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Expert Group on Acute Maternity Services: Reference Report
ANNEX E: Exit and Entry Examples to Levels of Maternity Care
Section V explained the rationale for the identified entry and exclusion criteria to the different levels of maternity care. The attached tables provide examples of morbidities and co-morbidities, which would not be suitable for delivery in the specified units, but this requires local and regional agreement and the development of guidelines and explicit networks. This list is not all-inclusive and examples are given for clarity. The identification criteria may be for; referral at any level of care for advice regarding management, or transfer to a higher level of care, depending on local agreements. It must be stressed that any woman with significant morbidity is
not suitable for delivery in levels 1a-d. It is crucial that appropriate referral pathways are used for any mother and baby who give cause for concern.
Level 11a exit criteria, especially for maternal reasons, will require consultant obstetrician involvement and care will depend on the available level of service, local facilities and emergency support. Level 11c units should be able to care for the majority of pregnancies.
Though the document has concentrated on exclusion criteria, the following table identifies the women who are suitable to level 1a-d of maternity care.
Entry examples for Levels 1a-d care
Age | Primigravidae > 16 years Primigravidae < 40 years Multigravidae < 40 years |
Parity | Multigravida < 5 |
Height | Height >150 cms. |
Weight | Booking or 36 week weight BMI of > 20 or < 32 |
Annex E1:
Exit examples Level 1a-d: Maternal medical/surgical history
Significant Respiratory Disease | Significant Neurological Disease | Cardiac Disorders |
Significant asthma i.e. requiring previous hospitalisation or parenteral steroid therapy Cystic fibrosis Congenital abnormality Emphysema (COPD) | Neurological disorders, including ME, MS Epilepsy Spina bifida /hydrocephaly Paraplegia | Essential hypertension Heart disease: acquired, ischaemic heart disease, cardiomyopathy Heart disease: congenital heart disease corrected or uncorrected |
Haematological Disorders | Endocrine Disorders | Significant Gastro-intestinal Disorders |
Haematological disease: eg thrombocytopenia, aplastic anaemia Coagulation abnormality: thrombophilia, disseminated intravascular coagulation (DIC, DVT), pulmonary embolus (any history) Rhesus iso-immunisation including KELL Haemoglobinopathies | Any endocrine disease Diabetes (Type 1 and 11) or gestational diabetes Thyroid disease - (hypo and hyper) Adrenal disease e.g. Addisons | Cholelithiasis Fatty liver of pregnancy Hepatobilary disease Crohn's disease Ulcerative colitis |
Reproductive/Genital Tract | Musculo-Skeletal Disorders | Renal disease |
Malformations of reproductive/genital tract Uterine surgery Significant pelvic or cervical surgery | Trauma to pelvis, CDH, Kyphosis Significant connective tissue disorder | Renal failure, impairment or dialysis |
Infection | Malignant Disease | Significant Mental Illness |
Significant infection e.g. Group B haemolytic streptococci Any blood borne virus (HIV, Hep B, Hep C) Sepsis | Previous malignancy | Diagnosed schizophrenia Manic depressive psychosis Postnatal depression |
Drug or Alcohol Intake | Surgery & Anaesthesia | Transplant Surgery |
History of drug or alcohol abuse There should be a review if the woman uses therapeutic medication | Any history of significant surgery or anaesthetic complication must be considered. | Heart Lung Liver Kidney |
Genetic Disorders | Special Needs in Pregnancy | |
Marfan's syndrome Ehlers Danlos syndrome | Will need to be independently considered, e.g.: Learning disability Social exclusion Refugee mother | |
Exit examples Level 1a-d: Past Obstetric and Neonatal History
Antenatal | Fetal/Baby | Past delivery details | Neonatal |
Antepartum Haemorrhage (including recurrent placental abruption) | IUGR baby (< 10
th centile for gestational age) | Proven or suspected CPD | Stillbirth or neonatal death -case review required |
| Large Baby (> than 90
th centile for gestational age) | Caesarean section | Previous neonatal birth injury |
