Table 1.

Referral and Consultation Guidelines for Project Participants

Category ICategory IICategory IIICategory IV
For the following patient problems, the family physician must share responsibility or refer to a board-certified obstetrician-gynecologist (OB/GYN) or perinatal specialist. The family physician may participate in patient care under the direction of the OB/GYN or perinatologist.For the following patient problems, the family physician must obtain appropriate tests, or obtain consultation from a board certified obstetrician gynecologist or appropriate perinatal specialist. Patient care responsibilities may be shared if mutually agreeable to the family physician and other specialist.For the following patient problems, the family physician does not need to obtain consultation if his/her training and privileges allow for managing these problems. Complete documentation and appropriate management of these problems must be apparent in the record.The newborn factors listed below require immediate assessment by the physician and the initiation of treatment and referral if necessary.
Initial prenatal factorsInitial prenatal factorsInitial prenatal factorsMajor anomalies
 Multiple pregnancy Age >40 or <16 Habitual smokingRespiratory distress
 Insulin-dependent diabetes Drug dependency Single parent, questionable social supportFive minute APGAR <6
 Chronic hypertension High-risk family (lack of family/social support)* Height under 5 feetMaternal pelvic infection
 Renal Failure Uterine or cervical malformation or incompetency Obesity (normal glucose screening)Small for gestational age
 Heart disease (class II or greater) Contracted pelvis UnderweightMacrosomia
 Hyperthyroidism Previous cesarean section PrimigravidaInfant of a diabetic mother
 Rh isoimmunization Multiple spontaneous abortions (>3) Second pregnancy in 12 monthsHypoglycemia, hypocalcemia
 Chronic active hepatitis Grand multiparity (>8) History of congenital abnormalitiesSeizures
 Convulsive disorder History of gestational diabetes Family history of diabetesPrematurity, postmaturity, dysmaturity
 Isoimmune thrombocytopenia Previous fetal or neonatal demise Anemia (mild or moderate)Meconium aspiration
Subsequent prenatal and intrapartum factors Hypothyroidism Medical problems (eg, asthma, acid/peptic disease, maternal infections)Birth trauma
 Vaginal bleeding (2nd or 3rd trimester) Heart disease (class I)Subsequent prenatal and intrapartum factors
 Preeclampsia (Toxemia) Moderate or Severe Severe anemia (unresponsive to Fe) First trimester bleeding
 Fetal malformation, by AFP screening, ultrasound or amniocentesis Pelvic mass of neoplasia Urinary tract infection
 Abnormal presentation: breech, face, brow, transverseSubsequent prenatal and intrapartum factors Pelvic infection
 Intrauterine growth retardation Gestational diabetes Prenatal weight gain >40 lbs. or <15 lbs.
 Hydramnios Preeclampsia (toxemia) mild Prolonged latent phase or labor
 Pregnancy >43 weeks or <37 weeks Pregnancy at 41 weeks, obtain appropriate fetal/placental tests Meconium staining
 Abnormal fetal/placental tests Active genital herpes Pitocin augmentation of labor
 Persistent severe variable or late decelerations Positive high or low AFP screen Outlet forceps or vacuum extraction
 Macrosomia Estimated fetal weight >10 lbs or <6 lbs Repair of third or fourth degree laceration
 Cord prolapse Abnormal non-stress test Newborn resuscitation
 Mid forceps delivery Arrest of normal labor curve Manual removal of placenta
 Persistent moderate variable decelerations/poor baseline variability
 Ruptured membrane beyond 24 hours
 Second stage beyond 2 hours
 Induction of labor
  • * Consultation may be with appropriate social service agency

  • Consultation may be with perinatal genetic counselor.