MAT/GUI/0310/ANTASS

MATERNITY SERVICE GUIDELINE
TITLE:
AUTHORS:
GUIDELINE LEAD:
RATIFIED BY:
ACTIVE DATE:
RATIFICATION DATE:
REVIEW DATE:
APPLIES TO:
EXCLUSIONS:
RELATED POLICIES
Clinical Risk Assessment: Antenatal
Annie Nowell - Midwife
Denise McEneaney - Consultant
Midwife/ Supervisor of
Midwives
Denise McEneaney
Guidelines group
April 2010
March 2010
March 2013
All maternity staff
None
Women declining blood products in
pregnancy
The Management And Treatment Of
Clients Refusing Blood Transfusion
-BLT/POL/21809/MDR
Safeguarding Children
THIS DOCUMENT REPLACES
1.
INTRODUCTION/PURPOSE OF THE GUIDELINE
This guideline provides a framework to describe the process for antenatal and
intrapartum risk assessment, in order that women receive standardised and
appropriate care dependent on their own individualised needs.
Antenatal Risk Assessment
The National Service Framework’s guidance on maternity services advises
individualised antenatal risk assessment and care planning for all women and
their babies. Both CEMACH and NICE have recommended the development
of a national standardised risk assessment for all antenatal women.
2.




IMPLEMENTATION
Paper copy will be attached to guideline and audit notice boards.
Emailed copies to all midwives and obstetricians.
Will be available via the trust intranet.
Circulated to guidelines folders.
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MAT/GUI/0310/ANTASS
3.

ROLES AND RESPONSIBILITIES
It is the responsibility of all maternity unit staff to carry out clinical care as
described in the guideline unless there is justification for variation and the
reason is documented.
4.
GUIDELINE
This guideline relates to the timing of risk assessments, the management plan
and referral process if risk is identified.
4.1.1 TIMING OF ANTENATAL RISK ASSESSMENT
4.1.2 All women should have an initial risk assessment at their antenatal booking
appointment with a midwife. Women will be risk assessed by the midwife
asking the woman about specific conditions, documenting their response in
the pregnancy notes and determining the most appropriate care pathway
following local clinical guidelines. This will include identifying if a referral is
required to more specialist care of the maternity team. The relevant sections in
the maternity include:
 Lifestyle History - Social Assessment, smoking and drug use
 Ethnic origin
 Medical History including Mental Health
 Family History
 Previous Births and early pregnancy loss
4.1.2 Women will be offered antenatal screening blood tests at the booking
appointment. The results of these tests and next review of the risk
assessment will be undertaken at the midwife led Baby and Me Clinic
appointment at 11- 13 weeks gestation immediately following the combined
screening
appointment.
4.1.3 Women admitted antenatally should have an additional risk assessment at
every new attendance.
4.1.4 Risk assessment is a dynamic and potentially on-going process as risk factors
may arise or be disclosed at any point in pregnancy. Risk assessments can
therefore be revised at any stage of pregnancy.
4.1.5 Issues that women do not want to be documented in her handheld records
should be documented in the woman's trust records and the confidentiality
box (on page 2) should be ticked.
4.2
MEDICAL CONDITIONS TO BE CONSIDERED:
4.2.1 Any medical conditions will be documented in the ‘Medical History’ section of
the Pregnancy Notes; this includes anaesthetic history (on page 3). Any
issues will be expanded upon in the ‘notes’ section.