Preterm labour (<37 weeks gestation) | Shoulder Dystocia | Previous assisted mid cavity instrumental delivery | Previous baby with haemorrhagic disease of the newborn |
Pregnancy induced hypertension, Eclampsia | | Postpartum Haemorrhage (> 500 ml. primary or secondary) | Risk of, or known, inherited disease |
Specific infections, e.g. HIV, HIV, Hepatitis Carrier, Hep B, Hep C, Group B Streptococcal), | | Retained Placenta | Previous iso-immunisation or ABO incompatibility |
| | Perineal tear involving the anal sphincter (3
rd or 4
th degree tear) | |
| | Pelvic floor repair or cervical surgery | |
Exit examples Level 1a-d: Present Pregnancy
Maternal | Fetal | Combined |
Maternal choice | Post-maturity > 40/52+10 days | Multiple Pregnancy |
Hyperemesis gravidarum | Suspected or proven fetal abnormality | Preterm labour < 37 completed wks |
Suspected PIH, raised BP | Intrauterine death | Membrane rupture < 37 completed wks |
Cholestasis (including fatty liver of pregnancy and HELPP) | | Malpresentation > 37 completed wks (including breech) |
Raised AFP with abnormal growth scan at 34-36 weeks | | IUGR by U/S (below 10
th centile) |
Anaemia (Hb < 10 g/dl at 34-36 wks). | | Large for dates by U/S (over 90
th centile ) |
Significant antepartum haemorrhage | | ABO, rhesus iso -immunisation |
Placental abruption | | Current substance or alcohol misuse |
Placenta praevia | | Current therapeutic drug use ((Benzodiazepines, any psychotropic drugs) |
New medical disease not previously identified. | | Term rupture of membranes >12 hours |
Maternal wish for epidural analgesia | | Oligohydramnios |
Maternal wish for caesarean section or induction | | Polyhydramnios |
Newly identified malignancy | | Maternal infection (HIV, Hepatitis Carrier, Hep B, Hep C, Group B Streptococcal) |
| | Active viral infections such as chickenpox, rubella, measles, parvo-virus |
Exit examples Level 1a-d : Intrapartum
Unstable lie | Maternal pyrexia >38° C on two occasions (30 mins apart) | Retained Placenta | Infants of <36 weeks gestation |
Requirement for epidural analgesia | Intrapartum haemorrhage | | Congenital malformation |
Established labour > 12 hours review evidence from partogram and guidelines (NICE/RCOG) | Meconium stained liquor Hypertension: diastolic of >100 mm/Hg on 2 occasions or a rise of 20 mm/Hg suspicion of developing pre-eclampsia | | Respiratory difficulties after resuscitation (resp. rate > 60/min or requiring supplementary oxygen to maintain saturation > 92%) |
Prolonged rupture of membranes > 12 hours | Prolonged active Second Stage | | Birth weight < 2200g |
Abnormal fetal auscultation - fetal distress | 3
rd or 4
th degree perineal tear | | Apgar score 6 or less at 5 minutes of age |
Malpresentation | Postpartum haemorrhage (>500 mls) | | Infant gives cause for concern |
Exit examples Level 1a-d: Postnatal
Maternal | Neonatal | Neonatal | Neonatal |
Postpartum haemorrhage | Neonatal seizures | Feeding difficulties persisting at 36 hours of age | Persisting hypoglycaemia |
Sepsis | Persisting hypothermia | Failure to pass urine in first 24 hours | Failure to pass meconium in first 36 hours |
Mother gives cause for concern | | | Jaundice in first 24 hours or positive Coombe's test |
Annex E2:Exit examples for Level IIa :Past History
Significant Respiratory Disease | Significant Neurological Disease | Cardiac Disorders |
Significant asthma i.e. requiring previous hospitalisation or parenteral steroid therapy Cystic fibrosis Congenital abnormality Emphysema (COPD) Certain congenital abnormalities | Neurological disorders, including ME, MS Epilepsy Spina bifida /hydrocephaly Paraplegia | Essential hypertension Heart disease: acquired, ischaemic heart disease, cardiomyopathy Heart disease: congenital heart disease corrected or uncorrected |
Haematological Disorders | Endocrine Disorders | Significant Gastro-intestinal Disorders |
Haematological disease: eg thrombocytopenia, aplastic anaemia Coagulation abnormality: thrombophilia, disseminated intravascular coagulation (DIC, DVT), pulmonary embolus (any history) Rhesus iso-immunisation including KELL Haemoglobinopathies | Significant endocrine disease Significant medical disease especially if unstable (Diabetes, Thyroid , Adrenal disease e.g. Addisons) | Fatty liver of pregnancy Hepatobilary disease Crohn's disease Ulcerative colitis |
