Standards › Standard 12 › Policies
Policy · GYN-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 12 (Obstetrics and Gynaecology), criterion 12.11
At a glance
- Each woman with a gynaecological problem is assessed on GYN-FRM-001.
- Urgent problems (heavy bleeding, severe pain, suspected torsion) are seen within the set time.
- A woman who needs a gynaecologist or surgery is referred the same day.
- Each referral and its time are recorded.
- Stop and get help straight away if: a woman with urgent gynaecological symptoms waits beyond the set time, or is not referred when specialist care is needed.
1. Purpose
To assess gynaecological problems on a defined pathway, with a fast route to specialist care (12.11).
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
Gynaecological emergencies such as heavy bleeding or ovarian torsion can become life-threatening within hours. A defined pathway, with a set time for urgent review and a route to specialist care, protects women who present with them.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead gynaecologist or obstetrician | Owns the pathway and the referral route | Clinician |
| Nurse in charge | Triages and records each presentation | 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 each presentation on GYN-FRM-001, and mark urgent problems at once.
Key point: Urgent first.
Step 2. Review in time.
- Review each urgent problem within the set time.
Key point: Within the set time.
Step 3. Refer.
- Refer the same day to a gynaecologist or surgical service where needed, and record it.
Key point: Same day.
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 |
|---|---|---|---|---|
| Urgent gynaecology presentations reviewed within the set time | 100% | Monthly | Lead gynaecologist or 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 |
|---|---|---|
| GYN-FRM-001 | Gynaecological assessment and referral record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Managing complications in pregnancy and childbirth (2017) and ASF Expert Committee consensus. |
| 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)