WHO Antenatal Care Guideline Implementation Guide
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WHO Antenatal Care Guideline Implementation Guide, published by World Health Organization (WHO). This guide is not an authorized publication; it is the continuous build for version 0.3.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/WorldHealthOrganization/smart-anc/ and changes regularly. See the Directory of published versions

: ANC.DT.06 Physical symptoms and exam results requiring referral - JSON Representation

Active as of 2021-06-11

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{
  "resourceType" : "PlanDefinition",
  "id" : "ANCDT06",
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n    <table class=\"grid dict\">\n        \n        <tr>\n            <th scope=\"row\"><b>Id: </b></th>\n            <td style=\"padding-left: 4px;\">ANCDT06</td>\n        </tr>\n        \n        \n        <tr>\n            <th scope=\"row\"><b>Url: </b></th>\n            <td style=\"padding-left: 4px;\"><a href=\"PlanDefinition-ANCDT06.html\">ANC.DT.06 Physical symptoms and exam results requiring referral</a></td>\n        </tr>\n        \n        \n        <tr>\n            <th scope=\"row\"><b>Version: </b></th>\n            <td style=\"padding-left: 4px;\">0.3.0</td>\n        </tr>\n        \n        \n        <tr>\n            <th scope=\"row\"><b>Identifier: </b></th>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                <p style=\"margin-bottom: 5px;\">\n                    <b>value: </b> <span>ANC.DT.06</span>\n                </p>\n                \n            </td>\n        </tr>\n        \n        \n        <tr>\n            <th scope=\"row\"><b>Name: </b></th>\n            <td style=\"padding-left: 4px;\">ANCDT06</td>\n        </tr>\n        \n        \n        <tr>\n            <th scope=\"row\"><b>Title: </b></th>\n            <td style=\"padding-left: 4px;\">ANC.DT.06 Physical symptoms and exam results requiring referral</td>\n        </tr>\n        \n        \n        \n        <tr>\n            <th scope=\"row\"><b>Status: </b></th>\n            <td style=\"padding-left: 4px;\">active</td>\n        </tr>\n        \n        \n        <tr>\n            <th scope=\"row\"><b>Experimental: </b></th>\n            <td style=\"padding-left: 4px;\">false</td>\n        </tr>\n        \n        \n        <tr>\n            <th scope=\"row\"><b>Type: </b></th>\n            <td style=\"padding-left: 4px;\">\n                \n                    \n                        \n                        <p style=\"margin-bottom: 5px;\">\n                            <b>system: </b> <span><a href=\"http://terminology.hl7.org/5.5.0/CodeSystem-plan-definition-type.html\">PlanDefinitionType</a></span>\n                        </p>\n                        \n                        \n                        <p style=\"margin-bottom: 5px;\">\n                            <b>code: </b> <span>eca-rule</span>\n                        </p>\n                        \n                        \n                    \n                \n                \n            </td>\n        </tr>\n        \n        \n        \n        <tr>\n            <th scope=\"row\"><b>Date: </b></th>\n            <td style=\"padding-left: 4px;\">2021-06-11 22:32:40-0600</td>\n        </tr>\n        \n        \n        <tr>\n            <th scope=\"row\"><b>Publisher: </b></th>\n            <td style=\"padding-left: 4px;\">World Health Organization (WHO)</td>\n        </tr>\n        \n        \n        <tr>\n            <th scope=\"row\"><b>Description: </b></th>\n            <td style=\"padding-left: 4px;\">If the woman has any of the following physical exam results, refer to the hospital</td>\n        </tr>\n        \n        \n        \n        \n        <tr>\n            <th scope=\"row\"><b>Use Context: </b></th>\n            <td style=\"padding-left: 4px;\">\n                <table class=\"grid-dict\">\n                    <tr><th><b>code</b></th><th><b>value</b></th><th><b>display</b></th></tr>\n                    \n                      <tr>\n                        <td>task</td>\n                        <td>ANC.B8.