title: Risk indicators for referral during labor from community midwife to gynecologist: a prospective cohort study.
abstract: OBJECTIVE
  To identify risk indicators for referral during labor from community midwife to a gynecologist in a prospective cohort of women with a singleton term pregnancy, starting labor with a community midwife between 2000 and 2007, registered in the Dutch national perinatal registry.
  
  
  METHODS
  Referral from community midwife to a gynecologist during labor, because of fetal distress, failure to progress in second stage of labor, meconium stained amniotic fluid, failure to progress in first stage of labor, wish for pain relief, a combination of other less urgent reasons or no referral (reference).
  
  
  RESULTS
  A total of 241 595 (32%) were referred from community midwife to a gynecologist during labor, because of fetal distress (FD;5%), failure to progress in second stage of labor (FTP2;14%), meconium stained amniotic fluid (MSAF;24%), failure to progress in first stage of labor (FTP1;17%), wish for pain relief (WFPR;7%) or a combination of other less urgent reasons, for example, malpresentation (e.g. breech) or other nonspecified problems (OTHER;33%). The strongest overall risk indicators were gestational age (lower risk of referral because of FD, FTP2, MSAF, FTP1 and WFPR and a higher risk of referral because of OTHER at a gestational age between 37(+0) and 37(+)(6) weeks, and higher risks of referral for all reasons at a gestational age ≥41(+)(0) when compared to a gestational age between 38 (+)(0) and 40 (+)(6) weeks and no referral), the intended place of delivery (higher risk of all types of referral compared to no referral when the intended place of delivery was either at a midwife-led birth center or a hospital instead of at home) and birth history (higher risk of all types of referral compared to no referral when women had a history of instrumental vaginal delivery or when they were nulliparous instead of being multiparous without a history of an instrument vaginal delivery). Risk indicators associated with specific reasons of referral were maternal age, ethnicity, degree of urbanization, social economic status, neonatal gender and birth weight.
  
  
  CONCLUSIONS
  Among low-risk pregnant women, a referral during labor is associated with readily available risk indicators. These risk indicators may be used to increase referral risk awareness and to counsel women for the intended place to start labor.
authors.affiliation: a Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht , Utrecht , the Netherlands .|b Department of Obstetrics and Gynecology , Academic Medical Center , Amsterdam , the Netherlands .|c Stanford Prevention Research Center, Stanford University , Stanford , CA , USA .
authors.forename: Ewoud
authors.initials: E
authors.lastname: Schuit
authors.affiliation: d Perined , Utrecht , the Netherlands .
authors.forename: Chantal W P M
authors.initials: CW
authors.lastname: Hukkelhoven
authors.affiliation: b Department of Obstetrics and Gynecology , Academic Medical Center , Amsterdam , the Netherlands .
authors.forename: Birgit Y
authors.initials: BY
authors.lastname: van der Goes
authors.affiliation: e Department of Obstetrics and Gynecology , University Medical Center Utrecht , Utrecht , the Netherlands .
authors.forename: Ilanit
authors.initials: I
authors.lastname: Overbeeke
authors.affiliation: a Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht , Utrecht , the Netherlands .
authors.forename: Karel G M
authors.initials: KG
authors.lastname: Moons
authors.affiliation: f The Robinson Institute, School of Reproductive Health and Pediatrics, University of Adelaide , Adelaide , Australia , and.|g The South Australian Health and Medical Research Institute , Adelaide , Australia.
authors.forename: Ben W J
authors.initials: BW
authors.lastname: Mol
authors.affiliation: a Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht , Utrecht , the Netherlands .
authors.forename: Rolf H H
authors.initials: RH
authors.lastname: Groenwold
authors.affiliation: e Department of Obstetrics and Gynecology , University Medical Center Utrecht , Utrecht , the Netherlands .
authors.forename: Anneke
authors.initials: A
authors.lastname: Kwee
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D007743:Labor, Obstetric; D008880:Midwifery / Q000706:statistics & numerical data*; D009426:Netherlands / Q000453:epidemiology; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology*; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012042:Registries; D018570:Risk Assessment; D055815:Young Adult
keywords: Primary care; referral during labor; risk indicators; singleton; term pregnancy