Implementing A Framework for Maternity Services in Scotland: Overview Report of the Expert Group on Acute Maternity Services: page 11

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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