</td>\n                        <td>Conduct physical exam</td>\n                      </tr>\n                    \n                </table>\n            </td>\n        </tr>\n        \n        \n        <tr>\n            <th scope=\"row\"><b>Jurisdiction: </b></th>\n            <td style=\"padding-left: 4px;\">001</td>\n        </tr>\n        \n        \n        \n        \n        \n        \n        \n        \n\n        \n        <tr>\n          <th scope=\"row\"><b>Libraries: </b></th>\n          <td style=\"padding-left: 4px;\">\n            <table class=\"grid-dict\">\n              \n                <tr><td><a href=\"Library-ANCDT06.html\">ANC.DT.06 Physical symptoms and exam results requiring referral</a></td></tr>\n              \n            </table>\n          </td>\n        </tr>\n        \n\n        \n        <tr>\n          <th scope=\"row\"><b>Actions: </b></th>\n          <td style=\"padding-left: 4px;\">\n            <table class=\"grid-dict\">\n              \n                <tr>\n                  <td>\n                    <b> ANC.DT.06 Physical symptoms and exam results requiring referral:</b> <br/>\n                    <b>When:</b> <i>named-event:</i> ANC.B8. Conduct physical exam<br/>\n                    \n                    \n                      <b>Then:</b>\n                      <table class=\"grid-dict\">\n                        \n                          <tr>\n                            <td>\n                              Woman has a fever – provide treatment and refer urgently to hospital!\nProcedure:\n– Insert an IV line\n– Give fluids slowly<br/>\n                              \n                              <b>If:</b> <i>applicability:</i> (&amp;quot;Body temperature&amp;quot; ≥ 38°C)\n  AND (&amp;quot;Second body temperature&amp;quot; ≥ 38°C) <i>(Should Conduct further investigation and, if necessary, refer urgently if treatment not available at your facility )</i><br/>\n                              \n                                \n                              \n                            </td>\n                          </tr>\n                        \n                          <tr>\n                            <td>\n                              Abnormal pulse rate – refer for further investigation\nProcedure:\n– Check for fever, infection, respiratory distress, arrhythmia\n– Refer for further investigation<br/>\n                              \n                              <b>If:</b> <i>applicability:</i> 60 bpm &amp;gt; &amp;quot;Second pulse rate&amp;quot; &amp;gt; 100 bpm <i>(Should Refer to a hospital)</i><br/>\n                              \n                                \n                              \n                            </td>\n                          </tr>\n                        \n                          <tr>\n                            <td>\n                              Woman has respiratory distress – refer urgently to the hospital!<br/>\n                              \n                              <b>If:</b> <i>applicability:</i> ((((((&amp;quot;Respiratory exam result&amp;quot; = &amp;quot;Dyspnoea&amp;quot;)\n  OR (&amp;quot;Respiratory exam result&amp;quot; = &amp;quot;Cough&amp;quot;))\n  OR (&amp;quot;Respiratory exam result&amp;quot; = &amp;quot;Rapid breathing&amp;quot;))\n  OR (&amp;quot;Respiratory exam result&amp;quot; = &amp;quot;Slow breathing&amp;quot;))\n  OR (&amp;quot;Respiratory exam result&amp;quot; = &amp;quot;Wheezing&amp;quot;))\n  OR (&amp;quot;Respiratory exam result&amp;quot; = &amp;quot;Rales&amp;quot;))\n  OR (&amp;quot;Respiratory exam result&amp;quot; = &amp;quot;Other abnormal respiratory exam result (specify)&amp;quot;) <i>(Should Refer urgently to a hospital)</i><br/>\n                              \n                                \n                              \n                            </td>\n                          </tr>\n                        \n                          <tr>\n                            <td>\n                              Woman has low oximetry (&amp;lt;92%) – she should be referred urgently to the hospital<br/>\n                              \n                              <b>If:</b> <i>applicability:</i> &amp;quot;Oximetry&amp;quot; &amp;lt; 92% <i>(Should Refer urgently to a hospital 2)</i><br/>\n                              \n                                \n                              \n                            </td>\n                          </tr>\n                        \n                          <tr>\n                            <td>\n                              Woman's cardiac condition is abnormal and she should be referred urgently to the hospital<br/>\n                              \n                              <b>If:</b> <i>applicability:</i> (((((((&amp;quot;Cardiac exam result&amp;quot; = &amp;quot;Heart murmur&amp;quot;)\n  OR (&amp;quot;Cardiac exam result&amp;quot; = &amp;quot;Weak pulse&amp;quot;))\n  OR (&amp;quot;Cardiac exam result&amp;quot; = &amp;quot;Tachycardia&amp;quot;))\n  OR (&amp;quot;Cardiac exam result&amp;quot; = &amp;quot;Bradycardia&amp;quot;))\n  OR (&amp;quot;Cardiac exam result&amp;quot; = &amp;quot;Arrhythmia&amp;quot;))\n  OR (&amp;quot;Cardiac exam result&amp;quot; = &amp;quot;Cyanosis&amp;quot;))\n  OR (&amp;quot;Cardiac exam result&amp;quot; = &amp;quot;Cold sweats&amp;quot;))\n  OR (&amp;quot;Cardiac exam result&amp;quot; = &amp;quot;Other abnormal cardiac exam result (specify)&amp;quot;) <i>(Should Refer urgently to a hospital 3)</i><br/>\n                              \n                                \n                              \n                            </td>\n                          </tr>\n                        \n                          <tr>\n                            <td>\n                              Woman's breast exam was abnormal and she should be referred to hospital for further investigation<br/>\n                              \n                              <b>If:</b> <i>applicability:</i> ((((((&amp;quot;Breast exam result&amp;quot; = &amp;quot;Nodule&amp;quot;)\n  OR (&amp;quot;Breast exam result&amp;quot; = &amp;quot;Discharge&amp;quot;))\n  OR (&amp;quot;Breast exam result&amp;quot; = &amp;quot;Flushing&amp;quot;))\n  OR (&amp;quot;Breast exam result&amp;quot; = &amp;quot;Local pain&amp;quot;))\n  OR (&amp;quot;Breast exam result&amp;quot; = &amp;quot;Bleeding&amp;quot;))\n  OR (&amp;quot;Breast exam result&amp;quot; = &amp;quot;Increased temperature&amp;quot;))\n  OR (&amp;quot;Breast exam result&amp;quot; = &amp;quot;Other breast exam result (specify)&amp;quot;) <i>(Should Conduct further investigation and, if necessary, refer urgently to a hospital)</i><br/>\n                              \n                                \n                              \n                            </td>\n                          </tr>\n                        \n                          <tr>\n                            <td>\n                              Woman's abdominal exam was abnormal and she should be referred or further evaluated<br/>\n                              \n                              <b>If:</b> <i>applicability:</i> (((((((((((((((((&amp;quot;Abdominal exam result&amp;quot; = &amp;quot;Mass/tumour&amp;quot;)\n  OR (&amp;quot;Abdominal exam result&amp;quot; = &amp;quot;Pain on superficial palpation&amp;quot;))\n  OR (&amp;quot;Abdominal exam result&amp;quot; = &amp;quot;Pain on deep palpation&amp;quot;))\n  OR (&amp;quot;Abdominal exam result&amp;quot; = &amp;quot;Painful decompression&amp;quot;))\n  OR (&amp;quot;Abdominal exam result&amp;quot; = &amp;quot;Other abnormal abdominal exam result (specify)&amp;quot;))\n  OR (&amp;quot;Pelvic exam result (visual)&amp;quot; = &amp;quot;Abnormal vaginal discharge&amp;quot;))\n  OR (&amp;quot;Pelvic exam result (visual)&amp;quot; = &amp;quot;Evidence of amniotic fluid&amp;quot;))\n  OR (&amp;quot;Pelvic exam result (visual)&amp;quot; = &amp;quot;Foul-smelling vaginal discharge&amp;quot;))\n  OR (&amp;quot;Pelvic exam result (visual)&amp;quot; = &amp;quot;Clusters of erythematous papules&amp;quot;))\n  OR (&amp;quot;Pelvic exam result (visual)&amp;quot; = &amp;quot;Vesicles&amp;quot;))\n  OR (&amp;quot;Pelvic exam result (visual)&amp;quot; = &amp;quot;Genital ulcer&amp;quot;))\n  OR (&amp;quot;Pelvic exam