Labour & Birth Mother

Data Definition: Self-reported amount of smoking per day closest to time of labour/admission.

Data Definition: Indicates if birthing person lives with a smoker at time of labour/admission.

Data Definition: At the time of current pregnancy, the total number of children the pregnant person has given birth to that are presently living.

Data Definition: Self-reported alcohol consumption during pregnancy. A standardized serving of alcohol beverage is approximately a 12oz serving of regular beer (5%), a 5oz glass of wine (12%) or a 1.5oz glass of 40% spirit (SOGC, 2010). If the amount of drinking varied over the course of the pregnancy, estimate the total number of drinks and average it out over the entire pregnancy. Select the one that represents the highest exposure or impact. 'Episodic excessive drinking (binging)'is considered the greatest impact.

Data Definition: Diabetes status and type for this pregnancy.

Data Definition: Indicate Maternal self-reported drug and substance use during pregnancy. This refers to the use of street drugs and the inappropriate use of prescription and non-prescription drugs.

Data Definition: Indicate whether this women underwent radiation therapy if there is a diagnosis of cancer prior to or during this pregnancy

Data Definition: Any hypertensive conditions the pregnant person experienced during this pregnancy.

Data Definition: Any infections during this pregnancy. Select all that apply.

Data Definition: Prescription and/or non-prescription (over-the-counter) medication(s) taken during this pregnancy, prior to admission for labour/birth, as documented on the Ontario Perinatal Record and/or Admission history. Select all that apply.

Data Definition: Self-disclosed threat of or actual physical, sexual, psychological, verbal, emotional, or financial abuse in the current relationship.

Data Definition: Use of folic acid prior to and during pregnancy

Data Definition: Comment to capture details not identified in other data elements.

Data Definition: All indications for induction of labour. Induction refers to the initiation of labour.

Data Definition: All medical and non-medical indications for cesarean birth.

Data Definition: Pharmacologic method(s) used, only for the management of labour pain. Non-pharmacologic methods are found in the Supportive Care data element.

Data Definition: Method(s) of anesthesia for cesarean birth.

Data Definition: Indicate the location where intrapartum care took place immediately before this admission/midwifery visit. If no care was provided directly before this encounter, select “No Transfer”.

Data Definition: Indicates the location where intrapartum care took place immediately before this admission. If no care was provided directly before this encounter, select “No Transfer”.

Data Definition: Indicates the hospital that the birthing person was transferred to, within one hour of birth.

Data Definition: Indicates the hospital that the birthing person was transferred to during labour.

Data Definition: Health care provider type responsible for admission to organization for labour and birth.

Data Definition: Indicates Bishop Score based on the 5 factors of position, consistency, cervical length in cm, dilation, and fetal station. Bishop score is a pre-labour evaluation used in predicting whether induction of labour will be successful.  The SOGC strongly recommends documentation of the Bishop Score prior to induction of labour (IOL).  A score of 7 or more is associated with successful IOL.

Data Definition: Interval of time from when the birthing person is fully dilated and begins to push. Automatically calculated based on the time fully dilated and the time started pushing.

Data Definition: Interval of time from when the birthing person started pushing to the time of birth. Automatically calculated based on the time started pushing and the time of birth.

Data Definition: Interval of time from when the birthing person is fully dilated to the time of birth. Automatically calculated based on the time fully dilated and the time of birth.

Data Definition: Conditions or complications in intrapartum period resulting in consultation with physician and/or transfer of care.

Data Definition: All conditions or complications in intrapartum period resulting in consultation with physician and/or transfer of care.

Data Definition: Indicates whether prenatal genetic screening was offered.

Data Definition: Indicates use of non-pharmacological methods, only for the management of labour pain. Pharmacological methods are found in the Pharmacologic Pain Management data element.

Data Definition: Medication(s) administered during the intrapartum period.

Data Definition: Estimated date of birth as per ultrasound or Nägele's rule.

Data Definition: Outcome of the pregnancy/birth, including live birth, stillbirth, termination, and loss. BORN encourages all hospitals to complete a Labour Birth encounter for all pregnancy losses.

Data Definition: Number of fetuses in the current pregnancy. For Prenatal Screening Follow Up encounters, this field refers to the number of fetuses that the prenatal screening result was based on.

Data Definition: Health conditions that are present before pregnancy. Select all that apply.

Data Definition: Health conditions that are present before pregnancy that are not already listed.

Data Definition: Height, measured in imperial or metric units. Reported in metric units.

Data Definition: Height is not known.

