AI scribe and clinic software for obstetrics and private antenatal care

The antenatal record has a fixed order

NICE sets the frame. It recommends a first booking appointment with a midwife by 10+0 weeks of pregnancy, 10 routine antenatal appointments for a woman expecting her first baby and 7 for a woman who has given birth before.¹ At booking it asks for the medical, obstetric and family history, previous or current mental health concerns and the woman's social situation.¹ A private obstetric practice adds its own consultant visits to that schedule, so the same history is read many times. wai drafts the booking note in that order and carries it forward, so each later visit opens with a sourced brief of the pregnancy so far.

Screening and scans sit in fixed windows. The NHS fetal anomaly screening programme offers the combined test in the first trimester and the mid-pregnancy scan between 18+0 and 20+6 weeks, which can be completed up to 23+0 weeks.² NICE offers a 75 g 2-hour glucose tolerance test at 24 to 28 weeks to women with risk factors for gestational diabetes, and diagnoses it at a fasting plasma glucose of 5.6 mmol/litre or above or a 2-hour level of 7.8 mmol/litre or above.³ Women at high risk of pre-eclampsia are advised to take 75 mg to 150 mg of aspirin daily from 12 weeks until the birth.⁴ Each of those numbers belongs in a template field, and the draft fills it from what the obstetrician said.

Codes come from the note. wai suggests ICD-10 and SNOMED CT codes, each shown beside the line of the consultation it rests on, for the obstetrician to confirm. Typical WHO ICD-10 codes in a private antenatal clinic, as used in the UK and the Gulf, are Z34.0 for supervision of a normal first pregnancy, O24.4 for diabetes mellitus arising in pregnancy, O13 for gestational hypertension, O21.0 for mild hyperemesis gravidarum and O34.2 for maternal care due to a uterine scar from previous surgery. US practices code in ICD-10-CM, which adds characters, so a normal first pregnancy with the trimester unspecified is Z34.00 and gestational diabetes controlled by diet is O24.410. Procedure codes, CPT in the US and OPCS in the UK, stay with the clinic's coder.

The letters that leave an antenatal clinic

The Academy of Medical Royal Colleges recommends that most outpatient letters are written to the patient with a copy to the GP, and that writing to patients is the default setting for an AI scribe.⁷ In antenatal care that letter matters twice. In England the midwife gives each woman her maternity notes in an app, a book, a folder or on a secure website, and the NHS asks her to keep them with her until the baby is born so staff can read about the pregnancy if she needs urgent care.⁶ A signed letter written to her, with the results and the plan in plain words, is a document she can carry beside those notes.

Other letters follow the pregnancy. A referral letter to a fetal medicine unit carries the scan finding, the gestation and the question for the specialist. After a diagnosis of gestational diabetes, NICE asks for a review with the joint diabetes and antenatal clinic within 1 week and for the primary healthcare team to be told, so that referral and the GP letter go out together.³ Near term, a summary for the booked maternity unit sets out previous births, medicines, allergies and the birth plan. Results letters, fit-to-fly letters for travel in later pregnancy and UK fit notes on the official form come from the same consultation. For onward letters in general, see the referral letter.

After the birth, NICE asks for prompt communication when care moves from midwife to health visitor and from secondary to primary care, covering the pregnancy, the birth and any complications, the plan of ongoing care and any mental health concerns, and for a GP assessment at 6 to 8 weeks after the birth.⁵ The postnatal letter to the GP carries that handover, drafted from the postnatal review itself. The same structure runs through women's health and fertility clinics, where many private pregnancies begin.

Antenatal care in the woman's own language

wai works in 60 languages, among them English, Arabic, Spanish, French, Portuguese, Italian, Russian, Polish, Turkish, Urdu and Mandarin. English can be mixed in one consultation with Spanish, French, Portuguese, Russian, Italian, Dutch, German, Hindi or Japanese, and the other languages are captured in that language. The signed note is written in English for the record, or in another language the clinic chooses, and the woman's summary can be translated into her language beside it, with crisis and emergency numbers kept exactly as written.

In obstetrics that means the advice on the baby's movements, the warning signs of pre-eclampsia and the maternity unit's number reach her in words she reads every day. It does not replace an interpreter. NICE asks antenatal services to make reliable interpreting available, including British Sign Language, with interpreters independent of the woman rather than a family member or friend.¹ How the capture works is set out in multilingual consultations and on the multilingual scribe page.