The following conditions (including anaesthetic problems) are reviewed during
the booking appointment:
Anaesthetic problems
Back problems
Cancer
Epilepsy/neurological problems
Female circumcision
Genital infections, including Herpes
Page 2 of 16
Asthma or chest problems
Blood disorders
Diabetes
Fertility problems
Gastro-intestinal problems i.e. Crohns
Gynaecological operations/problems
MAT/GUI/0310/ANTASS
Heart problems
Incontinence – urinary and /or faecal
Kidney or urinary problems
Migraine or sever headache
Pelvic injury
Sickle cell or Thalassaemia
thrombosis
General questions about any other
medical problem not listed

High blood pressure
Infections i.e. MRSA, GBS
Liver disease i.e. hepatitis
Musculo-skeletal problems
Pregnancy problems i.e. cholestasis,
HELLP
TB exposure
Thyroid problems
Mental Health
4.2.2 In additional women are asked about the following:
Admissions to ITU
Allergies
Date and result of last cervical smear
Previous operations
If woman is taking folic acid tablets
4.3
4.4
Admissions to A&E in last 12 months
NB – this questions will then prompt the
midwife to ask about domestic
abuse and should always be
done when alone with the
woman. See Domestic Abuse
guideline for more detail
Blood transfusions
Exposure to toxic substances
Medication in the last 12 months
Vaginal bleeding in this pregnancy
FACTORS FROM PREVIOUS PREGNANCIES
The midwife will document details from previous pregnancies. The history
includes whether the current pregnancy is with a new partner. Areas to
highlight include:
 Date, sex, gestation, place of booking/birth
 The child’s conditions now and where the child lives
 Antenatal summary, identifying any complications
 Details of onset of labour, type of anaesthetic (if any) used.
 Type of birth, details of third stage management and blood loss, type (if
any) of perineal tear and repair
 Detail of labour and postnatal period
 Type of infant feeding
 Details of early pregnancy loss
LIFESTYLE AND SOCIAL HISTORY
The midwife will ask the woman about the following at the booking
appointment and record the woman’s response on pages 1 and 2 of the
pregnancy notes. (* these questions are repeated in the second and third
trimesters).
This section includes recording details of:
Communication needs and if assistance Marital status
required
Citizenship status
Partner’s details
Employment status
Housing situation
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MAT/GUI/0310/ANTASS
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Support - family, friends
Name of Social Worker (if any)
*Smoking – type/frequency/stopped in *Drug use – type, frequency, close
last 12 months
contacts and drug use
*Alcohol consumption – pre-pregnancy
and current
4.5
FAMILY HISTORY (woman’s children, women’s parents, grandparents,
siblings)
The midwife will document if there are positive responses to the following
questions:
Diabetes
High blood pressure/eclampsia
Thrombosis
Consanguinity
4.5.1 In addition the midwife will ask if there are specific questions about the woman
and partner’s families including history of familial/hereditary medical
conditions, stillbirths/miscarriages, congenital abnormalities, learning
disabilities, hearing loss.
4.6
IDENTIFICTION OF WOMEN WHO WILL DECLINE BLOOD AND BLOOD
PRODUCTS
4.6.1 At present, Jehovah’s Witnesses form the majority of women who may decline
blood and blood products. All women are asked about their religious beliefs
and this is recorded on page 2 of the Pregnancy Notes. Women identifying
themselves as Jehovah’s Witnesses are asked directly whether they would
accept or decline blood and blood products and this must be documented This
will prompt midwives to refer women who are Jehovah’s Witnesses to the
Obstetric/Anaesthetic High Risk Clinic. All women are asked if they have had
any blood transfusions on page 3 of the Pregnancy Notes – any response
from the woman indicating that she may decline blood or blood products will
prompt the midwife to refer the woman to the maternity team as above.
Further details are in the Maternity Guideline (Women declining blood
products in pregnancy) and Trust Policy - The Management and Treatment of
Clients Refusing Blood Transfusion.
4.7
DEVELOPMENT OF AN INDIVIDUAL MANAGEMENT PLAN
4.7.1 Any risk factors identified in the risk assessment (as outlined above) are
documented in the Risk Assessment Section on page 11 of the Pregnancy
Notes and a management plan will be agreed. This will be informed by the
relevant clinical guidelines and care pathways depending on the risks
identified. Appendix 1 contains some guidance on factors to consider when
agreeing the management plan. This midwife will document this at the booking
appointment and review this at the Baby and Me appointment.
4.7.2 Key factors from the management plan (on page 11) are documented in the
key points section (on page 15).
4.7.3 The individual management plan is reviewed at each subsequent antenatal
appointment and antenatal admission. The healthcare provider will document
this in the Antenatal Visit section (page 15)
4.8
PROCESS FOR REFERRAL OF WOMEN IN WHOM RISKS ARE
IDENTIFIED DURING THE CLINICAL RISK ASSESSMENT
4.8.1 The type and method of referral will varying according to the risk identified,
and can the form of completion of referral form or requesting specific
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MAT/GUI/0310/ANTASS
appointments. Appendix 1 contains information in risk factor identified, factors
to consider and possible referral route for planning subsequent management.