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Data Definition: Self-reported weight closest to conception and no later than 12 weeks of gestation (metric or imperial units).

Data Definition: Pre-pregnancy weight is not known.

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Data Definition: Pre-pregnancy Maternal Weight value entered by user through UI

Data Definition: Pre-pregnancy Body Mass Index (BMI) defined as weight in kilograms divided by the square of the height in metres (kg/m2). Auto-calculated.

Data Definition: Self-reported amount of smoking per day at time of first prenatal visit.

Data Definition: Resides with smoker at first prenatal visit.

Data Definition: Age of birthing person at time of live birth or stillbirth. Automatically calculated field.

Data Definition: Total number of previous pregnancies plus present pregnancy regardless of gestational age, type, time or method of termination/outcome. A pregnancy with twins/multiples is counted as one pregnancy.

Data Definition: Total number of previous pregnancies with birth occurring at greater than or equal to 37+0 weeks.

Data Definition: Total number of previous pregnancies with birth occurring between 20+0 and 36+6 weeks.

Data Definition: Total number of previous pregnancies resulting in a stillbirth. A stillbirth is defined as a product of conception weighing 500 grams or more or of 20+0 or more weeks’ gestation, which after being completely delivered shows no sign of life. Intentional terminations of pregnancy that meet either criterion are also classified as stillbirths in Ontario.

Data Definition: Total number of previous pregnancies resulting in a vaginal birth occurring at greater than or equal to 20+0 weeks gestation. Number excludes current pregnancy. Multiple gestations are counted as one birth event.

Data Definition: Total number of previous pregnancies resulting in a cesarean birth occurring at greater than or equal to 20+0 weeks gestation. Number excludes current pregnancy. Multiple gestations are counted as one birth event.

Data Definition: Total number of previous vaginal births after cesarean birth (VBAC).

Data Definition: Total number of spontaneous or therapeutic abortions occurring prior to 20+0 weeks. Spontaneous abortions include miscarriage, ectopic pregnancy, missed abortion, and molar pregnancy.

Data Definition: Indicates whether patient/client attended any prenatal education classes during the current pregnancy. This includes online education requiring registration or enrollment as well as in-person classes and does not include prenatal education provided by midwives/nurses/physicians during routine antenatal care visits.

Data Definition: Indicates prenatal visit with a regulated health care provider during the first trimester (<13+0 weeks) of the current pregnancy.

Data Definition: Indicates intention to feed infant human milk, regardless of the method of feeding. Includes intention to feed at the breast/chest, or provide expressed or donor milk. Self-reported during pregnancy or at time of birth.

Data Definition: Indicate any mental health concerns during this pregnancy including those pre-existing, diagnosed during pregnancy or active during pregnancy. Both diagnosed or self-reported.

Data Definition: Indicate all fetal surveillance methods that were used at anytime during this admission (including admission EFM strips)

Data Definition: The Admission to Birth Duration: Length of Stay in hospital (in hours and minutes) from Maternal Admission date/time to date/time of Birth. This is a calculated field.

Data Definition: Designation of the health care provider(s) (HCP) that provided antenatal care.

Data Definition: Enter the last documented patient/client weight in pregnancy.

Data Definition: Select if the patient/client declined weight checks at the end of pregnancy.

Data Definition: Maternal self-reported weight closest to the end of pregnancy.

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Data Definition: Maternal Weight value entered by user through UI

Data Definition: Calculated field of weight gain in pregnancy.

Data Definition: The date of maternal admission to hospital that results in the birth of her baby. Most often admission is inpatient but birth and transfer may occur without inpatient admission-may use ambulatory care admit time or ER triage time.

Data Definition: The time of maternal admission to hospital that results in the birth of her baby. Most often admission is inpatient but birth and transfer may occur without inpatient admission-may use ambulatory care admit time or ER triage time.

Data Definition: Indicates the type of labour as active labour (dilation greater than or equal to 4 cm) achieved without intervention(s) such as cervical ripening, amniotomy, oxytocin, misoprostol; induced in latent phase (dilation up to and including 3 cm); induced prior to contractions (cold induction); or, if there was no labour or latent phase only.

Data Definition: When entering Type of Birth in the maternal encounters in the event of multiple births, enter the highest intervention. On the child encounters, enter the actual Type of Birth for each infant.

Data Definition: Indicate presenting part of fetus during birthing process

Data Definition: Indicate the primary medical or non-medical reason for labour induction.

Data Definition: Indicate the primary medical or non-medical reason for cesarean section

Data Definition: Indication whether episiotomy was performed and type of incision.

