Admission & discharge guide
Find when a case needs hospital care, when outpatient care may be suitable, and what must be arranged before going home. Every clinical topic has its own admission/discharge plan, with medicine changes, result tracking, follow-up and return warnings.
IN REVIEW Guidance checked 2026-10-18; section-level checks do not certify every statement elsewhere in a module.
Case-specific admission and discharge
Chronic Hypertension in Pregnancy
Usual setting: Usually outpatient; admit for severe BP or complications
Admission trigger: Severe-range BP (systolic ≥160 or diastolic ≥110 mmHg), symptoms suggesting superimposed pre-eclampsia, concerning blood tests or fetal compromise need hospital assessment; admit when surveillance/treatment cannot be delivered safely outside hospital.
Open admission & discharge plan →Gestational Hypertension
Usual setting: Outpatient surveillance if stable; admit severe hypertension
Admission trigger: Admit severe hypertension; assess for pre-eclampsia when symptoms, proteinuria, laboratory abnormalities or fetal concerns develop.
Open admission & discharge plan →Pre-eclampsia (without severe features)
Usual setting: Hospital assessment; severe disease needs admission and possible critical care
Admission trigger: Admit for severe/persistent hypertension, seizure or neurological symptoms, pulmonary oedema, renal/liver/platelet deterioration, significant pain or fetal compromise.
Open admission & discharge plan →Pre-eclampsia with Severe Features / Severe Pre-eclampsia
Usual setting: Hospital assessment; severe disease needs admission and possible critical care
Admission trigger: Admit for severe/persistent hypertension, seizure or neurological symptoms, pulmonary oedema, renal/liver/platelet deterioration, significant pain or fetal compromise.
Open admission & discharge plan →Eclampsia
Usual setting: Hospital assessment; severe disease needs admission and possible critical care
Admission trigger: Admit for severe/persistent hypertension, seizure or neurological symptoms, pulmonary oedema, renal/liver/platelet deterioration, significant pain or fetal compromise.
Open admission & discharge plan →HELLP Syndrome
Usual setting: Hospital assessment; severe disease needs admission and possible critical care
Admission trigger: Admit for severe/persistent hypertension, seizure or neurological symptoms, pulmonary oedema, renal/liver/platelet deterioration, significant pain or fetal compromise.
Open admission & discharge plan →Postpartum Hypertension & Postpartum Pre-eclampsia
Usual setting: Hospital assessment; severe disease needs admission and possible critical care
Admission trigger: Admit for severe/persistent hypertension, seizure or neurological symptoms, pulmonary oedema, renal/liver/platelet deterioration, significant pain or fetal compromise.
Open admission & discharge plan →Postpartum Haemorrhage (PPH)
Usual setting: Emergency admission; major bleeding may need theatre/critical care
Admission trigger: Admit and treat ongoing heavy bleeding, abnormal haemodynamics, suspected retained tissue/infection or coagulopathy. Transfer to theatre/critical care according to bleeding and organ-support requirements.
Open admission & discharge plan →Placenta Praevia & Low-lying Placenta (APH pathway)
Usual setting: Bleeding requires hospital assessment; inpatient versus home surveillance is individualised
Admission trigger: Any new bleeding, contractions or pain requires immediate maternity assessment. Admit ongoing/recurrent significant bleeding, maternal instability, fetal concerns or inability to reach emergency care safely.
Open admission & discharge plan →Placental Abruption
Usual setting: Emergency obstetric assessment; suspected acute abruption usually needs admission
Admission trigger: Admit suspected abruption with pain, tenderness, bleeding, maternal instability, coagulopathy or fetal compromise; arrange timely delivery and resuscitation when indicated.
Open admission & discharge plan →Vasa Praevia
Usual setting: Specialist birth planning; emergency admission with labour, bleeding or membrane rupture
Admission trigger: Ruptured membranes, bleeding or labour with suspected/known vasa praevia requires immediate obstetric attendance and preparation for urgent caesarean/neonatal care.
