Standards › Standard 12 › Policies
Policy · OBS-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 12 (Obstetrics and Gynaecology), criterion 12.2
At a glance
- Each birth is attended by staff trained in normal and complicated birth (STF-SOP-001).
- A defined route to surgical and neonatal support is in place (PTR-SOP-003).
- A second trained person is available for complicated births.
- Attendance is recorded on OBS-FRM-002.
- Stop and get help straight away if: a birth is attended by staff with no training in complicated birth, or with no route to surgical support.
1. Purpose
To make sure every birth is attended by trained staff, with support close by (12.2).
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 make sure every birth is attended by trained staff, with support close by (12.2).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead obstetrician | Sets the attendance rule and the support route | Clinician |
| Midwife in charge | Keeps the rota with trained staff | 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. Staff.
- Keep trained staff on the rota for each birth, with a second person for complicated births.
Key point: Trained, and a second.
Step 2. Route.
- Keep a written route to surgical and neonatal support, tested each year.
Key point: Route written and tested.
Step 3. Record.
- Record attendance on OBS-FRM-002.
Key point: Attendance recorded.
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 |
|---|---|---|---|---|
| Births attended by trained staff | 100% | Monthly | Midwife in charge | 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-002 | Birth 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 antenatal care for a positive pregnancy experience (2016) and the WHO Standards for improving quality of maternal and newborn care in health facilities (2016). |
| 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)