Standards › Standard 12 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · OBS-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 12 (Obstetrics and Gynaecology), criterion 12.5
At a glance
- Each newborn is assessed at birth for breathing, heart rate and colour.
- Warmth, airway and drying are given at once, as the newborn care rule sets.
- Newborn resuscitation equipment is ready and checked each shift (OBS-FRM-004).
- A newborn needing more care is transferred on the defined route (PTR-SOP-003).
- Stop and get help straight away if: a newborn is not breathing and resuscitation is delayed, or the equipment is not ready.
1. Purpose
To give each newborn the care it needs from the first minutes (12.5).
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
A newborn needs care from the first minutes, including warmth, breathing and checks. Trained staff, and the equipment to do it, are the difference between a healthy start and an avoidable death.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Neonatal lead | Owns the protocol and the equipment | Clinician |
| Midwife or nurse | Runs the first assessment | Nurse |
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. Assess.
- Assess breathing, heart rate and colour at birth, and record the time.
Key point: At birth.
Step 2. Warm and support.
- Dry, warm and support the airway at once, and resuscitate if needed.
Key point: At once.
Step 3. Transfer if needed.
- Transfer a newborn needing more care on the defined route, with the record.
Key point: Route and record.
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 |
|---|---|---|---|---|
| Newborns assessed at birth with the time recorded | 100% | Monthly | Neonatal lead | 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-004 | Newborn care record | Record |
| PTR-SOP-003 | Neonatal, paediatric and critical transfers (existing, reused) | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO recommendations on newborn health (2017). |
| 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 |
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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)