Pregnancy Questioning

The exclusion of pregnancy in patients who are undergoing radiography.

As part of risk management within a department, a regular audit of the effectiveness of the local processes for avoiding irradiation of the pregnant individual is essential.

This audit can:

• Identify which examinations are overlooked when making pregnancy enquiries (e.g. operating theatre cases undergoing fluoroscopic screening)

• Identify local misconceptions

• Improve local practice by acting as an educational tool

The standard: 

An agreed standard with two parts:

a. All individuals of childbearing potential (age 12 to 50 inclusive) who are to undergo radiography to areas between the knees and the diaphragm should be asked about the possibility of them being pregnant

b. In all cases where it is known that the patient is, or might be pregnant, and radiography does take place, the request form should be countersigned by a doctor (usually the referrer/ consultant looking after the patient) to that effect

Target: 

100%

Indicators: 

1. Percentage of individuals of childbearing potential within the age groups and examination group asked about the possibility of being pregnant

2. Of cases where possibility of pregnancy exists and radiography takes place, percentage of request forms countersigned by a doctor

Data items to be collected: 

For each request, using the information on the request form, identify the presence or absence of:

• The patient’s signature indicating that they are not pregnant

• The signature of the radiographer carrying out the examination

• A signature of a doctor indicating that the radiographic examination should be undertaken despite the possibility of pregnancy

Suggested number: 

100 consecutive examination request forms in which:

• The age of an individual of childbearing potential lies between 12 years and 50 years

• The field of examination is between the knees and diaphragm

A joint audit meeting should be held with all radiographic staff to discuss the results of the audit

• By means of a confidential code enable individual staff members to identify their own errors from the audit results

• Identify those examinations in which errors have occurred, and take appropriate steps to see that they do not occur again

• Include a written policy for pregnancy questioning within the departmental radiographic techniques and processes file

• Increase the number and distribution of pregnancy posters within the department; site the posters in the examination, changing and waiting rooms

Many departments now routinely scan completed Inclusive Pregnancy Status (IPS) forms into CRIS. This greatly facilitates this audit.

RDA/radiographer: 2 hours to check CRIS records for last 100 individuals of childbearing potential age 12-50 undergoing relevant radiographic examinations, including theatre screening, to ensure appropriately completed IPS form scanned in

1. Protection of Pregnant Patients during Diagnostic Medical Exposures to Ionising Radiation. Produced jointly with the Royal College of Radiologists, Health Protection Agency and the College of Radiographers. 2009

2. Pre-procedure pregnancy checking for under 16s - Guidance for Clinicians. November 2012 Royal College of Paediatrics and Child Health. http://www.rcpch.ac.uk/system/files/protected/page/pregnancy%20checking%20guidance%20final.pdf

3. Radiation and the early fetus. The Royal College of Radiologists (RCR) 2013.

   https://www.rcr.ac.uk/system/files/publication/field_publication_files/BFCR%2813%294_radiation.pdf

4. A guide to understanding the implications of the Ionising Radiation (Medical Exposure) Regulations in diagnostic and interventional radiology. The Royal College of Radiologists (RCR) 2015. https://www.rcr.ac.uk/sites/default/files/bfcr152_irmer.pdf

Submitted by: 

Taken from Clinical Audit in Radiology 100+ recipes RCR 1996, updated by H Bailey

Published Date: 

Monday 7 January 2008

Last Reviewed: 

Sunday 24 July 2022