4.8.2 Obstetric Referral
Midwives and GP’s can refer directly to the obstetric team by requesting a
consultant led appointment in the relevant antenatal clinic session by calling
020 7377 7431. The obstetric team have clinic sessions Monday – Friday in
the hospital based Antenatal Clinic as follows:
Clinic
Mon am
Tues am
Tues am (1/4)
Tues pm
Wed am
Wed am
Thurs am
Thurs pm
Fri am
Lead
obstetrician
Mr Hogg
Miss Beski
Mr Khan
Mr Khan
Mr Wee
Mr Aquilina
Mr Okaro
Miss Sanghi
Specialty
General obstetrics
HIV
Barkantine link consultant
Medically high risk
Anaesthetic high risk
Cardiology
Neurology
Renal
Psychiatric,
Substance
Misuse
Twins and other multiples
General obstetrics
General obstetrics
Endocrine
Diabetes
4.8.3 Specialist Midwifery referral
The service has specialist midwives who provide midwifery care for a specified
caseload. GP’s, midwives, obstetricians and other healthcare providers can
refer directly to these services as follows:
 Gateway team
Vulnerable women including Mental Health,
domestic abuse, teenagers in need, child
protection concerns, asylum seekers or
refugees
 Contact:
via Gateway Team Referral Form (ring 0207
377 7000 ext. 3486 if further advise needed)
 Substance Misuse
Drug and Alcohol Misuse and HIV positive
women
 Contact:
Tel. 020 7377 7000 ext 3470
 Diabetes
Women known to have Type 1 or 2
Diabetes
 Contact
via Antenatal Clinic on 020 7377 7431 for
appointment
 Antenatal Screening
for further support advise re antenatal
screening tests
 Contact
Tel 020 7377 7000 ext 2467
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MAT/GUI/0310/ANTASS
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4.8.4 Children and Families Social Work Team
All referrals must be completed by using the Social Work Referral Form,
available in all clinic areas. This should be faxed on 020 7377 7416.
Telephones advise can be sought be calling 020 7377 7225 and ask for the
duty Social Worker.
4.8.5 Smoking Cessation
Referral is made to the smoking cessation team by completing the
‘Smokefree’ proforma available in all clinic areas.
4.8.6 Perinatal Mental Health Team
Ideally this referral will be facilitated following referral to the Gateway Team
Midwives. However, direct referral can be made by completion of referral form
available in all clinic areas and faxing this to 020 8121 5636. If there are acute
concerns regarding the woman’s mental health, consider referral either to the
Crisis Intervention Service (CIS) during office hours (contact via switch) or
the Psychiatric Liaison team outside office hours (contact by aircall via
switchboard).
4.8.7 Women who will decline blood and blood products
Women identified as likely to decline blood products should be referred to the
Obstetric/Anaesthetic high risk clinic by calling 020 7377 7431.
4.9
RISK ASSESSMENT FOR APPROPRAITE PLACE OF BIRTH – WOMEN
WHO PLAN TO LABOUR OUTSIDE THE CONSULTANT LED UNIT
4.9.1 Women who wish to book for a home birth or the Barkantine Birth Centre are
risk assessed at 36 weeks using the proforma (Appendix 2). Women should
have this proforma completed and fixed into their pregnancy notes.
4.9.2 Women with risk factors suggesting planned birth on labour ward, who wish to
continue to plan a non-hospital birth, are referred to a consultant obstetrician
for further care planning. Ideally this should the Barkantine/homebirth link
consultant. The midwife should contact the Supervisor of Midwives if support
is required in planning care according to the woman’s choice.
4.9.3 Women with risk factors suggesting individual risk assessment should be
referred to a consultant midwife or obstetrician for further care planning if they
wish to continue planning a non-hospital birth.
4.10 REFERRAL BACK TO MIDWIFERY LED CARE
4.10.1 The specialist team will document their findings and recommendations for
future care in the pregnancy notes. If it is appropriate to continue midwifery led
care and a midwife led appointment is not already in place, the woman will
be asked to contact her community midwife (usually facilitated by contacting
the GP surgery/health centre where clinics are held) to arrange an
appointment at the specified time.
