An Organisation-wide Document for the Care of Pregnant Women Seen in the Emergency Department or
Elsewhere in the Hospital
NHS Trust
An Organisation-wide Document for the Care of
Pregnant Women Seen in the Emergency Department
or Elsewhere in the Hospital
Version:
Ratified by:
Date ratified:
Name of originator/author:
Name of responsible committee/individual:
Name of executive lead:
Date issued:
Review date:
Target audience:
V.2
March 2012
Page 1 of 14
An Organisation-wide Document for the Care of Pregnant Women Seen in the Emergency Department or
Elsewhere in the Hospital
Contents
1
Introduction ............................................................................................................. 4
2
Purpose .................................................................................................................... 4
3
Explanation of Terms ............................................................................................... 4
4
Duties ....................................................................................................................... 4
4.1
Individual Professional Duties ................................................................................................. 5
5 Definition of which Women Attending the Emergency Department should be
Seen by an Appropriate Individual ................................................................................. 6
6
Care of Pregnant Women with a Non-Obstetric Problem ....................................... 7
7 Communication between the On Call Obstetric Consultant, the Local Obstetric
Team and the Gynaecology Team .................................................................................. 7
8
Equality Impact Assessment .................................................................................... 8
9
Monitoring Compliance with the Document ........................................................... 8
9.1
9.2
10
10.1
11
Process for Monitoring Compliance ........................................................................................ 8
Standards/Key Performance Indicators .................................................................................. 8
References ............................................................................................................ 9
Guidance from Other Organisations ....................................................................................... 9
Associated Documentation................................................................................... 9
Appendix A - An Organisation-wide Document for the Care of Pregnant Women Seen
in the Emergency Department or Elsewhere in the Hospital ....................................... 10
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An Organisation-wide Document for the Care of Pregnant Women Seen in the Emergency Department or
Elsewhere in the Hospital
Review and Amendment Log
Version no.
Type of change
Date
Description of change
V.2
Annual review
Mar 2011
V.2
Amendment
Mar 2011
Addition of amendment log
Addition of example of definition
Addition of examples of associated documents
V.3
Annual review
Mar 2012
Change of wording for clarity from medical
condition to non-obstetric condition
V.3
Amendment
Mar 2012
Update to format
contents page
including
automated
Please Note the Intention of this Document
This document has been developed with the aim of providing a model document template.
However, any documentation subsequently produced must follow its own rules and include details of
all the requirements set out in sections 1-11, where relevant. The maternity service may use this
template and adapt it to reflect procedures within the maternity service or alternatively use a
document already in existence. Whichever approach is used the maternity service must ensure it is
compliant with the minimum requirements of the Clinical Negligence Scheme for Trusts (CNST)
Maternity Clinical Risk Management Standards.
a
To assist the maternity service, areas have been identified in the margins where the section
within the template document relates to the minimum requirements for the criterion in the
relevant CNST Maternity Clinical Risk Management Standards.
It is important that the document should follow any pre-existing guidance within the maternity
service in relation to style and format of documentation. Please note that a template document
entitled An Organisation-wide Document for the Development and Management of Procedural
Documents can be found on the NHSLA website which may provide the maternity service with
additional guidance.
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An Organisation-wide Document for the Care of Pregnant Women Seen in the Emergency Department or
Elsewhere in the Hospital
1
Introduction
Give an overview of the importance of ensuring that the organisation has an approved
process for ensuring that all pregnant women seen in the Emergency Department or
elsewhere in the hospital are cared for appropriately.
2
Purpose
Within this section an explanation regarding the intent/aim of the document should be
described. This should include the rationale for development of the document and an
outline of the objectives and intended outcomes of the process. This may include:
3

a statement regarding the maternity service’s commitment to ensuring optimum
care for all pregnant women seen in the emergency department or elsewhere in the
hospital; and

a description of how the maternity service intends to ensure the implementation of
high quality and robust systems for caring for the pregnant woman.
Explanation of Terms
This section should list and describe the meaning of the terms used in the context of the
document.

