Author: Eleanor Jones (Institute of Applied Health Research)

ANTENATAL TRIAGE ASSESSMENT CARD FOR HYPERTENSION (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)	Consider IV access	Time	Initials
	Take blood samples for FBC/PET profile and/or G&S/clotting screen	Time	Initials
	Obtain urine sample for urinalysis and urinary protein PCR	Time	Initials
	Complete and categorise CTG (if gestation ≥26/40)	Time	Initials
	Inform obstetric registrar of admission & to attend	Time	Initials
	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
	Take blood samples for FBC/PET profile	Time	Initials
	Obtain urine sample for urinalysis for PCR	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)	Consider completion and categorisation of CTG (if gestation ≥26/40)	Time	Initials
	If 3x readings of normal BP (at least 30 minutes apart) and no proteinuria and not on antihypertensive medication, can be discharged home by MW with appropriate follow-up with CMW or ANC	Time	Initials
	Inform obstetric SHO of admission and to attend if not suitable for MW to discharge	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

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

Airway compromise
Respiration rate ≥30 or oxygen saturation <92%
Shock: BP <80 systolic, HR >130bpm
Maternal collapse
Fit
Altered level of consciousness or confusion
Massive haemorrhage
Constant severe pain
Fetal bradycardia
BP>180 systolic or 115 diastolic x2 readings

Shortness of breath or chest pain
Severe headache
Vomiting
Moderate or continuous pain
Moderate bleeding (fresh or old)
Active bleeding
Abnormal MEOWS (1x red or 2x yellow values)
BP >160 systolic or >110 diastolic x2 reading
Proteinuria ≥3
Fetal heart rate <110bpm or >160bpm
No fetal movements

Mild pain
Mild bleed (not currently active)
Headache
Altered MEOWS (1x yellow value)
BP ≥140/90
Proteinuria 1-2+
Normal fetal heart rate
Reduced fetal movements

Minimal or no pain
No headache
Normal MEOWS
BP <140/90
No/trace proteinuria
Normal fetal heart rate Normal fetal movements

Transfer immediately to Labour Ward or Obs Theatre
Inform LW MW in charge to inform senior obstetric and anaesthetic medical staff

Transfer immediately to delivery suite, HDU (room 6) or Obs Theatre
Inform MW in charge to inform senior obstetric and anaesthetic medical staff

Go direct to assessment bed or room on labour ward. If none; continue care in triage room until one available.
Consider IV access
Take blood samples for FBC/PET profile +/- GandS/clotting screen
4. Obtain urine sample for urinalysis and urinary protein PCR
5. Complete and categorise CTG (if gestation ≥26/40)
6. Inform ST3-7 obstetric medical staff of admission and to attend (re-inform or escalate if no review within 15 minutes)
7. Repeat observations every 15 minutes

Go direct to assessment bed or room on labour ward. If none continue care in triage room until one available
Consider IV access
Take blood samples for FBC/PET profile +/- G&S/clotting screen
Obtain urine sample for urinalysis and urinary protein PCR
Complete and categorise CTG (if gestation ≥26/40)
Inform obstetric SpR of admission and to attend (re-inform or escalate if no review within 15 minutes)
Repeat observations every 15 minutes

Can return to waiting room to await more detailed assessment, unless assessment bed available
Complete and categorise CTG (if gestation ≥26/40)
Take blood samples for FBC/PET profile
Obtain urine sample for urinalysis for PCR
Inform obstetric 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

1. Can return to waiting room to await more detailed assessment, unless medical assessment or room available
2. Consider completion and categorisation of CTG (if gestation ≥26/40)
3. If 3x readings of normal BP (at least 30 minutes apart) and no proteinuria and not on antihypertensive medication, can be discharged home by MW with appropriate follow-up with CMW or ANC
4. Inform ST1-2 obstetric medical staff of admission and to attend if not suitable for MW to discharge (re-inform or escalate if no review within 4 hours)

Can return to waiting room to await more detailed assessment
Consider completion and categorisation of CTG (if gestation ≥26/40)
If 3x readings of normal BP (at least 30 minutes apart) and no proteinuria and not on antihypertensive medication, can be discharged home by MW with appropriate follow-up with CMW or ANC
Inform obstetric SHO of admission and to attend if not suitable for MW to discharge (re-inform or escalate if no review within 4 hours)

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