Standards › Standard 12 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · OBS-SOP-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 12 (Obstetrics and Gynaecology), criterion 12.6
At a glance
- Each mother and baby have postnatal checks on a set schedule (OBS-FRM-005).
- Checks cover bleeding, infection, feeding, pain and mental health.
- A follow-up visit is booked before discharge.
- A woman who reports low mood is referred the same week.
- Stop and get help straight away if: a mother is discharged with no postnatal check or no follow-up booked.
1. Purpose
To check mother and baby in the first days after birth, when risk is high (12.6).
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 check mother and baby in the first days after birth, when risk is high (12.6).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Midwife in charge | Owns the schedule | Midwife |
| Midwife | Runs the checks and records them | 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. Check.
- Check bleeding, infection, feeding and mental health on the schedule, and record on OBS-FRM-005.
Key point: On schedule.
Step 2. Book.
- Book the follow-up visit before discharge.
Key point: Before discharge.
Step 3. Refer.
- Refer a woman with low mood the same week to mental health support.
Key point: Same week.
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 |
|---|---|---|---|---|
| Discharges with a follow-up booked | 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-005 | Postnatal check record | Record |
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 |
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)