Author: Eleanor Jones (Institute of Applied Health Research)

ANTENATAL TRIAGE ASSESSMENT CARD FOR (P)PROM (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)	Review growth scans and time since last assessment				Time		Initials
	Complete and categorise CTG (if gestation ≥26/40)				Time		Initials
	Consider taking blood samples for FBC, CRP/G&S (and blood cultures if pyrexial)				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 unless only meconium or RFM (then repeat in 1 hour)
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)	Perform speculum examination if necessary to confirm PROM if no liquor visible				Time		Initials
	Complete and categorise CTG (if gestation ≥26/40)				Time		Initials
	Offer immediate IOL if PROM >24 hours and not in active labour				Time		Initials
	If confirmed PROM and GBS positive, offer immediate IOL				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 (if no active bleeding or pain) unless medical assessment or room available
Investigations / required / (state time & print initials when done)	Perform speculum examination if necessary to confirm PROM if no liquor visible				Time		Initials
	If confirmed PROM and GBS positive, offer immediate IOL				Time		Initials
	Offer immediate IOL if PROM >24 hours and not in active labour				Time		Initials
	Arrange return for IOL or 24 hour review as policy: give written information; verbal advice re labour and signs of infection; complete IOL booking proforma only then suitable for MW to discharge				Time		Initials
	If no evidence of PROM, MW to discharge with appropriate routine follow-up with CMW or ANC				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

(P)PROM – Ruptured Membranes
This is not an exhaustive list of presenting symptoms and clinical judgement is required

1. Transfer immediately to Labour Ward or Obs Theatre
2. Inform LW 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
Review growth scans and time since last assessment
Complete and categorise CTG (if gestation ≥26/40)
Consider taking blood samples for FBC, CRP/G&S (and blood cultures if pyrexial)
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, unless only meconium or RFM (then repeat in 1 hour)

Can return to waiting room to await more detailed assessment, unless medical assessment or room available
If appropriate, perform speculum examination if necessary to confirm PROM if no liquor visible
Complete and categorise CTG (if gestation ≥26/40)
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

Can return to waiting room to await more detailed assessment
Perform speculum examination if necessary to confirm PROM if no liquor visible
If confirmed PROM and GBS positive, offer immediate IOL
Arrange IOL or 24 hour review as policy: give written information; verbal advice re labour and signs of infection; complete IOL booking proforma only then suitable for MW to discharge
If no evidence of PROM, MW to discharge with appropriate routine follow-up with CMW or ANC

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

© 2017 Birmingham Women’s and Children’s NHS Foundation Trust and University of Birmingham. All rights reserved