Author: Eleanor Jones (Institute of Applied Health Research)

ANTENATAL TRIAGE ASSESSMENT CARD FOR SUSPECTED LABOUR (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)	Take history including AN risk assessment	Time	Initials
	Complete and categorise either CEFM or intermittent auscultation	Time	Initials
	Inform Shift Leader	Time	Initials
	Inform Obstetric Registrar of admission and to attend if required	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)	Take history including AN risk assessment	Time	Initials
	Auscultate FH for 1 minute; if high-risk commence CEFM	Time	Initials
	Gain consent and complete vaginal examination	Time	Initials
	Offer immediate IOL if PROM >24hrs and not in active labour	Time	Initials
	If PROM and GBS positive, offer immediate IOL	Time	Initials
	If normal CTG/FHR and not in active labour, discharge home or transfer to antenatal ward with advice for early labour care	Time	Initials
	Repeat maternal and fetal observations every 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)	Take history including AN risk assessment	Time	Initials
	Consider vaginal examination	Time	Initials
	Offer immediate IOL if PROM >24 hours and not in active labour	Time	Initials
	Offer and arrange IOL at PROM at 24 hours if not in active labour	Time	Initials
	If PROM and GBS positive, offer immediate IOL	Time	Initials
	If normal FHR and not in active labour, discharge home by MW or transfer to antenatal ward with advice for early labour care	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

Vaginal examination indication:
Abdominal palpation	Lie
	Presentation																Position
	Engagement																Fifths palpable above the pelvic brim
Cervix	Not effaced		Length ................... cms
	Effaced		Thick / Thin
	Application		Close / Loose
	Dilatation
Fetal monitoring	Pinard or Doppler following VE: ......................bpm																	Continuous CTG
Membranes	Intact																	Ruptured
Liquor	Clear																	Meconium
Presenting part	Vertex / Breech / Other .............................................
Caput	Yes	No							Moulding											0				+					++			+++
Station / (in relation to ischial spines)	-2			-1										0								+1								+2
Bladder care	Spontaneous void									Catheterised															NPU
Signature:					GMC/PIN																						Date:
Print name:																											Time:

A

R

L

0	1	2	3	4	5

L

A

P

R

L

P

1	2	3	4	5	6	7	8	9	10

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

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

Transfer immediately to labour ward
Inform labour ward MW in charge and senior obstetric and anaesthetic staff (2222)

Go direct to assessment bed or room on labour ward. If none continue care in triage room until one available
Complete and categorise CTG
Inform labour ward MW in charge
Inform obstetric SpR of admission and to attend if required (re-inform or escalate if no review within 15 minutes)
Repeat baseline observations every 15 minutes, unless gestation <37/40 or meconium liquor, in which case repeat baseline observations every 30 minutes

Can return to waiting room to await more detailed assessment, unless assessment bed or room available
Take history and perform labour risk assessment
Auscultate FH for 1 minute; if high-risk commence CTG
Gain consent and complete speculum/vaginal examination
Offer immediate IOL if PROM >24hrs and not in active labour
If PROM and GBS positive, offer immediate IOL
If normal CTG/FHR and not in active labour, discharge home or transfer to antenatal bed with advice for early labour care
Repeat maternal and fetal observations every 30 minutes

Can return to waiting room to await more detailed assessment
Take history using labour risk assessment tool
Consider vaginal examination
Offer and arrange IOL at PROM 24hrs if not in active labour
If PROM and GBS positive, offer immediate IOL
If normal FHR and not in active labour, discharge home by MW or transfer to antenatal ward with advice on strategies for early labour

© 2020 Salisbury Maternity Unit