Standard 12: Obstetrics and Gynaecology

Why this criterion matters. Most problems in pregnancy can be found early if the checks happen on time. An antenatal schedule that follows current guidance, and is kept, catches the problems that a missed visit would hide.

Sample. Review the antenatal records for 30 women who gave birth in the last 6 months, including 10 high-risk women.

1. Antenatal visits follow the WHO schedule.

Method. Check each sampled record against the schedule for each visit.

Evidence to show. Antenatal care record (OBS-FRM-001).

Pass when. At least 90% of visits are on schedule.

2. Results and risk are recorded and reviewed at each visit.

Method. Check each visit for results and a risk score.

Evidence to show. Antenatal care record.

Pass when. Every visit has results and a risk score recorded.

3. A high-risk woman has a written plan and a named clinician.

Method. Check each high-risk record for the plan and the named clinician.

Evidence to show. Antenatal care record and high-risk plan.

Pass when. Every high-risk woman has a plan and a named clinician.

Immediate fail (any one means the criterion is not met)

• A high-risk pregnancy has no written plan.

Why this criterion matters. Birth is the highest-risk moment of pregnancy. Attendance by staff trained in normal and complicated birth, with the skills kept current, prevents the harm that untrained hands cause.

Sample. Review the birth records for 30 births in the last 6 months, and the staff training records for those attending.

1. Each birth is attended by trained staff.

Method. Check each birth record for the staff present and their training.

Evidence to show. Birth record (OBS-FRM-002).

Pass when. Every birth is attended by staff trained for the birth.

2. A second trained person is present for complicated births.

Method. Check each complicated birth for a second trained person.

Evidence to show. Birth record.

Pass when. Every complicated birth has a second trained person recorded.

3. A defined route to surgical and neonatal support is in place and tested.

Method. Read the route and check its test record.

Evidence to show. Birth attendance and staffing policy (OBS-POL-002).

Pass when. The route is written and tested in the last 12 months.

Immediate fail (any one means the criterion is not met)

• A birth is attended by staff with no training in complicated birth.

Why this criterion matters. Haemorrhage, eclampsia and other obstetric emergencies can kill within an hour. The equipment and drugs must be ready and checked, and the team must have practised the response.

Sample. Review the emergency kit check records for the last 3 months, and observe one obstetric emergency drill.

1. Emergency drugs and equipment are checked on a schedule.

Method. Check the log for each shift.

Evidence to show. Obstetric emergency kit check record (OBS-FRM-003).

Pass when. At least 95% of shifts have a check recorded.

2. Uterotonic, tranexamic acid and magnesium sulphate are available and in date.

Method. Check the stock and expiry at the drill.

Evidence to show. Obstetric emergency kit check record.

Pass when. All three are available and in date at each check.

3. The team follows the emergency steps.

Method. Observe the drill against the emergency steps.

Evidence to show. Obstetric emergency response procedure (OBS-SOP-001).

Pass when. The drill follows the steps at each stage.

Immediate fail (any one means the criterion is not met)

• A haemorrhage or eclampsia is treated with no written steps, or the drugs are not ready.

Why this criterion matters. Bleeding after birth can need blood within minutes. The route to blood must be defined and known, so the team does not spend the time searching.

Sample. Review the route test records for the last 12 months, and the time to blood for each obstetric haemorrhage in the period.

1. A defined route to a blood bank or transfusion service exists.

Method. Read the route and check the contact is named.

Evidence to show. Blood for obstetric emergencies procedure (OBS-SOP-002).

Pass when. The route is written with a named contact.

2. The route is tested each year with the time to blood recorded.

Method. Check the test record for the last 12 months.

Evidence to show. Blood request and issue record (BLD-FRM-002).

Pass when. The route is tested in the last 12 months and the time is recorded.

3. Each woman at risk is typed and screened on admission.

Method. Check each at-risk record for typing and screening.

Evidence to show. Blood request and issue record.

Pass when. Every at-risk woman is typed and screened on admission.

Immediate fail (any one means the criterion is not met)

• A haemorrhage occurs with no defined route to blood.

Why this criterion matters. A newborn needs care from the first minutes, including warmth, breathing and checks. Trained staff, and the equipment to do it, are the difference between a healthy start and an avoidable death.

Sample. Review the newborn records for 30 births in the last 6 months, and the resuscitation equipment checks for the same period.

1. Each newborn is assessed at birth with the time recorded.

Method. Check each newborn record for the assessment and time.

Evidence to show. Newborn care record (OBS-FRM-004).

Pass when. Every newborn has an assessment and time recorded.

2. Newborn resuscitation equipment is ready and checked each shift.

Method. Check the shift records for the equipment.

Evidence to show. Resuscitation equipment checks (HOS-SOP-015).

Pass when. At least 95% of shifts have a check recorded.

3. A newborn needing more care is transferred on the defined route.

Method. Check each transfer for the route and the record.

Evidence to show. Neonatal, paediatric and critical transfers (PTR-SOP-003).