Open admission & discharge plan →Placenta Accreta Spectrum (acreta/increta/percreta)
Usual setting: Planned specialist-centre admission; urgent admission for bleeding/labour
Admission trigger: Bleeding, labour, membrane rupture, maternal deterioration or fetal concern requires hospital assessment. Planned birth should be in an appropriately resourced multidisciplinary centre.
Open admission & discharge plan →Pregnancy of Unknown Location (PUL)
Usual setting: Early-pregnancy assessment; outpatient only with reliable ectopic surveillance
Admission trigger: Admit/escalate instability, significant or worsening pain, heavy bleeding, collapse or an unsafe follow-up situation; assess urgently for ectopic rupture.
Open admission & discharge plan →Ectopic Pregnancy
Usual setting: Emergency admission if rupture/instability; selected stable cases can be managed as outpatients
Admission trigger: Suspected rupture, instability, significant pain or major bleeding requires admission and urgent surgery. Inability to return for follow-up or surgical-treatment criteria changes the management choice.
Open admission & discharge plan →Miscarriage Management (threatened/incomplete/missed)
Usual setting: Usually outpatient/day care if stable; admit haemorrhage, infection or unsafe symptoms
Admission trigger: Admit heavy ongoing bleeding/instability, suspected sepsis, severe uncontrolled pain or inability to complete safe outpatient care. Exclude ectopic pregnancy when the location/outcome is uncertain.
Open admission & discharge plan →Recurrent Miscarriage
Usual setting: Usually specialist outpatient care
Admission trigger: Current heavy bleeding, instability, infection or severe pain follows the acute miscarriage/ectopic pathway; urgent mental-health assessment is needed for immediate safety concerns.
Open admission & discharge plan →Molar Pregnancy & Gestational Trophoblastic Disease
Usual setting: Planned admission/day surgery for evacuation; urgent admission with bleeding or complications
Admission trigger: Admit haemorrhage/instability, significant anaemia, severe pregnancy complications or a need for urgent evacuation; arrange experienced anaesthetic/transfusion support.
Open admission & discharge plan →Medical Termination of Pregnancy — Indian Legal Framework
Usual setting: Outpatient/day care or inpatient treatment according to gestation, method and clinical risk
Admission trigger: Admit haemorrhage, infection, severe uncontrolled pain, suspected ectopic pregnancy, major comorbidity or a procedure/gestation requiring hospital monitoring.
Open admission & discharge plan →Labour Management (term)
Usual setting: Birth-facility care for established labour; postnatal discharge requires mother-and-baby assessment
Admission trigger: Established labour/birth, concerning maternal observations, abnormal fetal assessment, significant bleeding, rupture of membranes with risk factors, or a need for analgesia/monitoring requires the appropriate maternity setting.
Open admission & discharge plan →Induction of Labour (IOL)
Usual setting: Planned maternity admission or a specifically selected outpatient induction pathway
Admission trigger: Maternal/fetal risk, abnormal assessment, labour, membrane rupture, bleeding, a concerning response to ripening or inability to return promptly requires inpatient care. Oxytocin infusion requires a monitored maternity setting.
Open admission & discharge plan →Caesarean Section
Usual setting: Planned or emergency inpatient surgery
Admission trigger: Admit for the planned operation or for any urgent maternal/fetal indication. Haemorrhage, sepsis, instability or organ-support needs require increased monitoring/critical care.
Open admission & discharge plan →VBAC / TOLAC
Usual setting: Birth-facility care for established labour; postnatal discharge requires mother-and-baby assessment
Admission trigger: Established labour/birth, concerning maternal observations, abnormal fetal assessment, significant bleeding, rupture of membranes with risk factors, or a need for analgesia/monitoring requires the appropriate maternity setting.
Open admission & discharge plan →Shoulder Dystocia
Usual setting: Emergency intrapartum care; post-event observation and newborn assessment
Admission trigger: Manage in an emergency birth setting with obstetric/neonatal help; admit/continue care for maternal trauma/haemorrhage or neonatal injury/compromise.
Open admission & discharge plan →Cord Prolapse
Usual setting: Immediate hospital obstetric emergency
Admission trigger: Urgent birth and neonatal support are needed according to fetal viability/status and the obstetric situation.