Ectopic pregnancy
An ectopic pregnancy is a complication of pregnancy in which the pregnancy implants
outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Most
ectopic pregnancies occur in the fallopian tube, but implantation can also occur in the cervix,
ovaries, and abdomen. An ectopic pregnancy is a potential medical emergency, and, if not
treated properly, can lead to death.
The following list is a guide only and is not exhaustive:
4

Vulnerable woman

Experienced doctor

Local obstetric team

Other professionals

Appropriate individual
Duties
Give a brief overview of the roles, responsibilities and accountabilities for the
implementation of the organisation’s process. This section should be a brief overview only
and the details of the process for managing this should be incorporated within later sections
of the document. The following list is a guide only and is not exhaustive:
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An Organisation-wide Document for the Care of Pregnant Women Seen in the Emergency Department or
Elsewhere in the Hospital
4.1
Individual Professional Duties
This section should include the duties and accountabilities of medical staff, nursing
staff, midwifery staff and any other staff groups involved in the care of the pregnant
woman attending/seen in the emergency department or elsewhere in the hospital.
Emergency Department Staff
The role of the emergency department staff should include as a minimum:

when to call the obstetric team, on call obstetric consultant, or labour ward
coordinator;

communication with other professionals;

communicating clinical details and indicating the need for review; and

recording all communication.
Ward Staff in the Hospital
The role of the ward staff should include as a minimum:

when to call the obstetric team, on call obstetric consultant, or labour ward
coordinator;

communication with other professionals;

communicating clinical details and indicating the need for review;

role in ongoing management of the woman; and

recording of all communication.
On Call Obstetric Consultant
The role of the on call obstetric consultant should include as a minimum:

when and how they should respond to a referral;

communication with other professionals;

communicating clinical details and indicating the need for review; and

recording of all communication.
Local Obstetric Team
The role of the local obstetric team should include as a minimum:
V.2

when and how they should respond to a referral;

communication with other professionals;

communicating clinical details and indicating the need for review; and

recording of all communication.
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An Organisation-wide Document for the Care of Pregnant Women Seen in the Emergency Department or
Elsewhere in the Hospital
Labour Ward Coordinator
The role of the labour ward coordinator should include as a minimum:
a
5

communication with other professionals;

communicating clinical details and indicating the need for review;

the arrangement/provision of appropriate midwifery care; and

recording of all communication.
Definition of which Women Attending the Emergency Department should be
Seen by an Appropriate Individual
This section should define which women attending the emergency department or elsewhere
in the hospital should be seen by an experienced doctor from the obstetric/gynaecology
team or a midwife.
The following list is a guide only and not exhaustive:

ectopic pregnancy;

abdominal or pelvic pain (staff should be aware of the guideline for ectopic
pregnancy);

vaginal bleeding;

post-operative/procedure readmission;

abnormal liver function tests;

low platelets;

pyrexia or any evidence of infection;

vomiting or diarrhoea;

involvement in a road traffic accident;

fractures involving lower limbs;

overdose or deliberate self harm;

suspicion of domestic violence;

wherever surgery is considered;

any other concerns whilst attending the emergency department.
The organisation should consider if any pregnant woman should be referred and transferred
to the delivery suite without waiting for obstetric review and include them within this
section.
The following list is a guide only and not exhaustive:
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An Organisation-wide Document for the Care of Pregnant Women Seen in the Emergency Department or
Elsewhere in the Hospital

hypertension;

proteinurea;

visual disturbance/photophobia;