5
BREACH OF GUIDELINE
The incident will be reviewed within the risk management framework. The
impact of this incident will be reviewed by the appropriate lead clinician and
feedback/training given to staff as required.
6
MONITORING COMPLIANCE
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MAT/GUI/0310/ANTASS

See monitoring template.
REFERENCES
1. Confidential Enquiry into Maternity and Child Health. (2004). Why Mother’s
Die 2000-2002. London: RCOG Press
2. Confidential Enquiry into Maternity and Child Health. (2007) Saving Mother’s
Lives: Reviewing maternal deaths to make motherhood safer 2003-2005.
London: CEMACH.
3. National Institute for Health and Clinical Excellence. (2008). Antenatal care:
Routine care for the healthy pregnant woman. London: NICE.
4. Royal College of Anaesthetist, Royal College of Midwives, Royal College of
Obstetrician and Gynaecologists, Royal College of Paediatrics and Child
Health. (2007). Safer Childbirth: Minimum Standards for the Organisation and
Delivery of Care in labour. London: RCOG Press
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MAT/GUI/0310/ANTASS
MONITORING TOOL
Elements to be monitored
Monitoring
lead
Monitoring
tool
Monitoring time
frame.
Risk assessment completed at
booking, 28 weeks and 34
weeks - page 11 of
pregnancy notes
Medical conditions
documented and referred
appropriately including factors
form other pregnancies
Audit and
Quality
midwife
Documentation
audit tool
10 sets of notes
each month
Audit and
Quality
Midwife
Documentation
audit tool
10 sets of notes
each month
Lifestyle, medical conditions
and obstetric history noted in
risk assessment
Management plan in place
Audit and
Quality
Midwife
Audit and
Quality
Midwife
Lead MW
ANC &
Consultant
MW
Lead MW
ANC &
Consultant
MW
Lead MW
Gateway team
Documentation
audit tool
10 sets of notes
each month
Documentation
audit tool
10 sets of notes
each month
Map referral
process against
risk factors
1 week of new
referrals bi-annually
Map referral
process
1 week of referrals
back to midwife led
care bi-annually
Map referral
process against
risk factors
1 week of new
referrals bi-annually
Lead Obstetric
consultant
anaesthetist/
lead ANC
midwife
Map referral
process,
Advanced
Decision form
completed and
in records
Audit tool
developed
All records for
women who decline
blood products
Referral process:
Obstetrics method/timing/appropriate
referral
Referral back to midwife led
care method/timing/appropriate
referral
Referral process;
Gateway team:
method/timing/appropriate
referral
Management plan in place for
women who decline blood &
blood products
Risk assessment completed
for all women birthing at home
or birth centre
Page 1 of 16
Lead midwife
BBC
Consultant
midwife
10 sets of notes
each month
Committee to receive
the report.
The Maternity and
Gynaecology Audit
Committee will receive
completed reports. Audit
feedback and resultant
action plans will be fed
back to the maternity and
Gynaecology
governance Board
The leads of the Audit
Committee will be
expected to read and
interrogate the report to
identify deficiencies in
the record keeping
system. Minutes will be
clearly documented.
Any deficiencies will be
addressed through multiprofessional action
planning. Actions will be
taken through teaching
where necessary.
The Maternity Services
Liaison Committee
reviews the Birth
Reflections Survey
Report each quarter.
Action plan lead
committe
e
Acting on
recommendation
s and Lead(s)
The Maternity and
Gynaecology
Audit Committee
will lead on the
action plan.
Recommendations
will be allocated to
key areas of
practice with
identified leads.
Required actions
will be identified
and completed in
a specified
timeframe and
monitored by the
Maternity and
Gynaecology audit
committee.
Implementing and
sharing best
practice
Change in practice
and lessons to be
shared
Required changes to
practice will be
identified and actioned
within a specific time
frame documented in
the agreed action plan.
A lead member of the
team will be identified
to take each change
forward where
appropriate. Lessons
will be shared with all
the relevant
stakeholders.

