Standards › Standard 12 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · OBS-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 12 (Obstetrics and Gynaecology), criterion 12.4
At a glance
- A defined route to a blood bank or transfusion service is in place for obstetric emergencies.
- The route is tested each year, with the time to blood recorded.
- Emergency release follows BLD-SOP-006 when full compatibility testing cannot wait.
- A woman who may need blood is typed and screened on admission.
- Stop and get help straight away if: a haemorrhage occurs with no defined route to blood.
1. Purpose
To make sure blood is available within minutes for obstetric haemorrhage (12.4).
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 blood is available within minutes for obstetric haemorrhage (12.4).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead obstetrician | Owns the route and the test | Clinician |
| Blood bank or transfusion lead | Confirms supply and tests the route | Scientist |
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. Define the route.
- Write the route to the blood bank, with the contact and the time to blood.
Key point: Route written.
Step 2. Type and screen.
- Type and screen each woman at risk on admission.
Key point: Typed on admission.
Step 3. Test.
- Test the route each year and record the time to blood.
Key point: Tested, timed.
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 |
|---|---|---|---|---|
| Route tests done each year | 100% | Yearly | Blood bank or transfusion 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 |
|---|---|---|
| BLD-SOP-006 | Emergency release of blood (existing, reused) | Procedure |
| BLD-FRM-002 | Blood request and issue record (existing, reused) | Record |
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 |
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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)