Data Definition: Identify the health care provider who actually caught/delivered (had hands on) the baby. Select one. This field is entered by midwives and hospital staff so the language 'caught' refers to midwifery and 'delivered' refers to hospital settings. If the person who caught/delivered the baby is not a health care provider, select 'Unattended (None)'.

Data Definition: Location where client intends to give birth at the onset of labour. Note: for a scheduled cesarean section, select Hospital.

Data Definition: Maternal Disposition Date

Data Definition: Maternal Disposition Date In Labour

Data Definition: Maternal Disposition Time

Data Definition: Maternal Disposition Time In Labour

Data Definition: The time (24 hour clock) at complete cervical dilation (dilatation). If Time Fully Dilated (e.g. baby born on route to hospital) is unknown then estimate based on Time Started Pushing and Time of Birth. If Time Started Pushing is prior to Time Fully Dilated then Time Started Pushing=Time Fully Dilated.

Data Definition: The date (day, month, year) at complete cervical dilation (dilatation). To be completed with the Time Fully Dilated data element.

Data Definition: Date & Time Fully Dilated Not Provided

Data Definition: Time Fully Dilated Not Provided

Data Definition: The time (24 hour clock) when mother initiates pushing. If Time Started Pushing (e.g. baby born on route to hospital) is unknown then estimate based on Time of Birth. Time Started Pushing should not be before Time Fully Dilated but the encounter can be submitted if Time Started Pushing is up to 5 hours before.

Data Definition: The date (day, month, year) when mother initiates pushing. To be completed with Time Started pushing

Data Definition: Time Started Pushing Not Provided

Data Definition: Date and Time Started Pushing Is Known

Data Definition: Enter the result of Group B Strep Screening by vaginal/rectal swab in pregnancy. If there has been more than one swab, enter the most recent result.

Data Definition: Indication that mother was treated with antibiotics for Group B Streptococcus in the intrapartum period.

Data Definition: Indicate all intrapartum complications during this labour and birth.

Data Definition: All complications experienced during this pregnancy, except for hypertension or diabetes as these conditions are captured in separate data elements.

Data Definition: MW - EMS Attend Home in Birth or Immediate Postpartum.

Data Definition: MW - EMS Attend Home in Labour

Data Definition: Identification number of most responsible health care provider attending the birth. Unique ID may be entered for internal organization use only. This is an optional field that can be left blank. The code entered in this field may consist of letters, numbers, or a combination of both.

Data Definition: Indicate where care was provided to mother from time of birth to one hour post-birth (Labour-Birth Mother encounter) or one hour post-birth to time of discharge or transfer (Postpartum Mother encounter).

Data Definition: Maternal Outcome in Labour

Data Definition: Indicates instruments used to attempt and/or successfully assist a vaginal birth. Do not include if these instruments were used during a cesarean birth only.

Data Definition: Enter the date of Group B Strep Screening. If there has been more than one swab, enter the most recent date.

Data Definition: GBS Screening Date is Unknown FlagGBS Screening Date is Unknown Flag

Data Definition: Select the reason Group B Strep screening was not done.

Data Definition: Other Care Providers at time of labour and/or birth. Optional.

Data Definition: Other Care Providers at time of labour and/or birth - Comment

Data Definition: Indicates if VBAC was ever planned during this pregnancy.

Data Definition: Progesterone taken daily for spontaneous preterm birth prevention, any time after 16 weeks gestation. Does not include progesterone used only in first trimester.

Data Definition: ASA (aspirin) taken daily for preeclampsia prevention, any time after 12 weeks’ gestation (Do NOT include if aspirin is used only in first trimester)

Data Definition: Gestational Carrier: Person carrying embryo/fetus who will not be the intended parent of this child.

Data Definition: The date, if known, of a positive COVID-19 test during this pregnancy.

Data Definition: Indicates whether the person was admitted to hospital during this pregnancy specifically for respiratory or other issues related to COVID-19.

Data Definition: The ABO blood group and the presence (+) or absence (-) of the Rh factor of the pregnant individual.

Data Definition: Indicates whether the results of the antibody screen of the pregnant individual was positive or negative. A negative screen indicates that no atypical antibody was detected, and a positive screen indicates that an atypical antibody was detected.

Data Definition: Indicates if the pregnant individual has received an injection of Rh(D) Immunoglobulin during the current pregnancy and the number of doses they have received.

Data Definition: Indicates the date that the latest Rh(D) Immunoglobulin dose was given to the pregnant individual prior to birth.

Data Definition: Indicates that the date that the latest Rh(D) Immunoglobulin dose was given to the pregnant individual prior to birth is not known.

