Standards › Standard 12 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · OBS-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 12 (Obstetrics and Gynaecology), criterion 12.3
At a glance
- Postpartum haemorrhage and eclampsia have written steps the team follows at once.
- Uterotonic, tranexamic acid and magnesium sulphate are kept ready and checked (OBS-FRM-003).
- Blood loss is measured and recorded, not estimated.
- Each emergency is recorded and reviewed (INC-SOP-001).
- Stop and get help straight away if: a haemorrhage or eclampsia is treated with no written steps, or the drugs are not ready.
1. Purpose
To treat obstetric emergencies at once, with the equipment and drugs ready (12.3).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Haemorrhage, eclampsia and other obstetric emergencies can kill within an hour. The equipment and drugs must be ready and checked, and the team must have practised the response.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead obstetrician | Owns the steps and the drug list | Clinician |
| Midwife in charge | Checks the kit and leads the team | Midwife |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Recognise.
- Call the emergency at once for haemorrhage (over the set volume) or eclampsia.
Key point: Call at once.
Step 2. Treat.
- Give the first-line drug and measures set out in the SOP, and measure blood loss.
Key point: First line, measured.
Step 3. Escalate and review.
- Escalate to surgery and blood, and review the case.
Key point: Escalate, then review.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Emergencies with written steps followed | 100% | Each emergency | Lead obstetrician | Escalate to medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| OBS-FRM-003 | Obstetric emergency kit check record | Record |
| HOS-SOP-015 | Resuscitation equipment checks (existing, reused) | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO recommendations for the prevention and treatment of postpartum haemorrhage (2012). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
No e-learning course is linked to this document yet.
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)