Open admission & discharge plan →Breech Presentation & ECV
Usual setting: Usually outpatient planning; ECV in a unit with emergency caesarean access
Admission trigger: Bleeding, labour, membrane rupture, abnormal fetal assessment or maternal instability needs hospital evaluation/admission; ECV complications require immediate obstetric care.
Open admission & discharge plan →CTG Interpretation & Intrauterine Resuscitation
Usual setting: Assessment/monitoring in the appropriate maternity setting
Admission trigger: An abnormal trace, persistent reduced movements, bleeding, hypertension, growth concern or suspected infection requires escalation and admission when further monitoring/treatment or birth is indicated.
Open admission & discharge plan →Threatened Preterm Labour (<37 weeks with contractions, unchanging cervix)
Usual setting: Urgent maternity assessment; selected low-likelihood cases may go home
Admission trigger: Admit diagnosed labour, maternal/fetal concerns, membrane rupture, bleeding/infection or an unsafe home situation. If assessment at ≥30 weeks cannot obtain the indicated tests, NICE advises treating as diagnosed preterm labour.
Open admission & discharge plan →Established Preterm Labour (<37 weeks, cervical change)
Usual setting: Inpatient maternity/neonatal pathway
Admission trigger: Admit labour with cervical change or a high likelihood of imminent preterm birth; arrange appropriate steroids, neuroprotection, antibiotics/tocolysis when indicated and neonatal discussion.
Open admission & discharge plan →PPROM (Preterm Prelabour Rupture of Membranes 24+0-36+6)
Usual setting: Initial hospital observation; selected stable patients may later receive home surveillance
Admission trigger: Admit suspected infection, labour, bleeding, fetal compromise, maternal illness or inability to attend monitoring/return rapidly.
Open admission & discharge plan →Term PROM (>=37 weeks)
Usual setting: Maternity assessment; selected expectant management may be at home with a time-limited plan
Admission trigger: Admit labour or an indication for induction/monitoring, maternal/fetal concern, bleeding, abnormal fluid or suspected infection. GBS-related circumstances may favour immediate birth planning.
Open admission & discharge plan →Fetal Growth Restriction / SGA
Usual setting: Specialist surveillance; admit if maternal/fetal findings require closer care or birth
Admission trigger: Abnormal/worsening fetal assessment, concerning Doppler findings, reduced movements, maternal hypertension or another complication may require admission and delivery planning.
Open admission & discharge plan →Multiple Pregnancy (twins incl. TTTS/TAPS/TRAP)
Usual setting: Specialist outpatient care when uncomplicated; admit for complications or planned birth
Admission trigger: Admit preterm labour, bleeding, membrane rupture, maternal illness or fetal concern; suspected TTTS/TAPS or other monochorionic complications needs urgent fetal-medicine assessment.
Open admission & discharge plan →Reduced Fetal Movements
Usual setting: Prompt maternity assessment; home only after a reassuring complete review
Admission trigger: Abnormal fetal assessment, persistent/recurrent concern with other risk findings, maternal illness or a need for monitoring/birth requires escalation and possible admission.
Open admission & discharge plan →Gestational Diabetes Mellitus
Usual setting: Usually outpatient; admit acute metabolic or obstetric complications
Admission trigger: Admit suspected DKA/ketosis with illness, severe/recurrent hypoglycaemia, dehydration, marked symptomatic hyperglycaemia or maternal/fetal compromise. Poor control may need supervised treatment adjustment.
Open admission & discharge plan →Pregestational Diabetes (T1/T2)
Usual setting: Outpatient coordinated care when stable; hospital admission for DKA or severe hypoglycaemia
Admission trigger: Suspected DKA in pregnancy requires urgent hospital/critical-care assessment even when glucose is not extremely high. Admit severe/recurrent hypoglycaemia, inability to maintain intake or maternal/fetal compromise.
Open admission & discharge plan →Thyroid Disease in Pregnancy
Usual setting: Usually outpatient; thyroid storm or severe decompensation requires admission
Admission trigger: Admit suspected thyroid storm, significant arrhythmia/heart failure, severe systemic illness or inability to take essential treatment.