Data Definition: The cervical dilation (cm) of the initial internal examination performed (if applicable) when admitted to hospital for care during labour and birth.

Data Definition: Indicates all cervical ripening (mechanical and medical) and induction methods used, excluding oxytocin.

Data Definition: Indicates oxytocin administration to induce and/or augment labour, prior to birth.

Data Definition: The cervical dilation (cm) either immediately prior to, or if not examined immediately prior to, the last documented cervical dilation prior to the administration of oxytocin.

Data Definition: The date and time when oxytocin was administered for induction/augmentation of labour (does not include postpartum oxytocin administration).

Data Definition: The date and time when oxytocin was administered for induction/augmentation of labour (does not include postpartum oxytocin administration) is not known.

Data Definition: Indicates the type of rupture of fetal membranes, 'breaking of the bag of waters', as either spontaneous (SROM), occurring without intervention, or artificial (AROM, ARM), occurring with intervention by amniotomy.

Data Definition: Date and time the fetal membranes ruptured (breaking of the 'bag of waters') either spontaneously (SROM) or artificially, known as artificial rupture of membranes (AROM, ARM)

Data Definition: Date and time the fetal membranes ruptured (breaking of the 'bag of waters'), either spontaneously (SROM) or artificially, known as artificial rupture of membranes (AROM, ARM) is not known.

Data Definition: Indicates onset of latent phase of labour, defined as a period of time (not necessarily continuous) where there are painful contractions and some cervical change, including cervical effacement and dilation up and including 3 cm.

Data Definition: Indicates that the onset of latent phase of labour, defined as a period of time (not necessarily continuous) where there are painful contractions and some cervical change, including cervical effacement and dilation up and including 3 cm, is not known.

Data Definition: Active labour is the presence of regular contractions leading to cervical effacement and dilatation at 4 cm or greater in a nulliparous person, or 4 to 5 cm dilatation in a multiparous person.

Data Definition: TBD

Data Definition: Date and time placenta was delivered. If not known, select "Unknown".

Data Definition: Date of time placenta was delivered is not known.

Data Definition: Method of conception for this pregnancy; indicates if reproductive assistance was required to achieve current pregnancy

Data Definition: Cannabis use during this pregnancy, expressed as the frequency of use (not dose or route).

Data Definition: Indicates all types of tears that occurred during the birthing process and the highest degree of perineal tear, if applicable. Select all that apply.

Data Definition: Indicate all barriers to maternal transfer. Barriers to Maternal Transfer is a conditional field that is only visible and required when a baby is born with a low GA at birth at a hospital with a lower Level of Care (LOC) and does not transfer to a higher level of care hospital: Level I < 36 + 0 weeks Level IIa < 34 + 0 weeks Level IIb < 32 + 0 weeks Level IIc < 30 + 0 weeks Level III (Not applicable)

Data Definition: Indicates vaginal or cesarean birth.

Data Definition: If cesarean section decision made in first stage of labour, measurement of cervical dilation (dilatation) during active labour in centimetres. Measurement taken just prior to decision for cesarean section is made.

Data Definition: Indicate if cesarean section was planned (as scheduled), planned (not as scheduled), or unplanned.

Data Definition: Indication that corticosteroid medication was administered between 24-34 weeks gestation to mother at risk of preterm birth

Data Definition: Indicates if the prenatal RSV vaccine was administered during this pregnancy.

Data Definition: The date when the prenatal RSV vaccine was administered during this pregnancy.

Data Definition: The date of the prenatal RSV vaccine is not known.

Data Definition: Product name of the prenatal RSV product that was given during this pregnancy.

Data Definition: Product name of the prenatal RSV product that was given during this pregnancy.

Data Definition: The provider number of the midwifery care coordinator. This can be the same or a different provider number as that selected as the billing midwife.

Data Definition: The provider number of the Primary Attending Midwife at the birth. Leave blank if no Midwife attended the labour, birth or immediate postpartum.

Data Definition: The provider number of the Second Midwife at the labour, birth or immediate postpartum. Leave blank if no Second Midwife attended. This number must be different than the provider number of the Primary Attending Midwife.

Data Definition: If no Second Midwife, indication of type of second attendant at birth.

Data Definition: Indication of whether a midwife attended the birth.

Data Definition: Birth order of each baby (Twin A= first born, Twin B=second born), irrespective of live birth or stillbirth.

Data Definition: Indicates that care was provided to this client by another Ontario Midwifery Practice Group.