result (visual)&amp;quot; = &amp;quot;Genital pain&amp;quot;))\n  OR (&amp;quot;Pelvic exam result (visual)&amp;quot; = &amp;quot;Tender bilateral inguinal and femoral lymphadenopathy&amp;quot;))\n  OR (&amp;quot;Pelvic exam result (visual)&amp;quot; = &amp;quot;Cervical friability&amp;quot;))\n  OR (&amp;quot;Pelvic exam result (visual)&amp;quot; = &amp;quot;Mucopurulent cervicitis&amp;quot;))\n  OR (&amp;quot;Pelvic exam result (visual)&amp;quot; = &amp;quot;Tender unilateral lymphadenopathy&amp;quot;))\n  OR (&amp;quot;Pelvic exam result (visual)&amp;quot; = &amp;quot;Curd-like vaginal discharge&amp;quot;))\n  OR (&amp;quot;Pelvic exam result (visual)&amp;quot; = &amp;quot;Other abnormal pelvic exam (visual) result (specify)&amp;quot;) <i>(Should Refer to a hospital 2)</i><br/>\n                              \n                                \n                              \n                            </td>\n                          </tr>\n                        \n                          <tr>\n                            <td>\n                              Woman should be referred urgently if there is evidence of amniotic fluid, which could indicate the start of labour<br/>\n                              \n                              <b>If:</b> <i>applicability:</i> (&amp;quot;Pelvic exam result (visual)&amp;quot; = &amp;quot;Evidence of amniotic fluid&amp;quot;)\n  AND (&amp;quot;Gestational age&amp;quot; &amp;lt; 37 weeks) <i>(Should Refer urgently to a hospital 4)</i><br/>\n                              \n                                \n                              \n                            </td>\n                          </tr>\n                        \n                          <tr>\n                            <td>\n                              If no fetal heartbeat is observed, inform the woman that there might be a problem and that she needs to be referred to the hospital for further examination and next steps.\n\nProcedure:\n– Inform the woman that you cannot find the heartbeat and need to refer her to check if there's a problem\n– Refer to hospital<br/>\n                              \n                              <b>If:</b> <i>applicability:</i> (&amp;quot;Fetal heartbeat present&amp;quot; = FALSE)\n  AND (&amp;quot;Gestational age&amp;quot; ≥ 20 weeks) <i>(Should Refer to a hospital 3)</i><br/>\n                              \n                                \n                              \n                            </td>\n                          </tr>\n                        \n                          <tr>\n                            <td>\n                              Fetal heart rate is abnormal after two readings: the woman should be referred to hospital<br/>\n                              \n                              <b>If:</b> <i>applicability:</i> (100 bpm &amp;gt; &amp;quot;Second fetal heart rate&amp;quot; &amp;gt; 180 bpm)\n  AND (&amp;quot;Gestational age&amp;quot; ≥ 20 weeks) <i>(Should Refer to a hospital 4)</i><br/>\n                              \n                                \n                              \n                            </td>\n                          </tr>\n                        \n                      </table>\n                    \n                  </td>\n                </tr>\n              \n            </table>\n          </td>\n        </tr>\n        \n    </table>\n</div>"
  },
  "url" : "http://fhir.org/guides/who/anc-cds/PlanDefinition/ANCDT06",
  "identifier" : [
    {
      "use" : "official",
      "value" : "ANC.DT.06"
    }
  ],
  "version" : "0.3.0",
  "name" : "ANCDT06",
  "title" : "ANC.DT.06 Physical symptoms and exam results requiring referral",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/plan-definition-type",
        "code" : "eca-rule"
      }
    ]
  },
  "status" : "active",
  "experimental" : false,
  "date" : "2021-06-11T22:32:40-06:00",
  "publisher" : "World Health Organization (WHO)",
  "contact" : [
    {
      "telecom" : [
        {
          "system" : "url",
          "value" : "https://www.who.int"
        }
      ]
    }
  ],