Clinic software for obstetrics clinics, from scan bookings to the postnatal check

The front desk of a private antenatal practice runs on dates. Each pregnancy has a predictable sequence of visits, scans, blood tests and screening windows, and a missed window cannot be recovered. wai Admin brings calls, email, web forms and WhatsApp into one thread per woman, drafts each reply in the clinic's voice and holds it until a person approves it. Booking links read each obstetrician's calendar in Google, Outlook or Apple, cancellations backfill from the waitlist and reminders go out before every visit.

Results reach the woman with her doctor's own comment and a plain explanation of each marker, so a glucose tolerance test arrives explained rather than as a row of numbers. Recalls go out for the next growth scan, the repeat blood pressure check or the 6 to 8 week postnatal review, each message approved by a person. In the UK, pathology orders go out and results come back through TDL, and private prescriptions are issued and signed through SignatureRx.

Private antenatal care is usually sold as a package, so payments matter. Deposits, invoices, memberships and payment links run through the clinic's own Stripe account, and insurer invoices go out where a policy covers part of the care. With the woman's consent, her partner can be given access to letters and messages. The patient app, wai Profile, holds her results, letters, messages and payments in her language. The full front desk is on the clinic management software page.

One antenatal visit, start to finish

Take a 34-year-old in her second pregnancy, seen at 28 weeks in a private obstetric clinic. Her first baby was born by caesarean section. Her glucose tolerance test last week came back with a fasting glucose of 5.8 mmol/litre, and she wants to talk about how this baby will be born. The obstetrician explains gestational diabetes, discusses diet and home glucose monitoring, records a blood pressure of 118/74, measures the fundal height at 28 cm and listens as she says she would like to try for a vaginal birth this time.

The draft lands in the antenatal template. It holds the gestation, blood pressure, urine result, fundal height, the glucose result with units, a diagnosis of gestational diabetes, the plan for glucose monitoring and a dietitian appointment, and a birth options section recording one previous caesarean, the options discussed and her wish for a vaginal birth after caesarean. wai suggests O24.4 and O34.2, each beside the line it rests on. The obstetrician corrects the fasting value, which the draft gave as 5.6, adds that the first caesarean was for a breech presentation, confirms both codes and signs.

Two letters go out. A letter to her, copied to her GP, explains the diagnosis in plain words, the monitoring plan and when to call the maternity unit, and she keeps the signed PDF in wai Profile beside her maternity notes. A referral to the joint diabetes and antenatal clinic carries the result and the question for the team. At the front desk, the dietitian appointment is offered through a booking link, the 32-week growth scan goes in the diary and a recall is set for the 36-week birth planning visit, each message approved by a person before it is sent.

The evidence behind wai's method

The note is one part of the day the evidence measures. In a randomised trial of 238 outpatient physicians across 14 specialties at UCLA Health, the ambient scribe with a significant effect cut the time spent writing each note by about 41 seconds, against 18 seconds in usual care.⁸ wai is built on that finding, so it takes on the letters, the replies, the scan bookings and the recalls as well as the note.

Obstetric guidance puts communication at the centre. NICE asks for effective and prompt communication between every professional involved in a woman's care during pregnancy.¹ A draft that carries the same facts into the letter, the referral and the postnatal handover serves that aim only when a clinician reads it, and the Academy of Medical Royal Colleges says the clinician checks every document a scribe produces.⁷ wai holds every draft until the obstetrician signs it, and every reply until a person at the clinic sends it.

The woman's own language. In a systematic review of 33 studies, 76% found at least one outcome better when patient and physician shared a language other than English.⁹

Measured in a working clinic. At The Wellness in London, which runs on wai every day, every clinician has 15 hours a week back, as published in the customer story.¹⁰

Where to start

Start with the booking visit for one obstetrician. Load the clinic's booking template, with fixed fields for dating, previous births, blood pressure, screening choices and the risk factors that call for aspirin, and run it for two weeks. Count the corrections made to gestation, doses and previous births, and time the gap between the end of clinic and signed letters.

In the second week, add the 28-week review and the results letter, and switch on recalls for growth scans and the postnatal review. Read patient consent for AI scribes before the first recorded visit, and see how other specialties run wai on the specialties hub. Prices are on the pricing page.

Frequently asked questions