MAT/GUI/0310/ANTASS
APPENDIX 1
Factor
Cardiac
disease
Hypertensive
disorders
Renal
disease
Endocrine
disorders
(excluding
diabetes)
Diabetes type
1&2
Severe and
enduring
mental health
issues and all
women with
history of
puerperal
psychosis
Haematologic
al disorders
Previous VTE
Previous
anaesthetic
problems
Autoimmune
disorders
Epilepsy
Severe
asthma
ANTENATAL RISK ASSESSMENT TOOL
Potential risk
Suggested management plan
Increased cardiovascular
demands
IUGR
Referral to high risk clinic for obstetric, cardiac and
anaesthetic review- Tues PM (urgent if symptomatic)
Request Uterine Artery Doppler’s at anomaly scan
May need anticoagulants
Consider referral to Guys for fetal cardiac scan
Refer for Uterine Artery Doppler's at anomaly scan
Refer to antenatal hypertension clinic- Tues PM
Superimposed PET
IUGR
Increased renal demands
Altered requirements of
pregnancy
Poor pregnancy outcome
IUGR
Macrosomia
Poor diabetic control
Fetal cardiac abnormalities
Deteriorating mental health
Child protection issues
Refer to joint diabetic/ obstetric clinic- Fri AM (to be
seen within 1 week)
Serial growth scans
Referral for cardiac scan at Guys
IUGR
IUD
Sickle crises
Fetal inheritance
Recurrence
Refer to high risk clinic
If haemoglobinopathy: refer to haemoglobinopathy
specialist nurse & screen expectant father for trait
Anaesthetic risk if reacting
to drugs/ difficult to
intubate etc
Referral to Obstetric/Anaesthetic high risk clinic or
consultant anaesthetic review
Miscarriage
IUD
Referral to high risk clinic- Tues AM
Increased fits
Teratogenicity of
medication
Increased cardiovascular
demands of pregnancy
Need for acute treatment/
deterioration
Referral to high risk clinic- Tues AM
Referral to epilepsy specialist nurse
Refer for serial scans and cardiac scan if medicated
Refer to obstetrician if increased need for medication
or hospital admission
Page 1 of 16
Refer to Gateway team
Referral to Social services by 28/40 if concerns about
child protection
Refer to Perinatal Mental Health team
Refer to Crisis Intervention Service if acute concerns
(office hours only) or Accident and Emergency for
review by Psychiatric Liaison Team (outside office
hours)
Urgent referral to high risk clinic
Refer to substance misuse specialist midwife who will
arrange care in Seacole (multidisciplinary substance
misuse) clinic
Social work referral by 28/40
Serial growth scans
Offer Hep C testing if ever used IV
Substance
misuse
(including
alcohol,
excluding
cannabis)
HIV
Referral to high risk clinic for obstetric review - Tues
PM
Request Uterine Artery Doppler’s at anomaly scan
Check thyroid function and refer to joint endocrine
clinic as appropriate- Fri AM (urgent if symptomatic)
Vertical transmission
Long term implications
Specific medical issues
Refer to specialist midwife.
Clinic includes: obstetrician, HIV physician, HIV
specialist nurse, Health advisers and neonatologist.
MAT/GUI/0310/ANTASS
Hepatitis B
Obesity (BMI
over 30)
Underweight
(BMI less
than 18)
Smokers
Aged ≤40
years
Aged < 18
years
Socially
vulnerable
women
(learning
disabilities,
asylum
seekers, child
protection
issues)
Disclosed
domestic
violence
Recurrent
(3+)
miscarriages
Preterm birth
Severe preeclampsia,
HELLP or
eclampsia
Rhesus isoimmunisation
or other
significant
blood group
antibodies
Uterine
surgery:
caesarean
section,
Page 2 of 16
Long term implications
Transmission to baby
Gestational diabetes
Raised BP
VTE
IUGR
Anaesthetic risk
Difficulty assessing fetal
growth / presentation
IUGR
Anaemia
IUGR
Abruption
Prematurity
Anxiety
Congenital abnormality/ies
Social issues
SIDS
Child protection issues
IUGR
Mental health issues
Anxiety
Abruption
Child protection issues
Mental health issues
Cervical incompetence
Miscarriage
Premature delivery
Autoimmune disorders
Preterm birth
Maternal anxiety
Recurrence
IUGR

Repeat identified sample (personally take blood and
confirm details on blood bottle with woman) and LFTs
Refer to hepatologist
Offer referral to dietician
Refer for GTT at 26/40
If BMI 35 or above refer for anaesthetic review
Offer referral to dietician
Refer for Doppler’s at anomaly scan
Offer carbon monoxide testing
Counsel regarding risk
Offer referral to smoking cessation
Counsel regarding screening tests
Lower threshold for referral to obstetricians if other
factors arise
Refer to Gateway team
Refer to Family Nurse Partnership Team (NHS Tower
Hamlets)
Refer to Gateway team
Referral to social services by 28/40 if child protection
issues
Tick confidentiality box. Do not document in handheld
records.