  "description" : "If the woman has any of the following physical exam results, refer to the hospital",
  "useContext" : [
    {
      "code" : {
        "system" : "http://terminology.hl7.org/CodeSystem/usage-context-type",
        "code" : "task",
        "display" : "Workflow Task"
      },
      "valueCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://fhir.org/guides/who/anc-cds/CodeSystem/activity-codes",
            "code" : "ANC.B8.",
            "display" : "Conduct physical exam"
          }
        ]
      }
    }
  ],
  "jurisdiction" : [
    {
      "coding" : [
        {
          "system" : "http://unstats.un.org/unsd/methods/m49/m49.htm",
          "code" : "001"
        }
      ]
    }
  ],
  "library" : [
    🔗 "http://fhir.org/guides/who/anc-cds/Library/ANCDT06"
  ],
  "action" : [
    {
      "title" : "ANC.DT.06 Physical symptoms and exam results requiring referral",
      "trigger" : [
        {
          "type" : "named-event",
          "name" : "ANC.B8. Conduct physical exam"
        }
      ],
      "action" : [
        {
          "id" : "1",
          "title" : "Conduct further investigation and, if necessary, refer urgently if treatment not available at your facility ",
          "description" : "Conduct further investigation and, if necessary, refer urgently if treatment not available at your facility ",
          "textEquivalent" : "Woman has a fever – provide treatment and refer urgently to hospital!\nProcedure:\n– Insert an IV line\n– Give fluids slowly",
          "documentation" : [
            {
              "type" : "citation",
              "label" : "Managing complications guide (IMPAC) (2017): Section S-113 (5)"
            }
          ],
          "condition" : [
            {
              "kind" : "applicability",
              "expression" : {
                "description" : "(\"Body temperature\" ≥ 38°C)\n  AND (\"Second body temperature\" ≥ 38°C)",
                "language" : "text/cql-identifier",
                "expression" : "Should Conduct further investigation and, if necessary, refer urgently if treatment not available at your facility "
              }
            }
          ]
        },
        {
          "id" : "2",
          "title" : "Refer to a hospital",
          "description" : "Refer to a hospital",
          "textEquivalent" : "Abnormal pulse rate – refer for further investigation\nProcedure:\n– Check for fever, infection, respiratory distress, arrhythmia\n– Refer for further investigation",
          "documentation" : [
            {
              "type" : "citation",
              "label" : "Managing complications guide (IMPAC) (2017): Section S-1 (5)"
            }
          ],
          "condition" : [
            {
              "kind" : "applicability",
              "expression" : {
                "description" : "60 bpm > \"Second pulse rate\" > 100 bpm",
                "language" : "text/cql-identifier",
                "expression" : "Should Refer to a hospital"
              }
            }
          ]
        },
        {
          "id" : "3",
          "title" : "Refer urgently to a hospital",
          "description" : "Refer urgently to a hospital",
          "textEquivalent" : "Woman has respiratory distress – refer urgently to the hospital!",
          "documentation" : [
            {
              "type" : "citation",
              "label" : "Managing complications in pregnancy and childbirth guide (IMPAC) (2017): Section S-149 (5)"
            }
          ],
          "condition" : [
            {
              "kind" : "applicability",
              "expression" : {
                "description" : "((((((\"Respiratory exam result\" = \"Dyspnoea\")\n  OR (\"Respiratory exam result\" = \"Cough\"))\n  OR (\"Respiratory exam result\" = \"Rapid breathing\"))\n  OR (\"Respiratory exam result\" = \"Slow breathing\"))\n  OR (\"Respiratory exam result\" = \"Wheezing\"))\n  OR (\"Respiratory exam result\" = \"Rales\"))\n  OR (\"Respiratory exam result\" = \"Other abnormal respiratory exam result (specify)\")",
                "language" : "text/cql-identifier",
                "expression" : "Should Refer urgently to a hospital"
              }
            }