headache not relieved with simple analgesia.
There should be a description of who from the midwifery/obstetric/gynaecology team
should be contacted, and the process for contacting these individuals.
This section should also describe and define what is deemed to be an ‘experienced doctor’
and should detail the process for ensuring systems are in place to make sure women are
only seen by either this approved grade of doctor or a midwife.
There should be a description of when it is acceptable for the pregnant woman to be seen by
a midwife and when it is a requirement that the pregnant woman is seen by an ‘experienced
doctor’.
The service may wish to consider having agreed and documented criteria for when the
clinical review of a woman is to be conducted by a doctor and when it is to be conducted by
a midwife.
6
b
Care of Pregnant Women with a Non-Obstetric Problem
This section relates to the care of all pregnant women, attending the emergency department
or elsewhere in the hospital with a non-obstetric problem, and who require admission. This
section should describe the process for making sure the woman’s care is discussed and
planned with the local obstetric team. The organisation should consider including guidance
on the following:
7
b
c
d

individual professional responsibilities;

process for communication between professionals;

process for recording all communication;

process for the management of care of the woman; and

process for determining the most appropriate area/speciality ward where the
woman will be admitted.
Communication between the On Call Obstetric Consultant, the
Obstetric Team and the Gynaecology Team
This section should describe the process for ensuring that the on call obstetric consultant is
aware of all sick pregnant women in the hospital who have a non-obstetric problem.
This section should also describe the process for ensuring that the on call obstetric
consultant is aware of all sick pregnant women in the hospital who have a problem related
to their pregnancy.
The organisation should consider including guidance on the following:

V.2
Local
individual professional responsibilities;
March 2012
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An Organisation-wide Document for the Care of Pregnant Women Seen in the Emergency Department or
Elsewhere in the Hospital
8

process for communication between professionals;

process for recording all communication;

process for communicating clinical details and indicating the need for review; and

process for identifying if the woman is ‘vulnerable’ and the subsequent care and
management required.
Equality Impact Assessment
The organisation should identify who will undertake the Equality Impact Assessment which is
required to consider the needs and assess the impact of this document in accordance with
the Organisation-wide Document for the Development and Management of Procedural
Documents. The Equality Impact Assessment Tool found at Appendix E of the Organisationwide Document for the Development and Management of Procedural Documents could be
completed and form part of the body of the document, but as a minimum a statement
should be included within the document to demonstrate that an Equality Impact Assessment
has been carried out and that the document does not discriminate, highlighting any areas of
good practice or risk areas requiring attention.
e
9
Monitoring Compliance with the Document
9.1
Process for Monitoring Compliance
This section should identify how the maternity service plans to monitor compliance
with the Organisation-wide Document for the Care of Pregnant Women Seen in the
Emergency Department or Elsewhere in the Hospital. This should include any
auditable standards and/or key performance indicators (KPIs) stated within the
document that can be monitored. As a minimum it should include the
review/monitoring of all the minimum requirements within the CNST Maternity
Standards. There should be an explicit process described as to:
9.2

Who will perform the monitoring?

When will the monitoring be performed?

How are you going to monitor?

What will happen if any shortfalls are identified?

Where will the results of the monitoring be reported?

How will the resulting action plan be progressed and monitored?

How will learning take place?
Standards/Key Performance Indicators
This section could contain auditable standards and/or key performance indicators
(KPIs) which may assist the organisation in the process for monitoring compliance.
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An Organisation-wide Document for the Care of Pregnant Women Seen in the Emergency Department or
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10
References
This section should contain the details of any reference materials reviewed in the
development of the procedural document.
Listed below are some useful sources of reference material:
11
10.1
Guidance from Other Organisations

Confidential Enquiry into Maternity and Child Health (2004) Why Mothers Die 20002002 London: RCOG Press

Confidential Enquiry into Maternity and Child Health (2007) Saving Mothers’ Lives:
Reviewing maternal deaths to make motherhood safer – 2003-2005 London:
CEMACH

Department of Health (2004) Maternity Standard, National Service Framework for
Children, Young People and Maternity Services London: COI
Associated Documentation
This section should provide a cross reference to any other related organisational procedural
document(s).
The following list is a guide only and is not exhaustive:
V.2