Pass when. Every transfer follows the defined route with a record.

Immediate fail (any one means the criterion is not met)

• A newborn is not breathing and resuscitation is delayed, or the equipment is not ready.

Why this criterion matters. The first days after birth carry risk for both mother and baby. Checks for bleeding, infection and the baby's feeding and breathing, done on a schedule, catch the problems early.

Sample. Review the postnatal records for 30 mothers and babies discharged in the last 6 months.

1. Each mother and baby has postnatal checks on schedule.

Method. Check each record for checks on the schedule.

Evidence to show. Postnatal check record (OBS-FRM-005).

Pass when. At least 90% have checks on schedule.

2. The checks cover bleeding, infection, feeding and mental health.

Method. Check each record for the four items.

Evidence to show. Postnatal check record.

Pass when. Every record covers the four items.

3. A follow-up visit is booked before discharge.

Method. Check each discharge for a booked follow-up.

Evidence to show. Postnatal care and follow-up procedure (OBS-SOP-004).

Pass when. Every discharge has a follow-up booked.

Immediate fail (any one means the criterion is not met)

• A mother is discharged with no postnatal check or no follow-up booked.

Why this criterion matters. A woman has the right to know her options and their risks, and to take part in choices about her own birth. Information given in time, and recorded, makes her decisions real.

Sample. Review the birth choice records for 30 women in the last 6 months, including any birth that changed from the woman's choice.

1. Each woman receives information on place and mode of birth.

Method. Check each record for the information given and its date.

Evidence to show. Birth choices record (OBS-FRM-006).

Pass when. At least 95% have the information recorded.

2. The woman's choice is recorded.

Method. Check each record for the choice.

Evidence to show. Birth choices record.

Pass when. Every record shows the choice.

3. A change from the choice is recorded with the reason.

Method. Check each changed birth for the reason and the explanation.

Evidence to show. Birth choices record.

Pass when. Every change has a reason and an explanation recorded.

Immediate fail (any one means the criterion is not met)

• A birth proceeds in a mode the woman did not choose, with no explanation or record.

Why this criterion matters. Maternal and newborn deaths and severe complications are rare enough to be missed. Reviewing each one, and the outcomes, shows the causes and what must change.

Sample. Review the outcomes register for the last 3 years, and the review record for each maternal death, perinatal death and severe complication.

1. Each maternal and perinatal death and severe complication is recorded.

Method. Compare the register with the clinical records for the period.

Evidence to show. Maternal and perinatal outcomes review register (OBS-REG-001).

Pass when. No event in the clinical records is missing from the register.

2. Each event is reviewed and the review is completed.

Method. Check each event for the review date and finding.

Evidence to show. Maternal and perinatal outcomes review register.

Pass when. Every event has a completed review.

3. Each finding leads to an action that is closed.

Method. Check each finding for its action and closure.

Evidence to show. Maternal and perinatal outcomes review register.

Pass when. At least 80% of actions are closed on time.

Immediate fail (any one means the criterion is not met)

Why this criterion matters. A newborn must be matched to its mother from the first minute. Identifiers that match at birth, checked before the mother and baby leave, prevent the mix-ups that are hardest to undo.

Sample. Review 30 birth records, checking the newborn identifier against the mother's record at each step.

1. The newborn is identified at birth with an identifier that matches the mother.

Method. Check each birth record for both identifiers and the match.

Evidence to show. Birth record (OBS-FRM-002) and newborn record (OBS-FRM-004).

Pass when. Every newborn has a matched identifier recorded.

2. The match is checked at each point where mother and baby are separated or moved.

Method. Check each separation and move for a second check.

Evidence to show. Patient identification check log (ID-FRM-001).

Pass when. Every separation and move has a check recorded.

3. The identification procedure is followed.

Method. Read the identification procedure and check it covers each step.

Evidence to show. Patient identification and specimen labelling procedure (ID-SOP-001).

Pass when. The procedure covers the match at birth and each move.

Immediate fail (any one means the criterion is not met)

• A newborn is separated from the mother's record with no match checked.

Why this criterion matters. Haemorrhage, infection and high blood pressure after birth can progress quickly. A recognised obstetric early-warning tool, used on a set schedule, flags the deterioration before the emergency.

Sample. Review the early-warning charts for 30 mothers after birth in the last 3 months, including every chart where a trigger was reached.

1. Each mother is monitored with the obstetric early-warning chart after birth.

Method. Check each sampled chart for scores at the set frequency.

Evidence to show. Obstetric early-warning chart (OBS-FRM-008).

Pass when. At least 90% of scheduled scores are recorded.

2. A trigger leads to a clinician review within the set time.

Method. Check each trigger for the time of review.

Evidence to show. Obstetric early-warning response procedure (OBS-SOP-006).

Pass when. At least 95% of triggers are reviewed within the set time.

3. A bleeding or high blood pressure trigger starts the emergency steps.

Method. Check each such trigger for the start of OBS-SOP-001.