          ]
        },
        {
          "id" : "4",
          "title" : "Refer urgently to a hospital",
          "description" : "Refer urgently to a hospital 2",
          "textEquivalent" : "Woman has low oximetry (<92%) – she should be referred urgently to the hospital",
          "documentation" : [
            {
              "type" : "citation",
              "label" : "Managing complications in pregnancy and childbirth guide (IMPAC) (2017): Section S-58 (5)"
            }
          ],
          "condition" : [
            {
              "kind" : "applicability",
              "expression" : {
                "description" : "\"Oximetry\" < 92%",
                "language" : "text/cql-identifier",
                "expression" : "Should Refer urgently to a hospital 2"
              }
            }
          ]
        },
        {
          "id" : "5",
          "title" : "Refer urgently to a hospital",
          "description" : "Refer urgently to a hospital 3",
          "textEquivalent" : "Woman's cardiac condition is abnormal and she should be referred urgently to the hospital",
          "documentation" : [
            {
              "type" : "citation",
              "label" : "Managing complications in pregnancy and childbirth guide (IMPAC) (2017): Section S-150 (5)"
            }
          ],
          "condition" : [
            {
              "kind" : "applicability",
              "expression" : {
                "description" : "(((((((\"Cardiac exam result\" = \"Heart murmur\")\n  OR (\"Cardiac exam result\" = \"Weak pulse\"))\n  OR (\"Cardiac exam result\" = \"Tachycardia\"))\n  OR (\"Cardiac exam result\" = \"Bradycardia\"))\n  OR (\"Cardiac exam result\" = \"Arrhythmia\"))\n  OR (\"Cardiac exam result\" = \"Cyanosis\"))\n  OR (\"Cardiac exam result\" = \"Cold sweats\"))\n  OR (\"Cardiac exam result\" = \"Other abnormal cardiac exam result (specify)\")",
                "language" : "text/cql-identifier",
                "expression" : "Should Refer urgently to a hospital 3"
              }
            }
          ]
        },
        {
          "id" : "6",
          "title" : "Conduct further investigation and, if necessary, refer urgently to a hospital",
          "description" : "Conduct further investigation and, if necessary, refer urgently to a hospital",
          "textEquivalent" : "Woman's breast exam was abnormal and she should be referred to hospital for further investigation",
          "documentation" : [
            {
              "type" : "citation"
            }
          ],
          "condition" : [
            {
              "kind" : "applicability",
              "expression" : {
                "description" : "((((((\"Breast exam result\" = \"Nodule\")\n  OR (\"Breast exam result\" = \"Discharge\"))\n  OR (\"Breast exam result\" = \"Flushing\"))\n  OR (\"Breast exam result\" = \"Local pain\"))\n  OR (\"Breast exam result\" = \"Bleeding\"))\n  OR (\"Breast exam result\" = \"Increased temperature\"))\n  OR (\"Breast exam result\" = \"Other breast exam result (specify)\")",
                "language" : "text/cql-identifier",
                "expression" : "Should Conduct further investigation and, if necessary, refer urgently to a hospital"
              }
            }
          ]
        },
        {
          "id" : "7",
          "title" : "Refer to a hospital",
          "description" : "Refer to a hospital 2",
          "textEquivalent" : "Woman's abdominal exam was abnormal and she should be referred or further evaluated",
          "documentation" : [
            {
              "type" : "citation",
              "label" : "WHO ANC recommendations (2016): B2.2 (2)\nManaging complications in pregnancy and childbirth guide (IMPAC) (2017): Section S-139 (5)"
            }
          ],
          "condition" : [
            {
              "kind" : "applicability",
              "expression" : {