Maternity early warning scoring system

Handover of care

Domestic violence
March 2012
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An Organisation-wide Document for the Care of Pregnant Women Seen in the Emergency Department or
Elsewhere in the Hospital
Appendix A - An Organisation-wide Document for the Care of Pregnant Women
Seen in the Emergency Department or Elsewhere in the Hospital
NHS Trust
An Organisation-wide Document for the Care of
Pregnant Women Seen in the Emergency Department
or Elsewhere in the Hospital
Version:
Ratified by:
Date ratified:
Name of originator/author:
Name of responsible committee/individual:
Name of executive lead:
Date issued:
Review date:
Target audience:
V.2
March 2012
Page 10 of 14
An Organisation-wide Document for the Care of Pregnant Women Seen in the Emergency Department or
Elsewhere in the Hospital
Contents
1
Introduction ........................................................................................................... 13
2
Purpose .................................................................................................................. 13
3
Explanation of Terms ............................................................................................. 13
4
Duties ..................................................................................................................... 13
4.1
Individual Professional Duties ............................................................................................... 13
5 Definition of which Women Attending the Emergency Department should be
Seen by an Appropriate Individual ............................................................................... 13
6
Care of Pregnant Women with a Non Obstetric Problem ..................................... 13
7 Communication between the On Call Obstetric Consultant, the Local Obstetric
Team and the Gynaecology Team ................................................................................ 13
8
Equality Impact Assessment .................................................................................. 13
9
Monitoring Compliance with the Document ......................................................... 13
9.1
9.2
10
10.1
11
Process for Monitoring Compliance ..................................................................................... 13
Standards/Key Performance Indicators ................................................................................ 13
References .......................................................................................................... 13
Guidance from Other Organisations ..................................................................................... 13
Associated Documentation ................................................................................ 14
Appendix A
Checklist for the Review and Approval of Procedural Documents ...... 14
Appendix B
Version Control Sheet ........................................................................... 14
Appendix C
Plan for Dissemination .......................................................................... 14
Appendix D
Equality Impact Assessment Tool ......................................................... 14
Examples of the Checklist for the Review and Approval of Procedural Documents, Version Control
Sheet, Plan for Dissemination and the Equality Impact Assessment can all be found within the
Organisation-wide Document for the Development and Management of Procedural Documents on
the NHSLA website.
Appendix B in the Organisation-wide Document for the Development and Management of Procedural
Documents contains a flowchart to assist with the process for the creation and implementation of
procedural documents.
V.2
March 2012
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An Organisation-wide Document for the Care of Pregnant Women Seen in the Emergency Department or
Elsewhere in the Hospital
Review and Amendment Log
Version no.
V.2
Type of change
Date
Description of change
March 2012
Page 12 of 14
An Organisation-wide Document for the Care of Pregnant Women Seen in the Emergency Department or
Elsewhere in the Hospital
1
Introduction
2
Purpose
3
Explanation of Terms
4
Duties
4.1
Individual Professional Duties
5
Definition of which Women Attending the Emergency Department should be Seen by an
Appropriate Individual
6
Care of Pregnant Women with a Non Obstetric Problem
7
Communication between the On Call Obstetric Consultant, the Local Obstetric Team and
the Gynaecology Team
8
Equality Impact Assessment
9
Monitoring Compliance with the Document
10
9.1
Process for Monitoring Compliance
9.2
Standards/Key Performance Indicators
References
10.1
V.2
Guidance from Other Organisations
March 2012
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An Organisation-wide Document for the Care of Pregnant Women Seen in the Emergency Department or
Elsewhere in the Hospital
11
V.2
Associated Documentation
Appendix A
Checklist for the Review and Approval of Procedural Documents
Appendix B
Version Control Sheet
Appendix C
Plan for Dissemination
Appendix D
Equality Impact Assessment Tool
March 2012
Page 14 of 14