Standards › Standard 12 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · GYN-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 12 (Obstetrics and Gynaecology), criterion 12.14
At a glance
- Each woman is cared for in private, with clinical care that is safe and clearly explained.
- Emotional support is offered, and the offer is recorded (GYN-FRM-003).
- Family, including the partner if the woman wishes, is included.
- Follow-up is booked before she leaves.
- Stop and get help straight away if: a woman who has lost a pregnancy is cared for without privacy or without the support offer recorded.
1. Purpose
To give safe, private and supportive care after a loss (12.14).
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
To give safe, private and supportive care after a loss (12.14).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead obstetrician | Owns the care pathway | Clinician |
| Nurse or counsellor | Gives the support and records the offer | 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. Care.
- Provide clinical care in private, explaining each step.
Key point: Private and clear.
Step 2. Support.
- Offer emotional support and family involvement, and record the offer (HSP-FRM-003).
Key point: Offered and recorded.
Step 3. Follow up.
- Book the follow-up before she leaves.
Key point: Booked before leaving.
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 |
|---|---|---|---|---|
| Losses with the support offer recorded | 100% | Monthly | 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 |
|---|---|---|
| GYN-FRM-003 | Pregnancy loss care record | Record |
| HSP-FRM-003 | Family support and bereavement follow-up record (existing, reused) | 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 |
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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)