Referral and Consultation Guidelines for Project Participants
| Category I | Category II | Category III | Category 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 factors | Initial prenatal factors | Initial prenatal factors | Major anomalies |
| Multiple pregnancy | Age >40 or <16 | Habitual smoking | Respiratory distress |
| Insulin-dependent diabetes | Drug dependency | Single parent, questionable social support | Five minute APGAR <6 |
| Chronic hypertension | High-risk family (lack of family/social support)* | Height under 5 feet | Maternal 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 | Underweight | Macrosomia |
| Hyperthyroidism | Previous cesarean section | Primigravida | Infant of a diabetic mother |
| Rh isoimmunization | Multiple spontaneous abortions (>3) | Second pregnancy in 12 months | Hypoglycemia, hypocalcemia |
| Chronic active hepatitis | Grand multiparity (>8) | History of congenital abnormalities | Seizures |
| Convulsive disorder | History of gestational diabetes | Family history of diabetes | Prematurity, 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, transverse | Subsequent 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.