Open admission & discharge plan →Anaemia in Pregnancy (Iron/Folate/B12)
Usual setting: Usually outpatient replacement; admit instability, severe symptoms or major bleeding
Admission trigger: Admit active significant bleeding, cardiovascular compromise, syncope, severe symptoms or a need for urgent transfusion/close monitoring. Consider proximity to birth and access to definitive treatment.
Open admission & discharge plan →VTE in Pregnancy (DVT/PE + Thromboprophylaxis)
Usual setting: Urgent hospital assessment; outpatient treatment only through a suitable specialist pathway
Admission trigger: Suspected PE, haemodynamic or respiratory compromise, major bleeding risk, severe pain, extensive thrombosis or unsafe home treatment requires hospital care; unstable PE needs urgent critical-care treatment.
Open admission & discharge plan →Maternal Sepsis
Usual setting: Emergency hospital admission; organ dysfunction may require critical care
Admission trigger: Admit suspected sepsis, hypotension, respiratory compromise, altered mental state, oliguria or inability to maintain intake. Arrange urgent source control and appropriate organ support.
Open admission & discharge plan →Hyperemesis Gravidarum
Usual setting: Ambulatory rehydration or inpatient care according to severity
Admission trigger: Admit dehydration, inability to retain fluids/oral medicines, abnormal blood tests, significant ongoing weight/nutritional loss or comorbidity made unsafe by vomiting.
Open admission & discharge plan →Intrahepatic Cholestasis of Pregnancy
Usual setting: Usually outpatient specialist monitoring; admit concerning symptoms/tests or planned birth
Admission trigger: Admit maternal/fetal compromise, severe alternative liver disease concerns, significant bleeding/coagulopathy or another obstetric indication; assess reduced movements immediately.
Open admission & discharge plan →Chronic Medical Disorders Quick-Reference (asthma · epilepsy · cardiac · CKD · SLE/APS)
Usual setting: Stable disease: coordinated outpatient care; acute decompensation: hospital assessment
Admission trigger: Severe breathlessness/hypoxia, chest pain/syncope, prolonged/recurrent seizure, acute kidney injury/oliguria, severe hypertension or systemic autoimmune/obstetric deterioration requires urgent hospital assessment and appropriate admission.
Open admission & discharge plan →UTI & Pyelonephritis in Pregnancy
Usual setting: Cystitis often outpatient; pregnancy pyelonephritis initially inpatient under the ACOG pathway
Admission trigger: Suspected pyelonephritis in pregnancy: initial inpatient management (ACOG). Admit sepsis, dehydration, vomiting/inability to take treatment, obstruction concerns or maternal/fetal compromise.
Open admission & discharge plan →Chorioamnionitis / Intra-amniotic Infection
Usual setting: Inpatient obstetric infection/birth pathway
Admission trigger: Admit suspected infection and assess for maternal sepsis, fetal compromise and the need for birth/source control.
Open admission & discharge plan →GBS Colonisation (prevention of early-onset neonatal disease)
Usual setting: Usually outpatient colonisation care; admission follows labour, membrane rupture or infection
Admission trigger: Labour/membrane rupture needs the documented maternity/antibiotic plan. Fever, maternal illness or fetal/newborn concerns requires hospital assessment.
Open admission & discharge plan →Syphilis in Pregnancy
Usual setting: Usually outpatient stage-specific treatment; admit severe neurological/systemic disease or obstetric complications
Admission trigger: Neurological/ocular/otic disease, severe systemic illness or a maternal/fetal complication needs urgent specialist assessment and possible admission/IV treatment.
Open admission & discharge plan →Chlamydia in Pregnancy
Usual setting: Usually outpatient treatment
Admission trigger: Pelvic/systemic illness, significant pain, fever or a suspected obstetric complication requires assessment for PID, ectopic pregnancy or another cause and admission when indicated.
Open admission & discharge plan →Gonorrhoea in Pregnancy
Usual setting: Usually outpatient treatment; admit disseminated/systemic or pelvic complications
Admission trigger: Disseminated illness, joint involvement, sepsis, severe pelvic pain or suspected PID requires hospital/specialist assessment.
