Module 2
Reasons for referral to secondary care (gynaecologist)
Of course we greatly hope that you will have a smooth and positive pregnancy, without complications! – and luckily that is the case for most people. But sometimes something happens that causes us, as midwives, to involve additional medical support. This means you (temporarily) are referred to the hospital, also known as “secondary care”.
In this article we discuss the 10 most common reasons why we might refer you during the pregnancy.
They are listed roughly in the order when the referral during pregnancy can occur.
1. You are pregnant with a twin or multiples
If you are pregnant with more than one baby, it is called a multiple pregnancy. The secondary care team will take over the care of your pregnancy and birth. Many ultrasound scans will be scheduled—first to determine whether it is a shared or separate multiple pregnancy, then to monitor the growth of the babies. As a mother you also have a somewhat higher chance of gestational diabetes or high blood pressure, so you will be monitored more closely.
- www.rcog.org.uk
- www.acog.org
- twinstrust.org
- www.degynaecoloog.nl – Multiple pregnancy (Dutch)
- www.nvom.nl – For parents of multiples (Dutch)
2. You are experiencing (significant) bleeding
Approximately 50% of women experience some bleeding during pregnancy. If the bleeding is heavy or recurrent, we will first perform an ultrasound. If no cause is found there, additional testing in secondary care follows—such as a speculum exam (‘duck‑bill’), a cervical swab and/or checking for infection. Depending on the cause, a care plan will be made—either with us or in secondary care.
3. You suffer from extreme nausea and vomiting (hyperemesis)
When nausea and vomiting are extreme, you can develop a fluid and nutritional deficiency. Sometimes hospital admission is required for IV fluids and electrolytes. Many women feel somewhat better for a few days afterwards. In such cases you remain in our care, but receive extra help from secondary care for a short period. Read the article: Hyperemesis: More than ordinary morning sickness
4. You have high blood pressure (hypertension)
If your blood pressure during pregnancy rises above 140/90 mmHg, or you have symptoms or symptoms that may indicate high blood pressure (or HELLP syndrome) we will refer you for a consultation with a gynaecologist. We want to check whether your blood pressure is affecting your organs or the baby. The secondary care team will assess this with blood tests and monitoring.
- If your blood pressure normalises and your tests are good, you will return to our care.
- If the blood pressure remains high and/or tests show organ strain, medication may be needed. Also, your baby’s growth will be more closely monitored (as the placenta may not function optimally). In some cases the birth may be induced earlier via a balloon catheter or oxytocin infusion.
Read more at
- www.cdc.gov
- www.nhlbi.nih.gov
- www.degynaecoloog.nl – High blood pressure (Dutch)
5. You have gestational diabetes
With gestational diabetes, there is too much sugar in your blood during the second half of pregnancy. It occurs in about 1 in 15 pregnancies. If you have increased risk of developing gestational diabetes, we will recommend a blood test after 24 weeks.
https://www.ncbi.nlm.nih.gov/books/NBK545196/
If your blood sugar is elevated we try first to control it through nutrition advice and dietitian guidance. If this is not successful, we refer you onward. Secondary care evaluates whether medication is needed. Read more at: www.nhs.uk and https://www.ncbi.nlm.nih.gov and www.degynaecoloog.nl (Dutch)
6. Insufficient growth of the baby (intrauterine growth restriction)
If your baby is too small — i.e., not growing sufficiently — the cause is often a poorly functioning placenta: the baby then receives insufficient nutrients. It can also result from infection.
The secondary care team will attempt to determine the cause via blood tests and ultrasound. If no cause is found, the baby’s growth will be closely monitored so that together we determine how long the baby should stay in the womb and when delivery might be better.
Read more at:
- www.mkuh.nhs.uk - a small for gestational age
- www.buckshealthcare.nhs.uk - my baby seems small
- www.degynaecoloog.nl (Dutch)– Baby growth restriction
- teKleineBaby.nl (Dutch)
7. A fetal abnormality has been detected
Sometimes an abnormality is detected on the ultrasound — e.g. at the 13‑ or 20‑week scan. We will then refer you to a specialized gynaecologist. They will perform a detailed scan and may offer additional tests such as bloodwork or amniocentesis to exclude infection.
If the abnormality is very serious and the baby is < 24 weeks, parents may decide to terminate the pregnancy.
In other cases the abnormality is mild, medication or surgery may be possible during pregnancy, or the baby may need extra care after birth.
A specialist team will work with you to determine the best care for you and your baby. Read more at: www.pns.nl – Follow‑up investigation
8. Your labour is at risk of starting too early
In the Netherlands about 7% of babies are born prematurely (that means water break or contractions before 37 weeks). In such a case we immediately refer you to secondary care, and they take over the care. The baby is then not fully developed yet, so the team will closely monitor how things progress and try to delay labour. If the baby is nevertheless born before 37 weeks, the neonatologist will examine and manage your baby in the neonatal unit.
9. Your baby is in breech position
Approximately 3‑4% of babies are in breech position (bottom or feet first) around week 36, which is not the ideal position for birth. That’s why we will discuss the option of an external cephalic version (ECV) — a manual turning attempt by a specialist. If this is unsuccessful or you choose not to try, you will be referred to secondary care — which manages births of breech babies. There they will discuss whether you can give birth vaginally or need a C‑section. In the Breech position article we explain your choices and how we can support you. With the right information you can still approach birth confidently even with a breech baby.
10. You go past your due date (post‑term pregnancy)
If you reach 42 weeks of pregnancy we recommend induction of labour — meaning the birth is medically initiated so the baby is born safely. In some cases we do this even earlier — e.g., at 40 or 41 weeks. Fortunately, we can still do a lot to start labour ourselves. However, if that is not sufficient and hormones must be given, secondary care takes over. In the Post‑term pregnancy article we explain everything.
In summary
Sometimes additional medical care is needed during pregnancy. In that case you are (temporarily) cared for by the hospital – secondary care. This does not automatically mean something serious is wrong, but it does mean that you and your baby will be monitored more closely.