Author: Eleanor Jones (Institute of Applied Health Research)

POSTNATAL TRIAGE ASSESSMENT CARD (Version 4 – July 2018)

Name:
DOB:
Registration number:

Arrival in Triage		Date		Time
Initial triage assessment		Date		Time
Triage midwife name				PIN
Date of delivery:	Gravida		Parity	Blood group

Mode of birth	ELCS	EMCS	Forceps	Spontaneous vaginal	Vaginal breech	Ventouse
Significant events in the postnatal period (e.g. wound infection, extended stay, PPH)
Symptoms on arrival
Relevant medical, obstetric, social, / lifestyle history ethnicity
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
Method of feeding (please circle)				Breast				Bottle						Mixed
Assessment of breasts (e.g. mastitis)				Right breast
				Left breast
Abdominal examination	Signs of infection / (if yes describe below)			Yes		No					Fundal height (in relation to umbilicus)
	Describe signs of infection:
Lochia (circle all that apply)		Colour	Bright red	Brown	Heavy				Moderate				Minimal			Offensive
Assessment of legs / (e.g. swelling, redness, hot to the touch, varicose veins)				Right leg
				Left leg
Assessment of wound/perineum (please circle)				CS wound
				Perineum

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)	Review details of birth	Time	Initials
	Obtain IV access and take blood samples for FBC/CRP/G&S/PET profile +/-venous lactate (and blood cultures if pyrexial)	Time	Initials
	Obtain urine sample for urinalysis	Time	Initials
	Inform obstetric regsitrar 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 if no active bleeding or pain to await more detailed assessment unless medical assessment or room available
Investigations / required / (state time & print initials when done)	Review details of birth	Time	Initials
	Consider obtaining IV access and taking blood samples for FBC/CRP/ G&S/PET profile +/-venous lactate (and blood cultures if pyrexial)	Time	Initials
	Obtain urine sample for urinalysis	Time	Initials
	Inform obstetric SHO of admission and to attend	Time	Initials
	Refer to anaesthetist if evidence of post-dural headache or possible nerve injury	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 if no active bleeding or pain to await more detailed assessment unless medical assessment or room available
Investigations / required / (state time & print initials when done)	Review details of birth	Time	Initials
	Obtain urine sample for urinalysis	Time	Initials
	Inform obstetric SHO of admission and to attend	Time	Initials
	Refer to anaesthetist if evidence of post-dural headache or possible nerve injury	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)

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)		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): CMW GP Other (please specify)
Discharge from Triage by	Print Name and PIN	Signature		Date	Time

Notes

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

Transfer immediately to Labour Ward or Obs Theatre
Inform LW MW in charge to inform senior obstetric and anaesthetic medical staff (2222

Go direct to assessment bed or room on labour ward. If none continue care in triage room until one available
Review details of birth
Obtain IV access and take blood samples for FBC/CRP/G&S/PET profile +/-venous lactate (and blood cultures if pyrexial)
Consider use of sepsis checklist
Obtain urine sample for urinalysis and LVS
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 if no active bleeding or pain to await more detailed assessment, unless assessment bed available
Review details of birth
Consider obtaining IV access and taking blood samples for FBC/CRP/G&S/PET profile +/-venous lactate (and blood cultures if pyrexial)
Obtain urine sample for urinalysis +/- MSU
Inform obstetric SHO of admission and to attend (re-inform or escalate if no review within 1 hour)
Refer to anaesthetist if evidence of post-dural headache or possible nerve injury
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
Review details of birth
Obtain urine sample for urinalysis
Inform obstetric SHO of admission and to attend (re-inform or escalate if no review within 4 hours)
Refer to anaesthetist if evidence of post-dural headache or possible nerve injury

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