Reproductive/Genital Tract | Musculo-Skeletal Disorders | Renal disease |
Cancer | Significant connective tissue disorder | Renal disease Renal failure, impairment dialysis |
Infection | Transplant Surgery | Significant Mental Illness |
Significant infection e.g. Group B haemolytic streptococci Any blood borne virus (HIV, Hep B, Hep C) Sepsis | Heart Lung Liver Kidney | Diagnosed schizophrenia Manic depressive psychosis |
Drug or Alcohol Intake | Surgery & Anaesthesia | Genetic Disorders |
History of drug or alcohol abuse There should be a review if the woman uses therapeutic medication | Any history of significant surgery or anaesthetic complication must be considered. | Marfan's syndrome Ehlers Danlos syndrome |
Special Needs in Pregnancy | Neonatal history | |
Will need to be independently considered e.g.: Learning disability Social exclusion Refugee mother | Any history of intrapartum asphyxia should be reviewed
. Previous neonatal birth injury Previous baby with haemorrhagic disease of the newborn Risk of, or known, inherited disease Previous iso-immunisation or ABO incompatibility | It is not advisable for any 'at risk' fetus to be delivered in a Level 11a unit |
Exit examples Level 11a: Present Pregnancy
Maternal | Fetal/Combined | Fetal/ Combined |
Maternal choice | Maternal infection (HIV, Hepatitis Carrier, Hep B, Hep C, Group B Streptococcal) | Post-maturity > 40/52+10 days |
New medical disease not previously identified. | Polyhydramnios | Suspected or proven fetal abnormality |
Significant antepartum haemorrhage | Oligohydramnios | Intrauterine death |
Cholestasis (including fatty liver of pregnancy and HELPP) | Multiple Pregnancy | Current therapeutic drug use ((Benzodiazepines, any psychotrophic drugs) |
Severe Pregnancy Induced Hypertension | Preterm labour < 37 completed wks | Large for dates by U/S (over 90
th centile ) |
Women at high obstetric anaesthetic risk | Membrane rupture < 37 completed wks | ABO, rhesus iso -immunisation |
Women at high risk of obstetric interventions which may require assistance of interventional radiology (e.g. placenta accreta) or severe PPH >4000mls. | Malpresentation > 37 completed wks (including breech) | 'at risk' fetus |
Raised AFP with abnormal growth scan at 34-36 weeks | | |
Placental abruption | | |
Placenta praevia | | |
Active viral infections such as chickenpox, rubella, measles, parvo-virus | | |
Newly Diagnosed Cancer | | |
Exit examples Level 11a: Intrapartum
Maternal | Maternal/Combined | Fetus/Baby |
Postpartum Haemorrhage (>500 mls) | Intrapartum haemorrhage | Birth weight <2200g |
3
rd or 4
th degree perineal tear | | |
| | Large Baby >4000g |
Mother gives cause for concern | Maternal pyrexia >38° C on two occasions (30 mins apart) | Apgar score 6 or less at 5 minutes of age |
Retained Placenta | | Respiratory difficulties after resuscitation (resp. rate >60/min or requiring supplementary oxygen to maintain saturation >92%) |
Placenta Acreta | Newly diagnosed medical disease or morbidity | Infant gives cause for concern |
Exit examples Level 11a: Postnatal
Maternal | Neonatal | | |
Postpartum haemorrhage | Neonatal seizures | Feeding difficulties persisting at 36 hours of age | Persisting hypoglycaemia |
Sepsis | Persisting hypothermia | Failure to pass urine in first 24 hours | Failure to pass meconium in first 36 hours |
Mother gives cause for concern | | Baby gives cause for concern | Jaundice in first 24 hours/ pos Coombes test |
Annex E3: Exit Examples for Level 11b: Past History
Significant Respiratory Disease | Significant Neurological Disease | Cardiac Disorders |
Emphysema (COPD) Cystic fibrosis Congenital abnormality | Spina bifida /hydrocephaly Paraplegia | Heart disease - congenital heart disease corrected or uncorrected Heart disease - acquired - ischaemic heart disease, cardiomyopathy |
Haematological Disorders | Endocrine Disorders | Transplant Surgery |
Haematological disease: eg thrombocytopenia, aplastic anaemia Coagulation abnormality: thrombophilia, disseminated intravascular coagulation (DIC, DVT), pulmonary embolus (any history) Rhesus iso-immunisation including KELL Haemoglobinopathies | Significant medical disease especially if unstable (Diabetes Type 1, Thyroid , Adrenal disease e.g. Addison's Disease | Heart Lung Liver Kidney |
