterior [The fetal sacrum is towards the right and anterior.]
- at0.53::Right Sacro-posterior [The fetal sacrum is to the right and posterior.]
- at0.54::Sacro-Anterior [The fetal sacrum is towards the symphasis.]
- at0.55::Sacro-Posterior [The fetal sacrum is towards the sacrum.]
- at0.56::Left Sacro-transverse [The fetal sacrum is towards the left.]
- at0.57::Left Sacro-anterior [The fetal sacrum is to the left and symphasis.]
- at0.58::Left Sacro-posterior [The fetal sacrum is to the left and posterior.]
- at0.59::Right Mento-transverse [The fetal chin is towards the right.]
- at0.60::Right Mento-anterior [The fetal chin is towards the right and anterior.]
- at0.61::Right Mento-posterior [The fetal chin is to the right and posterior.]
- at0.62::Mento-Anterior [The fetal chin is towards the symphasis.]
- at0.63::Mento-Posterior [The fetal chin is towards the sacrum.]
- at0.64::Left Mento-transverse [The fetal chin is towards the left.]
- at0.65::Left Mento-anterior [The fetal chin is to the left and symphasis.]
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| Station | Station: Posiiton relative to the ischial spines (minus is above, 0 is at the spines and plus is below).
Property: Length
Units: -5.0..5.0 cm
Limit decimal places: 0 |
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| Image | Image: Drawing or image of the area examined.
image/gif, image/png, image/jpeg |
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| Other contributors | Heather Leslie, Ocean Informatics, Australia |
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| Translators | |
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