Refer to Gateway Midwifery team
Give immediate safety advice
Consider immediate social work referral if existing
children or by 28/40 if primip
Referral to obstetrician in early pregnancy
Referral to Emergency Gynaecology Unit for early
pregnancy scan (7+ weeks)
Consider reason for preterm birth and risk of
recurrence
Offer cervical length scan at 16/40
Offer Doppler's at anomaly scan
Refer to obstetrician
Consider commencing aspirin 75mg
Refer for Doppler's at anomaly scan
Refer to obstetricians (urgency dependent on historic
gestation of onset and current clinical picture)
Fetal anaemia
Miscarriage
IUD
Referral to Fetal Medicine
Rupture
Repeat c/s
Placenta previa
Placenta accreta
If first pregnancy since CS or 2CS refer to VBAC clinic
If has had a subsequent vaginal birth can have VBAC
discussion in community
If 3 uterine surgeries or classical incision refer to
obstetricians

MAT/GUI/0310/ANTASS
myomectomy,
cone biopsy
4th degree
tear or
persistent
urinary or
faecal
incontinence
following birth
APH x2
Para 5+
Previous
stillbirth or
neonatal
death of
unknown
cause
Previous
stillbirth or
neonatal
death
Recurrence
Deterioration
Referral to obstetricians
Recurrence
Consider referral to obstetrician
Anaemia
Unstable lie
PPH
Recurrence
Anxiety
Treat anaemia proactively
Refer to obstetricians if unstable lie ≥37/40
Discuss sterilisation should c/s occur
Refer to obstetricians
GTT at 26/40
Recurrence
Anxiety
Consider referral to Fetal Medicine
Consider referral to geneticist
Refer to obstetricians
Recurrence
Consider aspirin 75mg
Referral for Doppler's
Refer to obstetricians
Monitor growth closely and refer for growth scan if
concerns
Recurrence
Shoulder dystocia
C/s
GTT at 26/40
Monitor growth closely and refer for growth scans if
concerns
Recurrence
Anxiety
Consider referral to fetal medicine
Consider GTT at 26/40
Referral to obstetricians
GP to remove at 12/40 if easy
Urgent referral to Emergency Gynae Unit if pain prior
to USS
USS and referral to obstetrician
Refer to obstetrician- urgency as appropriate
due to a
recurrent or
genetic cause
Small for
gestational
age infant,
IUGR or BW
less than
2.5kg
Large for
gestational
age, BW
4.5kg+ (4.0kg
if South
Asian)
Congenital
abnormality
IUCD in situ
Fibroid
Female
genital
mutilation/
FGM
Previous
gestational
diabetes
First degree
Page 3 of 16
Eptopic
Miscarriage
Premature labour
Pain
Malpresentation
Obstructed labour
Premature labour
Cancer
Difficulty with internal
examinations
Obstructed labour
Refer to obstetricians who will assess need for referral
for antenatal reversal at Sylvia Pankhurst
Recurrence
GTT at 16/40
Gestational diabetes
GTT at 26/40

MAT/GUI/0310/ANTASS
relative with
diabetes
Glucosurea
once before
20 weeks for
twice after 20
weeks or high
random blood
sugar
Rhesus
negative with
no antibodies
Page 4 of 16
Gestational diabetes
Refer for GTT
Rhesus iso-immunisation
Referral for anti D at 28/40
APPENDIX 2
Name:
Sign
MRN:
Gest:
Risk assessment completed by:
Print
Date
+
/40
/
/

If yes not suitable for non-hospital birth
If O yes refer to consultant midwife or obstetrician for opinion
Indications of increased risk suggesting planned birth on labour ward
Disease area
Medical condition
Indications of increased risk suggesting planned birth on labour ward
Other factors
Additional information
Cardiovascular
Current
Respiratory
Haematological
Infective
Immune
Endocrine
Renal
Neurological
Gastrointestinal
Psychiatric
Other factors
Previous
compl
icatio
ns
Page 5 of 16
Confirmed cardiac disease
Hypertensive disorders
Yes □ No □