Open admission & discharge plan →Genital Herpes in Pregnancy
Usual setting: Usually outpatient if oral intake and urinary function are maintained
Admission trigger: Severe/disseminated infection, neurological illness, hepatitis concern, urinary retention, inability to take oral therapy or obstetric/fetal concern requires hospital assessment.
Open admission & discharge plan →Vaginitis Bundle (BV · candidiasis · trichomoniasis)
Usual setting: Usually outpatient; systemic/pelvic symptoms require another diagnosis to be assessed
Admission trigger: Fever, severe pelvic/abdominal pain, systemic illness, pregnancy fluid-loss concern or inability to tolerate treatment needs assessment for another/complicated condition.
Open admission & discharge plan →Pelvic Inflammatory Disease
Usual setting: Outpatient for selected mild/moderate disease; admission for defined high-risk features
Admission trigger: CDC admission criteria include pregnancy, tubo-ovarian abscess, severe illness/vomiting or temperature >38.5°C, inability to tolerate/follow oral therapy, lack of response, or inability to exclude a surgical emergency.
Open admission & discharge plan →Viral Infections Quick-Reference (HIV · HBV · HCV · rubella · CMV · varicella · influenza · COVID)
Usual setting: Most stable cases need specialist outpatient coordination; severe infection needs admission
Admission trigger: Respiratory compromise, severe dehydration, encephalopathy, acute liver failure concern, sepsis or obstetric/fetal deterioration requires urgent hospital assessment.
Open admission & discharge plan →Abnormal Uterine Bleeding (PALM-COEIN)
Usual setting: Usually outpatient if stable; admit acute heavy bleeding or severe symptomatic compromise
Admission trigger: Admit uncontrolled heavy bleeding, instability/syncope, severe symptomatic anaemia, suspected infection or a surgical emergency. Acute pain requires assessment for other causes rather than assuming fibroids.
Open admission & discharge plan →Polycystic Ovary Syndrome
Usual setting: Usually outpatient; admission is for an acute complication, not PCOS itself
Admission trigger: Severe bleeding/instability, acute pelvic pain suggesting another diagnosis, or complications of fertility treatment requires urgent assessment; OHSS follows the fertility-complication pathway.
Open admission & discharge plan →Endometriosis
Usual setting: Usually outpatient treatment; planned surgery or an acute complication may need admission
Admission trigger: Uncontrolled acute pain, systemic illness, heavy bleeding, bowel/urinary obstruction concern or another surgical diagnosis requires hospital assessment.
Open admission & discharge plan →Uterine Fibroids
Usual setting: Usually outpatient if stable; admit acute heavy bleeding or severe symptomatic compromise
Admission trigger: Admit uncontrolled heavy bleeding, instability/syncope, severe symptomatic anaemia, suspected infection or a surgical emergency. Acute pain requires assessment for other causes rather than assuming fibroids.
Open admission & discharge plan →Adnexal Masses, Ovarian Cysts & Torsion
Usual setting: Suspected torsion: urgent admission/surgical assessment; stable cyst: specialist outpatient pathway
Admission trigger: Sudden significant unilateral pain, vomiting, peritoneal signs, haemorrhage/instability or suspected torsion requires urgent hospital assessment. A normal Doppler signal alone does not establish that torsion is absent.
Open admission & discharge plan →Urogynaecology Core (SUI · OAB · POP · rUTI · fistula)
Usual setting: Usually outpatient; admit acute retention, infection, organ compromise or postoperative complications
Admission trigger: Urinary retention, sepsis, severe pain, obstructed/compromised prolapse, renal concern or a significant postoperative complication requires urgent assessment and admission if ongoing care is needed.
Open admission & discharge plan →Menopause, Perimenopause & POI
Usual setting: Usually outpatient assessment and treatment
Admission trigger: Heavy bleeding/instability, severe acute pain, suspected VTE or another serious acute illness requires urgent assessment rather than attributing it to menopause.
Open admission & discharge plan →Endometrial Cancer
Usual setting: Specialist oncology pathway; admit acute complications or planned treatment when required
Admission trigger: Major bleeding, bowel/urinary obstruction, uncontrolled pain, dehydration, VTE, sepsis or an unwell patient receiving anticancer therapy needs urgent hospital assessment.
