Author: Eleanor Jones (Institute of Applied Health Research)

ANTENATAL TRIAGE ASSESSMENT CARD FOR ANTENATAL BLEEDING (Version 4 – July 2018)

Name:
DOB:
Registration number:

Arrival in Triage		Date		Time
Initial triage assessment		Date		Time
Triage midwife name				PIN
Gestation /40	Gravida		Parity	Blood group

Symptoms on arrival
Relevant medical & obstetric, social, lifestyle history and ethnicity.
Current pregnancy
Medication/s		Allergies:

OBSERVATIONS ENTERED ONTO MEWS (please circle)					Yes/No	Urinalysis / P: Protein / G: Glucose / K: Ketones / B: Blood	NAD	P	G	K	B
Normal pattern of fetal movements (please circle)					Yes/No
Abdominal palpation	Lie:		Presentation:			Fundal height plotted (if applicable): cms
						OR Growth scan reviewed
	Tenderness (please circle)			Yes/No		5ths palpable (above pelvic brim)
Fetal heart rate (Pinard or Doppler) / 110-160bpm - normal range (for 1 minute)		bpm		If abnormal, commence CTG if ≥26/40 (please circle)				Yes/No

Pain assessment / (please circle)	None	Mild	Moderate	Severe
Priority to be seen / (please circle)	Green / Within 4 hours	Yellow / Within 1 hour	Orange / Within 15 minutes	Red / IMMEDIATELY
Plan of care

This is not an exhaustive list of INVESTIGATIONS: clinical judgement is required

PLEASE ENTER ALL OBSERVATIONS ONTO MEWS & DOCUMENT ADDITIONAL NOTES ON NEXT PAGE

ORANGE (15 mins) Remain in triage room until medical assessment or room available on DS
Investigations / required / (state time & print initials when done)	Complete and categorise CTG (if gestation ≥26/40)	Time	Initials
	Review placental site on previous USS	Time	Initials
	Obtain IV access & take blood samples for FBC/clotting/G&S/ Kleihauer (if Rhesus negative)	Time	Initials
	Inform obstetric registrar of admission & to attend	Time	Initials
	Keep nil by mouth and repeat baseline observations every 15 minutes

YELLOW (1 hour) Can return to waiting room to await more detailed assessment unless medical assessment or room available
Investigations / required / (state time & print initials when done)	Review placental site on previous USS	Time	Initials
	Complete and categorise CTG (if ≥26/40 gestation)	Time	Initials
	Consider bloods for FBC/clotting/G&S/ Kleihauer (if Rhesus negative)	Time	Initials
	Inform obstetric SHO of admission & to attend	Time	Initials
	Repeat baseline observations after 1 hour unless altered MEWS, in which case in 30 minutes

GREEN (4 hours) Can return to waiting room to await more detailed assessment unless medical assessment or room available
Investigations / required / (state time & print initials when done)	Complete and categorise CTG (if ≥26/40 gestation)	Time	Initials
	Inform obstetric SHO of admission & to attend	Time	Initials

Assessing midwife	Print name & PIN	Signature	Date	Time assessment / started
Request for medical staff	Name of medic bleeped	Date and time bleeped	Responded (Y/N)	Can attend (Y/N)

Antenatal CTG Proforma
NB If the woman is in established labour use intrapartum CTG categorisation

Date and time	ADDITIONAL INFORMATION / Review relevant history including pre-existing conditions, medications and antenatal investigation. Remember to document relevant social and lifestyle history	Signature and PIN

Date and time	ADDITIONAL INFORMATION / Review relevant history including pre-existing conditions, medications and antenatal investigation. Remember to document relevant social and lifestyle history	Signature and PIN

Medical review	Print name & GMC no	Signature	Seniority	Date	Time

Transferred to / (please circle)		MLU Delivery Suite HDU/ITU Ward Other (please specify)
Handover	Situation
	Background
	Assessment
	Recommendation
	Decision
Handover given by		Print Name and PIN	Signature	Date	Time
Handover received by		Print Name and PIN	Signature	Date	Time

Discharged to (please circle)	Home Other (please specify)
Next appointment	Date:		Time:
	Location (please circle): Antenatal clinic CMW GP Other (please specify)
Discharge from Triage by	Print Name and PIN	Signature		Date	Time

Notes

Antenatal Bleeding
This is not an exhaustive list of presenting symptoms and clinical judgement is required

