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Implementing A Framework for Maternity Services in Scotland
Appendix 2 Risk Assessment
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 Level Ia-d. It is crucial that appropriate referral pathways are used for any mother and baby who give cause for concern.
Level IIa 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 IIc 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 Ia-d of maternity care.
Exit examples for Level Ia-d care
Age | Parity | Height | Weight |
Primigravida of >16
Primigravida of <40
Multigravida of <40 | Multigravida <5 | Height > 150 cms | Booking or 36 week weight BMI of >20 or <32 |
Exit examples for Level Ia-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
Acquired heart disease - ischaemic heart disease, cardiomyopathy
Congenital heart disease - corrected or uncorrected |
Haematological Disorders | Endocrine Disorders | Significant Gastro-intestinal Disorders |
Haematological disease - e.g. 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 I and II) 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 Ia-d: past obstetric and neonatal history
Antenatal | Fetal/Baby | Past delivery details | neonatal |
Antepartum Haemorrhage (including recurrent placental abruption) | IUGR baby (<10th centile for gestational age) | Proven or suspected CPD | Stillbirth or neonatal death - case review required |
Preterm labour (<37 weeks gestation) | Large Baby (> than 90th centile for gestational age) | Caesarean section | Previous neonatal birth injury |
Pregnancy induced hypertension, eclampsia | Shoulder dystocia | Previous assisted mid cavity instrumental delivery | Previous baby with haemorrhagic disease of the newborn |
Specific infections, e.g. HIV, Hepatitis carrier, Hep B, Hep C, Group B streptococcal | | Postpartum haemorrhage (>500 mls primary or secondary) | Risk of, or known, inherited disease |
| | Retained placenta | Previous iso-immunisation or ABO incompatibility |
| | Perineal tear involving the anal sphincter (3rd or 4th degree tear) | |
| | Pelvic floor repair or cervical surgery | |
Exit examples Level Ia-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 weeks |
Suspected PIH, raised BP | Intrauterine death | Membrane rupture <37 completed weeks |
Cholestasis (including fatty liver of pregnancy and HELPP) | | Malpresentation >37 completed weeks (including breech) |
Raised AFP with abnormal growth scan at 34-36 weeks | | IUGR by U/S (below 10th centile) |
Anaemia (Hb <10 g/dl at 34-36 weeks) | | Large for dates by U/S (over 90th 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 Ia-d: intrapartum
Maternal | | | Neonatal |
Unstable lie | Maternal pyrexia >38ºC 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/ suspicion of developing pre-eclampsia | | Respiratory difficulties after resuscitation (respiratory 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 | 3rd or 4th 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 Ia-d: 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 | | | Jaundice in first 24 hours or positive Coombe's test |
Exit examples 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 | Congenital heart disease - corrected or uncorrected
Acquired heart disease - ischaemic heart disease, cardiomyopathy |
Haematological Disorders | Endocrine Disorders | Significant Gastro-intestinal Disorders |
Haematological disease - e.g. thrombocytopenia, aplastic anaemia
Coagulation abnormality -
thrombophilia, disseminated
intravascular coagulation
(DIC) DVT or pulmonary embolus (any history) | Significant endocrine disease
Significant medical disease especially if unstable (thyroid, adrenal disease e.g. Addisons)
Diabetes (Type I) | 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 IIa unit |
Exit examples Level IIa: present pregnancy
Maternal | 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 | |
Severe pregnancy induced hypertension | Preterm labour <37 completed weeks | |
Women at high obstetric anaesthetic risk | Membrane rupture <37 completed weeks | |
Women at high risk of obstetric interventions which may require assistance of interventional radiology (e.g. placenta accreta) or severe PPH >4000 mls | Malpresentation >37 completed weeks (including breech) | |
Raised AFP with abnormal growth scan at 34-36 weeks | Active viral infections such as chickenpox, rubella, measles, parvo-virus | |
Placental abruption | Current therapeutic drug use (Benzodiazepines, any psychotrophic drugs) | |
Placenta praevia | Large for dates by U/S (over 90th centile ) | |
Newly diagnosed cancer | ABO, rhesus iso-immunisation | |
| 'At risk' fetus | |
Exit examples Level IIa: intrapartum
Maternal | Maternal/Combined | Fetus/Baby |
Postpartum haemorrhage (>500 mls) | Intrapartum haemorrhage | Birth weight <2200g |
3rd or 4th degree perineal tear | | Large Baby >4000g |
Mother gives cause for concern | Maternal pyrexia >38ºC on two occasions (30 mins apart) | Apgar score 6 or less at 5 minutes of age |
Retained placenta | Newly diagnosed medical disease or morbidity | Respiratory difficulties after resuscitation (respiratory rate >60/min or requiring supplementary oxygen to maintain saturation >92%) |
Placenta acreta | | Infant gives cause for concern |
Exit examples Level IIa: 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/ positive Coombes test |
Exit examples Level IIb: past history
Significant Respiratory Disease | Significant Neurological Disease | Cardiac Disorders |
Emphysema (COPD)
Cystic fibrosis
Congenital abnormality | Spina bifida /hydrocephaly
Paraplegia | Congenital heart disease - corrected or uncorrected
Acquired heart disease - 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 (thyroid , adrenal disease e.g. Addisons)
Diabetes (Type I) | 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 IIb: present pregnancy
Maternal | Fetal | Combined |
Maternal choice | Below 10th centile for gestational age | Malpresentation <32 completed weeks |
Malignancy identified in early pregnancy or any significant newly diagnosed morbidity | Suspected or proven fetal abnormality including cardiac, metabolic disorders, CNS or facial abnormality | Preterm labour <32 completed weeks |
Women at high obstetric anaesthetic risk | Ultrasound identified twin-twin transfusion | Membrane rupture <32 completed weeks |
Women at high risk of obstetric interventions which may require assistance of interventional radiology (e.g. placenta accreta) or severe PPH >4000 mls | Congenital diaphragmatic hernia | Severe pregnancy induced hypertension (early onset, <28 weeks gestation) |
| Abdominal wall defect | Severe IUGR (<1000g with delivery likely) |
| Urogenital malformations (genital malformations, posterior urethral valves) | High multiple pregnancies |
| Viral infection | |
Exit examples for Level IIc: past history
Significant Respiratory Disease | Significant Neurological Disease | Cardiac Disorders |
Significant infection | Spina bifida /hydrocephaly
Paraplegia | Congenital heart disease - corrected or uncorrected
Acquired heart disease - 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 if associated with severe complications | Heart
Lung
Liver
Kidney |
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 IIc: 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 >4000 mls | 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) | |
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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