Asthma requiring increase in treatment or hospital treatment
Cystic fibrosis
Yes □ No □
Haemoglobinopathies – sickle cell, beta thalassaemia major
History of thromboembolic disorders
Immune thrombocytopenia purpura, other platelet disorder
or platelet count below 100,000
Von Willebrand’s disease
Bleeding disorder in woman or fetus
Atypical antibodies with a risk of haemolytic disease in the baby
Yes □ No □
Group B strep risk factors where antibiotics in labour would be recommended
(GBS+ in current pregnancy, previous baby with GBS disease,
PPROM in GBS+ woman, choroamnionitis)
Hepatitis B/C with abnormal LFTs
HIV positive
Currently infected with or receiving treatment for:
● Toxoplasmosis
● Genital herpes
● Tuberculosis
● Chicken pox
● Rubella
Yes □ No □
SLE
Scleroderma
Yes □ No □
Any endocrine condition
Yes □ No □
Abnormal renal function
Renal disease requiring supervision by a renal specialist
Epilepsy
Myasthenia gravis
Previous cerebrovascular accident
Liver disease with current abnormal LFTs
Psychiatric disorder requiring current inpatient care
Additional information
Unexplained stillbirth or death or related to intrapartum difficulty
PET requiring preterm birth
Placental abruption with adverse outcome
Eclampsia
Uterine rupture
PPH requiring additional treatment or blood transfusion
Retained placenta requiring manual removal in theatre
Caesarean section
Shoulder dystocia
Previous baby:
-With neonatal encepholopathy
-Over 4kg
Major gynaecological surgery:
Myomectomy
Hysterotomy
Previous 4th degree tear
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Multiple pregnancy
Para 5 or more
Placenta praevia
Pre-eclampsia or pregnancy induced hypertension
Preterm labour or preterm rupture of membranes
Placental abruption
Fibroids
Anaemia of less than 10.0g/dl at onset of labour
Confirmed intrauterine death
Induction of labour
Substance misuse (including alcohol dependency)
Gestational diabetes requiring medication or with
suboptimal BM control or with suspected macrosomia
(see diabetes guideline)
Malpresentation: breech transverse or oblique lie
BMI at booking of greater than 35
Recurrent antepartum haemorrhage
Small for gestational age (less than the 5th percentile,
reduced growth velocity or current SFH ≥3cm less
than gestational age in weeks and no ultrasound
performed in last 4 weeks).
Abnormal Doppler’s
Abnormal fetal heart rate
Ultrasound diagnosis of olgio or polyhydramnios
Indications for individual risk assessment when planning place of birth
Cardiovascular
Cardiac disease without intrapartum complications
Haematological
Atypical antibodies without risk of haemolytic
disease of the newborn
Sickle cell or thalassaemia trait
Infective
Hepatitis B/C with normal LFTs
Endocrine
Unstable hypothyroidism requiring a change in treatment
Skeletal/
Spinal abnormalities
neurological
Previous fractured pelvis
Neurological deficits
Gastrointestinal
Liver disease with normal LFTs
Crohn’s disease
Ulcerative colitis
Previous
Neonatal death with a known none recurrent cause
compli
Pre-eclampsia developing at term
cation
Placental abruption with a good outcome
s
Extensive vaginal, cervical or third degree tear or trauma
Previous term baby with jaundice requiring exchange transfusion
Previous
Antepartum bleeding of unknown origin once after 24/40
compli
Recreational drug use
cation
Current out-patient psychiatric care
s
Maternal age ≥40 years
Fetal abnormality
pregna
ncy
Yes □ No □
Yes O No O
Yes O No O
Yes O No O
Yes O No O
Yes O No O
Yes O No O
Yes O No O
Yes O No O

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