Reproductive/Genital Tract | Musculo-Skeletal Disorder | Renal disease |
Cancer | Significant connective tissue disorder | Renal failure, impairment or dialysis |
Infection | Genetic Disorders | Significant Mental Illness |
Significant infection e.g. Group B haemolytic streptococci | Marfan's syndrome Ehlers Danlos syndrome | Manic depressive psychosis |
| | Fetus/Neonate |
| | Any history of low birthweight babies should be reviewed |
Exit Examples for Level 11b: Present pregnancy
Maternal | Fetal | Combined |
Maternal choice | Below 10
th centile for gestational age | Malpresentation <32 completed weeks |
| Suspected or proven fetal abnormality including, cardiac, metabolic disorders, CNS or facial abnormality. | Preterm labour < 32 completed wks |
Malignancy identified in early pregnancy or any significant newly diagnosed morbidity | Ultrasound identified twin-twin transfusion | Membrane rupture < 32 completed wks |
Women at high obstetric anaesthetic risk | Congenital diaphragmatic hernia | Severe Pregnancy Induced Hypertension (early onset, < 28 weeks gestation) |
Women at high risk of obstetric interventions which may require assistance of interventional radiology (e.g. placenta accreta) or severe PPH >4000mls. | Abdominal wall defect | Severe IUGR (<1000g with delivery likely) |
| Urogenital malformations (genital malformations, posterior urethral valves) | High multiple pregnancies |
| Viral infection | |
Annex E4:
Exit Examples for Level 11c:Past History
Significant Respiratory Disease | Significant Neurological Disease | Cardiac Disorders |
Infection Significant infection | Spina bifida /hydrocephaly Paraplegia | Heart disease - congenital heart disease corrected or uncorrected Heart disease - acquired - ischaemic heart disease, cardiomyopathy |
Haematological Disorders | Endocrine Disorders | Transplant Surgery |
Haematological disease - e.g. thrombocytopenia, aplastic anaemia Coagulation abnormality - thrombophilia, disseminated intravascular coagulation (DIC) | Significant medical disease especially if unstable (Diabetes, Thyroid , Adrenal disease e.g. Addisons | Heart Lung Liver Kidney |
Genetic Disorders | Musculo-Skeletal Disorders | Renal disease |
Marfan's syndrome Ehlers Danlos syndrome | Significant connective tissue disorder | Renal failure, impairment or dialysis |
Exit Examples for Level I1c: Present Pregnancy
Maternal | Fetal | Combined |
Women at high obstetric anaesthetic risk | Suspected or proven fetal abnormality including, cardiac, metabolic disorders, CNS or facial abnormality. | Severe Pregnancy Induced Hypertension (early onset, < 28 weeks gestation) |
Women at high risk of obstetric interventions which may require assistance of interventional radiology (e.g. placenta accreta) or severe PPH >4000mls. | Congenital diaphragmatic hernia | Severe IUGR (<1000g with delivery likely) |
Malignancy identified in early pregnancy | Abdominal wall defect | High multiple pregnancies (depending on SCBU facilities) |
| Ultrasound identified twin-twin transfusion | |
| Viral infection | |
| Urogenital malformations (genital malformations, posterior urethral valves) | |
Annex E5: Entry examples for Level III
Maternal | Fetal | Neonate |
Renal failure, impairment or dialysis | Suspected or proven fetal abnormality including, cardiac, metabolic disorders, CNS or facial abnormality. | Need for assisted ventilation beyond initial resuscitation |
Transplant Surgery (Heart, Lung, Liver, Kidney) | congenital diaphragmatic hernia | Persistent central cyanosis |
Genetic Disorders (Marfan's syndrome, Ehlers Danlos syndrome) | Abdominal wall defect | Congenital abnormality needing urgent surgical intervention |
| Ultrasound identified twin-twin transfusion | Necrotising enterocolitis (discretion of the consultant paediatrician) |
| Viral infection | Neonate less than 28 weeks gestation |
| Skeletal malformations | Need for specialist investigation and treatment e.g. metabolic problem which may require extraordinary therapies such as dialysis |
| Urogenital malformations (genital malformations, posterior uretheral valves) | |
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