Author: Eleanor Jones (Institute of Applied Health Research)

ANTENATAL TRIAGE ASSESSMENT CARD FOR UNWELL/OTHER (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)	Obtain IV access	Time	Initials
	Take blood samples for FBC/CRP/PET profile/G&S/glucose (and blood cultures if pyrexial)	Time	Initials
	Obtain urine sample for urinalysis	Time	Initials
	Complete and categorise CTG (if gestation ≥26/40)	Time	Initials
	Inform Obstetric Registrar of admission & 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)	Consider taking blood samples as directed by history and for FBC/CRP/ G&S/PET profile (& blood cultures if pyrexial)	Time	Initials
	Inform Obstetric SHO of admission and to attend	Time	Initials
	Obtain urine sample for urinalysis – send for MSU if positive	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)	Consider taking blood samples as directed by history and for FBC/CRP/ G&S/PET profile (& blood cultures if pyrexial)	Time	Initials
	Obtain urine sample for urinalysis	Time	Initials
	Inform Obstetric SHO of admission and to attend	Time	Initials
	If itching with normal LFTs & BA result, midwife can discharge with appropriate routine follow-up with CMW or ANC (at any gestation)	Time	Initials
	If itching persists/worsens, advise repeat bloods required after 1-2 weeks	Time	Initials
	If after examination and discussion, pain is identified as musculoskeletal/pelvic girdle pain, MW can offer discharge home (at any gestation) and written advice with appropriate 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

Unwell or Other
This is not an exhaustive list of presenting symptoms and clinical judgement is required

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

Go direct to assessment bed or room on labour ward. If none continue care in triage room until one available
Obtain IV access
Take bloods for FBC/CRP/PET profile/G&S/glucose (and blood cultures if pyrexial)
Consider sepsis care bundle checklist
Obtain urine sample for urinalysis
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)
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 or room available
Consider taking blood samples as directed by history and for FBC/CRP/ G&S/PET profile (and blood cultures if pyrexial)
Inform obstetric SHO of admission and to attend (re-inform or escalate if no review within 1 hour)
Obtain urine sample for urinalysis – send for MSU if positive
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
Consider taking blood samples as directed by history and for FBC/CRP/PET profile/LFT/BA (and blood cultures if pyrexial)
Obtain urine sample for urinalysis
Inform obstetric SHO staff of admission and to attend (re-inform or escalate if no review within 4 hours)
If itching with normal LFTs and BA result, midwife can discharge with appropriate routine follow-up with CMW or ANC (at any gestation)
If after examination and discussion, pain is identified as musculoskeletal/pelvic girdle pain, MW can offer discharge home (at any gestation) and written advice with appropriate follow-up with CMW or ANC

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