Data Definition: MW - Intrapartum Transfer of Care

Data Definition: MW - Discharge from Midwifery care during intrapartum/immediate Postpartum

Data Definition: Client OHIP coverage.

Data Definition: For each transfer from midwifery care, indication of whether care was returned in the intrapartum period.

Data Definition: Total number of midwives providing care, determined at time of discharge from midwifery care.

Data Definition: The calendar date of the last midwife visit provided to the client prior to discharge from midwifery care.

Data Definition: Indicates if there were there any consults, transfers of care, or use of hospital/outpatient/emergency services during that period.

Data Definition: Other maternal condition or complication

Data Definition: Comments about the reason for the consult, transfer of care or the use of hospital/outpatient/emergency services.

Data Definition: MW - Maternal Transport to Hospital Flag in Birth or Immediate Postpartum.

Data Definition: MW - Maternal Transport to Hospital Flag

Data Definition: MW - Reason(s) for Transport in Birth or Immediate Postpartum.

Data Definition: MW - Reason(s) for Transport Prior to Birth

Data Definition: MW - Primary Reason for Transport Prior to Birth in Birth or Immediate PostPartum

Data Definition: MW - Primary Reason for Transport Prior to Birth

Data Definition: Indicates if Emergency Medical Services (EMS) was required for transport to hospital during intrapartum or immediately postpartum.

Data Definition: Indicates if Emergency Medical Services (EMS) was required for transport to hospital prior to birth.

Data Definition: Any barrier to Emergency Medical Services (EMS) transport intrapartum or immediately postpartum.

Data Definition: Any barrier to Emergency Medical Services (EMS) transport during labour.

Data Definition: Select "yes" if midwife attended to the client at home, at any point in labour.

Data Definition: Indicates if there was there a known midwife or midwifery student at the birth.

Data Definition: Birth Centre where labour occurred

Data Definition: Components of third stage management employed: (unrelated to corrective measures for bleeding)

Data Definition: Was the baby born in water

Data Definition: Maternal Position at Time of Birth

Data Definition: Was this a planned water birth?

Data Definition: Prior to birth, when was the maternal transport to hospital? (First Stage or Second Stage)

Data Definition: Indication of whether there was a consultation with a physician for each listed Maternal condition or complication in the intrapartum period.

Data Definition: Select all places where midwifery client laboured

Data Definition: Client discharged from midwifery care prior to giving birth flag.

Data Definition: There are multiple reasons why a midwife may choose to transfer care, including midwifery judgement, scope of practice limitations as defined by the midwifery regulatory body, and hospital/physician protocol. Was this consultation/transfer of care ONLY because of hospital/physician protocol?

Data Definition: There are multiple reasons why a midwife may choose to consult, including midwifery judgement, scope of practice limitations as defined by the midwifery regulatory body, and hospital/physician protocol. Was this consultation/transfer of care ONLY because of hospital/physician protocol?

Data Definition: Enter the date/time that the first midwife arrived at the home (or clinic) to attend labour and birth

Data Definition: Date and time of midwife’s arrival to home to attend labour and birth is Uknown

Data Definition: Enter the date/time that the last midwife who attended the birth departed from the home following birth

Data Definition: Date and time of midwife’s departure from the home following birth is Unknown

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Data Definition: Infant date of birth (day/month/year).

Data Definition: Location where the birth occurred (hospital, home, other, etc.).

Data Definition: Time when infant is born (24 hour clock).

Data Definition: Infant's gestational age at the time of birth calculated using "Estimated Date of Birth" and "Newborn Date of Birth" data elements in weeks and days.

Data Definition: For hospital births, indication of whether newborn was discharged with mother.

Data Definition: The midwife's billing number for this course of care.

Data Definition: Method by which the estimated date of birth was determined for prenatal screening

Data Definition: Indicates the number of deliveries (including live births and stillbirths) where pregnancies reached viable gestational age (minimum 20 weeks). When completed postnatally, parity includes current birth for HBHC

Data Definition: Name of Hospital Site.

Data Definition: Fetal ID of a multiple pregnancy

Data Definition: Birth order of each baby (Twin A= first born, Twin B=second born, etc.) irrespective of live birth or stillbirth.

Data Definition: Name of Midwifery Practice Group

Data Definition: Indicates the primary Reason for maternal transfer (From)

Data Definition: Reason for maternal transfer (To) (In Birth)

Data Definition: Reason for maternal transfer (To) in Labour

Data Definition: The name of the hospital where the birth occurred if Birth Location =hospital. Includes all Ontario hospitals with and without birthing units and some out of province and out of country hospitals.