Open admission & discharge plan →Cervical Cancer
Usual setting: Specialist oncology pathway; admit acute complications or planned treatment when required
Admission trigger: Major bleeding, bowel/urinary obstruction, uncontrolled pain, dehydration, VTE, sepsis or an unwell patient receiving anticancer therapy needs urgent hospital assessment.
Open admission & discharge plan →Cervical Screening & HPV (incl. vaccination)
Usual setting: Usually outpatient screening/colposcopy/day treatment
Admission trigger: Uncontrolled bleeding, severe pain, infection concern, an anaesthetic complication or suspected invasive cancer with acute complications requires assessment/admission as indicated.
Open admission & discharge plan →Ovarian · Vulval · Vaginal Cancer & GTN Index
Usual setting: Specialist oncology pathway; admit acute complications or planned treatment when required
Admission trigger: Major bleeding, bowel/urinary obstruction, uncontrolled pain, dehydration, VTE, sepsis or an unwell patient receiving anticancer therapy needs urgent hospital assessment.
Open admission & discharge plan →Contraception Master Module
Usual setting: Usually outpatient counselling/procedure
Admission trigger: Severe abdominal pain, suspected ectopic pregnancy/perforation, uncontrolled bleeding, infection/sepsis or a serious medicine complication requires urgent assessment.
Open admission & discharge plan →Female Infertility Evaluation & Management
Usual setting: Usually outpatient evaluation; admit severe fertility-treatment complications
Admission trigger: Severe OHSS, pain not controlled by oral treatment, persistent vomiting/dehydration, reduced urine, breathing/chest symptoms, thrombosis concern or inability to attend monitoring may require admission.
Open admission & discharge plan →Antenatal care: trimester tests & visit schedule
Usual setting: Routine outpatient antenatal care; admit complications rather than uncomplicated pregnancy
Admission trigger: Bleeding, severe pain, reduced movements, membrane rupture/labour concerns, severe BP symptoms, sepsis, significant dehydration or other maternal/fetal deterioration requires prompt maternity assessment and admission when needed.
Open admission & discharge plan →Postnatal stay and follow-up contacts
| Setting / source | Timing and conditions |
|---|---|
India NHM / LaQshya | After normal delivery: do not discharge before 48 hours; clinical or newborn concerns require longer care. |
WHO international baseline | Healthy women/newborns should receive facility care for at least 24 hours after birth; assess individual needs before transfer. Routine further contacts: 48–72 hours, day 7–14 and week 6. |
NICE UK caesarean pathway | Selected women recovering well, afebrile and without complications may be offered discharge after 24 hours with home follow-up. This is not an automatic Indian post-caesarean discharge time. |
Individualised care | Use the applicable local service plan and condition-specific criteria. Maternal and newborn readiness, access to follow-up and support can require a longer stay. |
Before transfer, assess maternal recovery and newborn needs, confirm feeding support, and arrange the actual local follow-up. A minimum stay is not a discharge order when complications remain.
Complete discharge checklist
Complete the items that apply to this patient and the condition-specific plan. Record the decision, prescriptions, results ownership and follow-up in the discharge summary.
1. Diagnosis, course and responsible clinician
- Record the diagnosis, pregnancy/postnatal status, relevant comorbidities, reason for admission, procedures, significant events and treatment response.
- Document the clinician approving transfer/home care, date/time, destination and the level of support still required. ICU-to-ward transfer is a separate decision from going home.
2. Clinical readiness and ongoing risks
- Reassess observations, consciousness, breathing, circulation, bleeding, infection and pain against the condition-specific plan below.
- Confirm oral fluids/food and required medicines are feasible, mobility is safe and bladder function is adequate or has an explicit catheter plan. Review bowel function when the illness/operation makes it relevant.
- Review important blood/imaging findings and the trend. A normal single BP, glucose, Hb or CTG does not by itself establish discharge readiness.
3. Complete medicine reconciliation
- For every take-home medicine write its indication, generic/formulation name, dose, route, frequency, duration or stop/review date, and quantity. Record medicines started, changed, continued and stopped.