Evidence to show. Obstetric emergency response procedure (OBS-SOP-001).

Pass when. Every bleeding or high blood pressure trigger starts the emergency steps.

Immediate fail (any one means the criterion is not met)

• A trigger for bleeding is not reviewed and the emergency steps do not start.

Why this criterion matters. 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.

Sample. Review 20 urgent gynaecology presentations in the last 6 months, with the time to review and any referral.

1. Urgent problems are seen within the set time.

Method. Check the time from presentation to review for each urgent case.

Evidence to show. Gynaecological assessment and referral record (GYN-FRM-001).

Pass when. At least 90% of urgent cases are seen within the set time.

2. A woman who needs a specialist or surgery is referred the same day.

Method. Check each referral for the date and the time.

Evidence to show. Gynaecological assessment and referral record.

Pass when. At least 95% of referrals are made the same day.

3. A written pathway is in place and current.

Method. Read the pathway and check its review date.

Evidence to show. Gynaecological assessment and urgent referral pathway (GYN-POL-001).

Pass when. The pathway is written and reviewed in the last 12 months.

Immediate fail (any one means the criterion is not met)

• A woman with urgent gynaecological symptoms waits beyond the set time with no review.
• A woman who needs surgery is not referred.

Why this criterion matters. A woman has the right to decide whether and when to have children. Information on each method, and a recorded choice, supports that right and reduces unplanned pregnancy.

Sample. Review 30 women offered contraception in the last 6 months.

1. Each woman is given information on the methods.

Method. Check each record for the information given and its date.

Evidence to show. Contraception choice record (GYN-FRM-002).

Pass when. At least 95% of records show the information given.

2. Eligibility is checked before any method is given.

Method. Check each method given for the eligibility check.

Evidence to show. Contraception choice record.

Pass when. Every method given has the eligibility check recorded.

3. The choice, or the decision not to choose, is recorded.

Method. Check each record for the choice or the decision.

Evidence to show. Contraception choice record.

Pass when. Every record shows the choice or the decision.

Immediate fail (any one means the criterion is not met)

• A method is given without an eligibility check.

Why this criterion matters. Cervical and breast cancers are found earlier when screening is offered on schedule and results are acted on. A screening result that is not followed up can cost a life.

Sample. Review the screening register for the last 12 months, with 20 abnormal results and the recall list.

1. Screening is offered on the national schedule.

Method. Check the register for an offer to each eligible woman.

Evidence to show. Screening recall and result register (GYN-REG-001).

Pass when. At least 90% of eligible women have an offer recorded.

2. Each abnormal result is referred within the set time.

Method. Check the time from result to referral for each abnormal result.

Evidence to show. Screening recall and result register.

Pass when. At least 95% of abnormal results are referred within the set time.

3. Women who do not attend are recalled.

Method. Check the recall record for each non-attender.

Evidence to show. Recall register (PHC-REG-003).

Pass when. Every non-attender is recalled and recorded.

Immediate fail (any one means the criterion is not met)

• An abnormal screening result is not referred within the set time.

Why this criterion matters. Miscarriage and pregnancy loss are common and can be traumatic. Care that is clinically safe, private and emotionally supportive protects the woman and her family.

Sample. Review the care records for 15 losses in the last 6 months.

1. Care is given in private.

Method. Check each record for the privacy and the care given.

Evidence to show. Pregnancy loss care record (GYN-FRM-003).

Pass when. Every record shows care given in private.

2. Emotional support is offered and the offer is recorded.

Method. Check each record for the offer and the answer.

Evidence to show. Pregnancy loss care record.

Pass when. Every loss has the offer and answer recorded.

3. A follow-up is booked before the woman leaves.

Method. Check each record for the booked follow-up date.

Evidence to show. Pregnancy loss care record.

Pass when. Every woman leaves with a follow-up booked.

Immediate fail (any one means the criterion is not met)

• A woman is cared for without privacy, or without the support offer recorded.

Why this criterion matters. Most deaths on a ward were preceded by hours of warning signs. A score that is recorded but leads to no response protects no one.

Sample. Review the observation charts for 30 inpatients in the last 3 months, including every patient whose score rose.

1. Vital signs are recorded at a set frequency.

Method. Check each sampled chart for observations at the set frequency.

Evidence to show. Observation and early warning chart (HOS-FRM-002).

Pass when. At least 90% of scheduled observations are recorded.

2. The frequency rises when the patient worsens.

Method. Check each rise in score for an increased frequency.

Evidence to show. Vital signs and deterioration response (HOS-SOP-002).

Pass when. Every rise in score is followed by an increased frequency.

3. A recognised early warning score is used and acted on.

Method. Check each score that reached the trigger for a response.

Evidence to show. Vital signs and deterioration response (HOS-SOP-002).

Pass when. Every trigger has a response recorded.

Immediate fail (any one means the criterion is not met)

• A patient whose score reaches the trigger has no response recorded.