1. Transfer immediately to Labour Ward or Obstetric Theatre
2. Inform LW Midwife in Charge to inform senior obstetric and anaesthetic medical staff

Go direct to assessment bed or room on labour ward. If none ; continue to care in triage room until one available.
Complete and categorise CTG (if gestation ≥26/40)
Review placental site on previous USS
Obtain IV access and take blood samples for FBC/clotting/G & S/Kleihauer (if Rhesus negative)
Inform obstetric SpR of admission and to attend (re-inform or escalate if no review within 15 minutes)
Keep nil by mouth
Repeat baseline observations every 15 minutes

Can return to waiting room to await more detailed assessment, unless assessment room available
Complete and categorise CTG (if gestation ≥26/40)
Consider bloods for FBC/clotting/G&S/ Kleihauer (if Rhesus negative)
Review placental site on previous USS
Inform SHO of admission and to attend (re-inform or escalate if no review within 1 hour)
Repeat baseline observations after 1 hour unless altered MEWS, in which case in 30 minutes

Can return to waiting room to await more detailed assessment .
Complete and categorise CTG (if gestation ≥26/40)
Inform ST1-2 obstetric medical staff of admission and to attend (re-inform or escalate if no review within 4 hours)

Symptoms on arrival
Relevant medical & obstetric, social & lifestyle history
Current pregnancy
Medication/s		Allergies:

OBSERVATIONS ENTERED ONTO MEWS (please circle)					Yes/No	Urinalysis / P: Protein / G: Glucose / K: Ketones / B: Blood	NAD	P	G	K	B
Normal pattern of fetal movements (please circle)					Yes/No
Abdominal palpation	Lie:		Presentation:			Fundal height plotted (if applicable): cms
						OR Growth scan reviewed
	Tenderness (please circle)			Yes/No		5ths palpable (above pelvic brim)
Fetal heart rate (Pinard or Doppler) / 110-160bpm - normal range (for 1 minute)		bpm		If abnormal, commence CTG if ≥26/40 (please circle)				Yes/No

Pain assessment / (please circle)	None	Mild	Moderate	Severe
Priority to be seen / (please circle)	Green / Within 4 hours	Yellow / Within 1 hour	Orange / Within 15 minutes	Red / IMMEDIATELY
Plan of care

PLEASE ENTER ALL OBSERVATIONS ONTO MEWS & DOCUMENT ADDITIONAL NOTES ON NEXT PAGE

Assessing midwife	Print name & PIN	Signature	Date	Time assessment / started
Request for medical staff	Name of medic bleeped	Date and time bleeped	Responded (Y/N)	Can attend (Y/N)

Date and time	ADDITIONAL INFORMATION / Review relevant history including pre-existing conditions, medications and antenatal investigation. Remember to document relevant social and lifestyle history	Signature and PIN

YELLOW (1 hour) Can return to waiting room to await more detailed assessment unless medical assessment or room available
Investigations / required / (state time & print initials when done)	Review placental site on previous USS	Time	Initials
	Complete and categorise CTG (if ≥26/40 gestation)	Time	Initials
	Consider bloods for FBC/clotting/G&S/ Kleihauer (if Rhesus negative)	Time	Initials
	Inform ST1-2 obstetric medical staff of admission & to attend	Time	Initials
	Repeat baseline observations after 1 hour unless altered MEWS, in which case in 30 minutes

GREEN (4 hours) Can return to waiting room to await more detailed assessment unless medical assessment or room available
Investigations / required / (state time & print initials when done)	Complete and categorise CTG (if ≥26/40 gestation)	Time	Initials
	Inform ST1-2 obstetric medical staff of admission & to attend	Time	Initials

ORANGE (15 mins) Remain in triage room until medical assessment or room available on DS
Investigations / required / (state time & print initials when done)	Complete and categorise CTG (if gestation ≥26/40)	Time	Initials
	Review placental site on previous USS	Time	Initials
	Obtain IV access & take blood samples for FBC/clotting/G&S/ Kleihauer (if Rhesus negative)	Time	Initials
	Inform ST3-7 obstetric medical staff of admission & to attend	Time	Initials
	Keep nil by mouth and repeat baseline observations every 15 minutes

Arrival in Triage		Date		Time
Initial triage assessment		Date		Time
Triage midwife name				PIN
Gestation /40	Gravida		Parity	Blood group

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