                "description" : "(((((((((((((((((\"Abdominal exam result\" = \"Mass/tumour\")\n  OR (\"Abdominal exam result\" = \"Pain on superficial palpation\"))\n  OR (\"Abdominal exam result\" = \"Pain on deep palpation\"))\n  OR (\"Abdominal exam result\" = \"Painful decompression\"))\n  OR (\"Abdominal exam result\" = \"Other abnormal abdominal exam result (specify)\"))\n  OR (\"Pelvic exam result (visual)\" = \"Abnormal vaginal discharge\"))\n  OR (\"Pelvic exam result (visual)\" = \"Evidence of amniotic fluid\"))\n  OR (\"Pelvic exam result (visual)\" = \"Foul-smelling vaginal discharge\"))\n  OR (\"Pelvic exam result (visual)\" = \"Clusters of erythematous papules\"))\n  OR (\"Pelvic exam result (visual)\" = \"Vesicles\"))\n  OR (\"Pelvic exam result (visual)\" = \"Genital ulcer\"))\n  OR (\"Pelvic exam result (visual)\" = \"Genital pain\"))\n  OR (\"Pelvic exam result (visual)\" = \"Tender bilateral inguinal and femoral lymphadenopathy\"))\n  OR (\"Pelvic exam result (visual)\" = \"Cervical friability\"))\n  OR (\"Pelvic exam result (visual)\" = \"Mucopurulent cervicitis\"))\n  OR (\"Pelvic exam result (visual)\" = \"Tender unilateral lymphadenopathy\"))\n  OR (\"Pelvic exam result (visual)\" = \"Curd-like vaginal discharge\"))\n  OR (\"Pelvic exam result (visual)\" = \"Other abnormal pelvic exam (visual) result (specify)\")",
                "language" : "text/cql-identifier",
                "expression" : "Should Refer to a hospital 2"
              }
            }
          ]
        },
        {
          "id" : "8",
          "title" : "Refer urgently to a hospital",
          "description" : "Refer urgently to a hospital 4",
          "textEquivalent" : "Woman should be referred urgently if there is evidence of amniotic fluid, which could indicate the start of labour",
          "documentation" : [
            {
              "type" : "citation",
              "label" : "Managing complications in pregnancy and childbirth guide (IMPAC) (2017): Sections S-51, C-91 (5)"
            }
          ],
          "condition" : [
            {
              "kind" : "applicability",
              "expression" : {
                "description" : "(\"Pelvic exam result (visual)\" = \"Evidence of amniotic fluid\")\n  AND (\"Gestational age\" < 37 weeks)",
                "language" : "text/cql-identifier",
                "expression" : "Should Refer urgently to a hospital 4"
              }
            }
          ]
        },
        {
          "id" : "9",
          "title" : "Refer to a hospital",
          "description" : "Refer to a hospital 3",
          "textEquivalent" : "If no fetal heartbeat is observed, inform the woman that there might be a problem and that she needs to be referred to the hospital for further examination and next steps.\n\nProcedure:\n– Inform the woman that you cannot find the heartbeat and need to refer her to check if there's a problem\n– Refer to hospital",
          "documentation" : [
            {
              "type" : "citation",
              "label" : "Pregnancy, childbirth, postpartum and newborn care guide (IMPAC) (2015): C7 (1)"
            }
          ],
          "condition" : [
            {
              "kind" : "applicability",
              "expression" : {
                "description" : "(\"Fetal heartbeat present\" = FALSE)\n  AND (\"Gestational age\" ≥ 20 weeks)",
                "language" : "text/cql-identifier",
                "expression" : "Should Refer to a hospital 3"
              }
            }
          ]
        },
        {
          "id" : "10",
          "title" : "Refer to a hospital",
          "description" : "Refer to a hospital 4",
          "textEquivalent" : "Fetal heart rate is abnormal after two readings: the woman should be referred to hospital",
          "documentation" : [
            {
              "type" : "citation",
              "label" : "Pregnancy, childbirth, postpartum and newborn care guide (IMPAC) (2015): C7 (1)"
            }
          ],
          "condition" : [
            {
              "kind" : "applicability",
              "expression" : {
                "description" : "(100 bpm > \"Second fetal heart rate\" > 180 bpm)\n  AND (\"Gestational age\" ≥ 20 weeks)",
                "language" : "text/cql-identifier",
                "expression" : "Should Refer to a hospital 4"
              }
            }
          ]
        }
      ]
    }
  ]
}