Criteria for referral to level 6 public hospital maternity service

  • Maternal cardiac, renal, respiratory and neurological conditions that:
    • place the mother at such high risk of an adverse outcome that termination would be considered
    • are associated with significant risks of preterm birth or severe early-onset growth restriction
    • are associated with a significant risk of neonatal compromise requiring NICU-level care (e.g. myasthenia gravis)
    • require specialist multidisciplinary care, especially anaesthetics, allied health, to achieve an optimal outcome. 

See the additional comments section for a list of conditions.

Information to be included in the referral

Information that must be provided

  • Ultrasound report
  • Gestational age
  • Name of specialists or centres currently responsible for the woman's ongoing management
  • Indication of current disease status and copies of correspondence from relevant specialists
  • Copies of recent relevant investigation results (e.g. echocardiograms, lung function tests).

Provide if available

Not applicable.

Additional comments

The Summary and referral information lists the information that should be included in a referral request.

Referral to a level 6 maternity service should be considered in the context of the local maternity service system. Referring clinicians should contact the closest level 5 maternity service to discuss options. 

The cardiac, renal, respiratory and neurological conditions requiring referral to a level 6 service are:


•    Modified WHO classification of maternal cardiovascular risk classes II-III, III and IV
•    Severe, refractory hypertension
•    Ischaemic heart disease (IHD), especially with residual ischaemia / LV dysfunction.


•    Significant chronic kidney disease (CKD) where preterm delivery is likely
•    Lupus nephritis
•    Pyelonephritis if preterm labour
•    Acute renal failure.


  • Cystic fibrosis
  • Severe restrictive or reversible lung disease (due to risks associated with anaesthesia)
  • Sarcoidosis, especially if pulmonary hypertension.


  • Myasthenia gravis
  • Myotonic dystrophy
  • Stroke or subarachnoid haemorrhage in pregnancy, although access to neurology/neurosurgery is clearly paramount
  • Active Guillain Barré syndrome
  • Some brain tumours, if surgery required at an early gestation, or there are risks associated with anaesthesia
  • Multiple sclerosis, if refractory
  • Spinal cord injury, if risk of autonomic dysreflexia
  • Refractory epilepsy, if significantly preterm delivery is likely to be required.

Referral to a level 6 public hospital maternity service is not appropriate for

  • If the woman's condition can be managed by the local service.