Author: Eleanor Jones (Institute of Applied Health Research)

ANTENATAL TRIAGE ASSESSMENT CARD FOR REDUCED FETAL MOVEMENTS (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:

A full assessment of associated risk factors for stillbirth as per local guidance : Yes No
No risk factors risk factors present
NB If risk factor is identified, level of clinical urgency is ORANGE

OBSERVATIONS ENTERED ONTO MEWS (please circle)					Yes/No	Urinalysis / P: Protein / G: Glucose / K: Ketones / B: Blood	NAD	P	G	K	B
Fetal movements on attendance (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)	USS if unable to auscultate FH	Time	Initials
	Complete abdominal palpation and plot on GROW chart, or review growth scans and timing since last assessment	Time	Initials
	Complete and categorise CTG (if ≥26/40 gestation)	Time	Initials
	Inform obstetric Regsitrar of admission and to attend if pain or bleeding or additional concerns	Time	Initials
	If normal CTG, but perception of reduced fetal movements persists or additional risk factors are present, then USS for EFW, LV & UA Doppler as per local policy and guidance	Time	Initials
	Repeat baseline observations after 30 minutes unless altered MEWS, in which case in 15 minutes

YELLOW (1 hour) If fetal heart rate is normal, 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 serial growth USS measurements and consider USS if no recent serial growth USS	Time	Initials
	Complete abdominal palpation and plot on GROW chart, or review growth scans and timing since last assessment	Time	Initials
	Complete and categorise CTG (if ≥26/40 gestation)	Time	Initials
	If normal CTG, but perception of reduced fetal movements persists or additional risk factors are present, then USS for EFW, LV & UA Doppler as per local policy and guidance	Time	Initials
	If normal CTG, no identified risk factors & perception of fetal movements returns to usual pattern, can be discharged by MW with appropriate follow-up with CMW or ANC	Time	Initials
	Inform Obstetric SHO of admission and to attend if pain or bleeding	Time	Initials
	Repeat baseline observations after 1 hour unless altered MEWS, in which case in 30 minutes	Time	Initials

GREEN (4 hours) If fetal heart rate is normal, 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 abdominal palpation and plot on GROW chart, or review growth scans and timing since last assessment	Time	Initials
	Complete and categorise CTG (if ≥26/40 gestation)	Time	Initials
	If normal CTG, but perception of reduced fetal movements persists, then USS for EFW, LV & UA Doppler as per local policy and guidance	Time	Initials
	If normal CTG, no identified risk factors & perception of fetal movements returns to usual pattern, can be discharged by MW with appropriate follow-up with CMW or ANC	Time	Initials
	If required, inform Obstetric 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

Reduced Fetal Movements
This is not an exhaustive list of presenting symptoms and clinical judgement is required

Transfer immediately to Labour Ward HDU (room 6), Obs Theatre.
Inform MW in charge to inform senior obstetric and anaesthetic medical staff (2222)
USS if unable to auscultate FH

Go direct to assessment bed or room on labour ward. If none continue care in triage room until one available
USS if unable to auscultate FH
Complete abdominal palpation and plot on GROW chart, or review growth scans and timing since last assessment
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 and/or abnormal CTG) if pain or bleeding or additional concerns
If normal CTG, but perception of reduced fetal movements persists or additional risk factors are present, then USS for EFW, LV and UA Doppler as per local policy and guidance
Repeat baseline observations every 15 minutes

If FHR is normal, can return to waiting room to await more detailed assessment, unless assessment bed available
Complete abdominal palpation and plot on GROW chart
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) if pain or bleeding
Repeat baseline observations after 1 hour unless altered MEWS, in which case in 30 minutes
If normal CTG, but perception of reduced fetal movements persists or additional risk factors are present, then book USS for EFW, LV and UA Doppler as per local policy and guidance
If 1st episode RFM and normal CTG, no risk factors and perception of fetal movements returns to normal, can be discharged by MW with follow-up
If 2nd episode RFM and normal CTG, no risk factors and perception of FM returns to normal, book USS and same day obs review

If FHR is normal, can return to waiting room to await more detailed assessment
Complete abdominal palpation and plot on GROW chart
Complete and categorise CTG (if gestation ≥26/40)
If normal CTG, but perception of reduced fetal movements persists, book USS for EFW, LV and UA Doppler
If 1st episode RFM, normal CTG, no risk factors and perception of fetal movements returns to usual pattern, can be discharged by MW with appropriate follow-up
If 2nd episode RFM and normal CTG, no risk factors and perception of FM returns to normal, book USS and same day obs review (within 4 hours)

© 2020 Salisbury Maternity Unit