Author: Eleanor Jones (Institute of Applied Health Research)

ANTENATAL TRIAGE ASSESSMENT CARD FOR ABDOMINAL PAIN (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
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
	Consider IV access	Time	Initials
	Obtain blood for FBC	Time	Initials
	If bleeding PV, take blood for G&S and if Rhesus Negative for Kleihauer	Time	Initials
	Consider bloods for PET profile/CRP/glucose/clotting	Time	Initials
	Obtain urine sample for urinalysis +/- MSU	Time	Initials
	Inform obstetric registrar of admission and 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)	Complete and categorise CTG (if gestation ≥26/40)	Time	Initials
	Obtain urine sample for urinalysis +/- MSU	Time	Initials
	Inform obstetric SHO of admission and 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 gestation ≥26/40)	Time	Initials
	Obtain urine sample for urinalysis +/- MSU	Time	Initials
	If after examination & discussion, pain is identified as musculoskeletal/ pelvic girdle pain, MW can offer discharge home (at any gestation) & written advice with appropriate follow-up with CMW or ANC	Time	Initials
	If not appropriate for MW to discharge then inform SHO of admission and 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

Abdominal Pain
This is not an exhaustive list of presenting symptoms and clinical judgement is required

1. Go direct to assessment bed or room on labour ward. If none continue care in triage room until one available
2. Complete and categorise CTG (if gestation ≥26/40)
3. Consider IV access
4. Obtain blood for FBC
5. If bleeding PV take blood for G & S and if Rhesus Negative for Kleihauer. Consider bloods for PET profile/CRP/glucose/clotting
6. Obtain urine sample for urinalysis +/- MSU
7. Inform Obstetric SpR of admission and to attend (re-inform or escalate if no review within 15 minutes)
8. Keep nil by mouth
9. Repeat baseline observations every 15 minutes

1. Transfer immediately to Labour ward or Obstetric Theatres
2. Inform LW Lead Midwife to inform senior obstetric and anaesthetic medical staff ( 2222)

1. Can return to waiting room to await more detailed assessment, unless medical assessment or room available
2. Complete and categorise CTG (if gestation ≥26/40)
3. Obtain urine sample for urinalysis +/- MSU
4. Inform obstetric SpR of admission and to attend (re-inform or escalate if no review within 1 hour)
5. Repeat baseline observations after 1 hour unless altered MEWS, in which case in 30 minutes

1. Can return to waiting room to await more detailed assessment, unless medical assessment or room available
2. Complete and categorise CTG (if gestation ≥26/40)
3. Obtain urine sample for urinalysis +/- MSU
4. If after examination and discussion, pain is identified as musculoskeletal/pelvic girdle pain, MW can offer discharge home (at any gestation) and written advice with appropriate follow-up with CMW or ANC
5. Or inform ST1-2 obstetric medical staff of admission and to attend (re-inform or escalate if no review within 4 hours)

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

ORANGE (15 mins) Remain in triage room until medical assessment or room available on LW
Investigations / required / (state time & print initials when done)	Complete and categorise CTG (if gestation ≥ 26/40)	Time	Initials
	Consider IV access	Time	Initials
	Obtain blood for FBC	Time	Initials
	If bleeding PV, take blood for G&S and if Rhesus Negative for Kleihauer	Time	Initials
	Consider bloods for PET profile/CRP/glucose/clotting	Time	Initials
	Obtain urine sample for urinalysis +/- MSU	Time	Initials
	Inform ST3-7 obstetric medical staff of admission and 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)	Complete and categorise CTG (if gestation ≥26/40)	Time	Initials
	Obtain urine sample for urinalysis +/- MSU	Time	Initials
	Inform ST1-2 obstetric medical staff of admission and 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 gestation ≥26/40)	Time	Initials
	Obtain urine sample for urinalysis +/- MSU	Time	Initials
	If after examination & discussion, pain is identified as musculoskeletal/ pelvic girdle pain, MW can offer discharge home (at any gestation) & written advice with appropriate follow-up with CMW or ANC	Time	Initials
	If not appropriate for MW to discharge then inform ST1-2 of admission and to attend	Time	Initials

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