- Check allergies, pregnancy/breastfeeding, renal/hepatic function, interactions and duplicate OTC products. Explain the last hospital dose and next home dose where timing matters.
- Confirm supply, affordability, administration technique and understanding. Insulin, anticoagulants, devices and other high-risk medicines need practical teaching and a monitoring/rescue plan.
4. Pending results and repeat investigations
- List every pending culture, histology, hCG, imaging or other relevant result. Name who checks it, by when, how the patient is contacted and what to do if no result arrives.
- Book required repeat blood tests/scans with a reviewer and action plan for an abnormal result. A pending result can be followed outside hospital only when clinical safety and reliable tracking allow it.
5. Bleeding and thrombosis prevention
- Reassess thrombosis risk against current bleeding, operation, mobility and other risk factors. Record whether prophylaxis is indicated and why.
- If anticoagulation is prescribed, specify prophylactic versus therapeutic dose, duration, hold/restart instructions and injection/sharps training. Explain bleeding and VTE warning signs.
6. Wounds, perineum, drains, catheters and bowel care
- Record the wound/repair assessment and teach hygiene, dressing and activity care relevant to the actual operation.
- For any catheter/drain/stoma left in place, record its purpose, care, output/blockage warnings and who removes/reviews it at which appointment. Record suture/clip removal if needed.
7. Pregnancy, birth and newborn handover
- If still pregnant, document gestation, fetal assessment, pending surveillance, birth plan and indications for earlier return/birth.
- After birth, communicate delivery/operative details, major blood loss, infection/GBS, RhD/antibody findings and any indicated prophylaxis or neonatal assessment.
- Assess mother and baby separately. Confirm newborn clinical assessment, an observed effective feed or documented feeding support plan, and screening/jaundice/weight follow-up. Arrange maternal support if the baby remains in neonatal care.
8. Recovery and practical home care
- Explain expected bleeding/discharge and pain, diet/hydration, graded activity, hygiene and bladder/bowel recovery. Give operation-specific restrictions and driving advice when relevant.
- Discuss feeding support, contraception and future pregnancy/fertility advice appropriate to the diagnosis and treatment. Explain medicine safety while breastfeeding.
9. Appointments that are actually arranged
- Write the date/time or defined interval, place/contact, purpose and responsible service for each follow-up. Include BP, hCG, glucose, Hb, wound, specialty and neonatal reviews as applicable.
- Confirm who continues care in the community and how the discharge summary/prescription reaches them. Give the patient a copy in an understandable format.
10. Urgent-return instructions and access
- Give condition-specific warnings and a 24-hour contact/appropriate destination. Confirm transport and a realistic way to return for urgent care.
- After birth: heavy/increasing bleeding, severe headache/visual symptoms, fever/offensive lochia, worsening pain, chest pain/breathlessness, unilateral leg swelling, collapse or marked mental-state change needs urgent assessment.
- Discuss newborn poor feeding, abnormal breathing, unusual sleepiness, temperature concerns and early/worsening jaundice with the newborn team’s return instructions.
11. Mental health, support and safeguarding
- Ask about emotional recovery, distress, loss/trauma and available support. Arrange help for significant mental-health or immediate safety concerns.
- Assess support at home, communication/language needs, ability to care for self/baby and any safeguarding concern. Unresolved safety barriers can change the care setting.
12. Final handover and understanding
- Ask the patient/support person to explain the medicine plan, next appointments and what symptoms would make them seek help.
- Document the advice, prescriptions, results ownership and contact details provided. Confirm that the patient agrees with and can carry out the plan; complete applicable items rather than treating elapsed hours as a discharge order.
What the discharge summary must contain
Diagnosis and clinical course; procedures and complications; condition at transfer; medicines with doses and stop/review dates; allergies; pending results with their reviewer; wound/device instructions; pregnancy/newborn information when relevant; follow-up appointments; urgent-return advice and contacts; the responsible clinician and destination.
Provide the patient and receiving service with a clear copy. Confirm understanding of the medicine, test and return plan before leaving.