• M P Amelink-Verburg, S P Verloove-Vanhorick, R M A Hakkenberg, I M E Veldhuijzen, J Bennebroek Gravenhorst, and S E Buitendijk.
• TNO Quality of Life, Netherlands Organisation for Applied Scientific Research TNO, Leiden, The Netherlands. marianne.amelink@planet.nl
• BJOG. 2008 Apr 1; 115 (5): 570-8.

ObjectiveTo assess the nature and outcome of intrapartum referrals from primary to secondary care within the Dutch obstetric system.DesignDescriptive study.SettingDutch midwifery database (LVR1), covering 95% of all midwifery care and 80% of all Dutch pregnancies (2001-03).PopulationLow-risk women (280,097) under exclusive care of a primary level midwife at the start of labour either with intention to deliver at home or with a personal preference to deliver in hospital under care of a primary level midwife.MethodsWomen were classified into three categories (no referral, urgent referral and referral without urgency) and were related to maternal characteristics and to neonatal outcomes.Main Outcome MeasuresDistribution of referral categories, main reasons for urgent referral, Apgar score at 5 minutes, perinatal death within 24 hours and referral to a paediatrician within 24 hours.ResultsIn our study, 68.1% of the women completed childbirth under exclusive care of a midwife, 3.6% were referred on an urgency basis and 28.3% were referred without urgency. Of all referrals, 11.2% were on an urgency basis. The main reasons for urgent referrals were fetal distress and postpartum haemorrhage. The nonurgent referrals predominantly took place during the first stage of labour (73.6% of all referrals). Women who had planned a home delivery were referred less frequently than women who had planned a hospital delivery: 29.3 and 37.2%, respectively (P < 0.001). On average, the mean Apgar score at 5 minutes was high (9.72%) and the peripartum neonatal mortality was low (0.05%) in the total study group. No maternal deaths occurred. Adverse neonatal outcomes occurred most frequently in the urgent referral group, followed by the group of referrals without urgency and the nonreferred group.ConclusionsRisk selection is a crucial element of the Dutch obstetric system and continues into the postpartum period. The system results in a relatively small percentage of intrapartum urgent referrals and in overall satisfactory neonatal outcomes in deliveries led by primary level midwives.

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