Read standard 9: Unscheduled, emergency and critical care

Maternity standards
Healthcare Improvement Scotland

Standard statement

NHS boards ensure women and babies receive unscheduled, emergency and critical care that is timely, safe and effective.

Rationale

It is essential that women/birthing people and their babies who require immediate care (unscheduled, emergency and critical care) can access the right care at the right time. Timely and equitable access to immediate care is fundamental for ensuring the safety and wellbeing of women and their babies. Care is delivered in line with related clinical guidance.

Clinical conditions in pregnancy can change rapidly and delays in assessment may increase the risk of preventable harm. Providing 24/7 access to assessment supports early identification of complications, enables prompt clinical decision making and ensures that women receive the right level of care at the right time.26 Equitable access also helps reduce variation in outcomes by ensuring that all women, regardless of location or circumstances, can seek urgent assessment and receive appropriate maternity care without delay. The management of antenatal and intrapartum emergencies should always prioritise the wellbeing and safety of the woman. All unscheduled, emergency and critical care should be delivered in line with Standards 1 and 2. This includes ensuring women who receive unscheduled, emergency and critical care continue to be offered tailored information and are supported to make informed decisions.

Assessment for any unscheduled maternity care should be undertaken by appropriately trained midwifery staff working within a multidisciplinary team. Women should be triaged in an appropriately staffed and equipped unit that is accessible 24 hours a day, seven days a week (see Standard 4 on facilities).1, 25 Maternity triage units should be located in, or have established links to, a maternity unit. All NHS boards should ensure the safe transfer of women and their babies who require emergency or critical care, by working collaboratively with the Scottish Ambulance Service.

Clear pathways for referral to alternative services, including early pregnancy care or services outwith the board of residence, ensure that every woman receives timely and appropriate assessment based on clinical need.

The multidisciplinary team, including an obstetric anaesthetist, should be involved at an early stage when women require complex analgesia, assisted birth, Caesarean birth or any other surgical intervention. Care should be coordinated through shared care plans, effective communication and integrated records.

Inspection reports from Healthcare Improvement Scotland highlight the importance of minimising delays when escalating care for women and/or their baby who show signs of clinical deterioration. Clinical deterioration can be identified using validated tools such as Maternity Early Warning Score (MEWS). Local protocols should clearly set out requirements for regular clinical assessment, prioritisation and escalation. Guidelines emphasise that subjective reports from women, and those of care partners, are a vital component of clinical assessment and safety. When a woman presents, or reports, warning signs or concerning symptoms, staff must escalate these concerns to the multidisciplinary team using a structured communication format, such as an SBAR (Situation, Background, Assessment, Recommendation).27

Women who require emergency or critical care may present in a range of clinical settings, not only within maternity units.3 Clear pathways and protocols across non-maternity areas, such as emergency departments, hospital wards, neonatal settings and critical care units, are essential to ensure that women and their babies receive safe, timely and appropriate care wherever they present. Effective coordination of critical care by a multidisciplinary team, led jointly by a consultant obstetrician and a consultant anaesthetist, helps ensure that complex clinical decisions are well managed and consistent. Midwives, including specialist midwives, are key members of this team, contributing essential maternity expertise and continuity. Consistent standards of emergency and critical care across all settings ensure that women and their babies receive the same high-quality care as any other critically ill patients, regardless of location.

Keeping women and their babies together in emergency and critical care settings is a vital, evidence-based practice promoting better health outcomes for all. It supports recovery and strengthens early bonding, even when either the woman or her baby is critically unwell. NHS boards can support this through models such as supported transitional care, enhanced maternity units and family-centred models, including parental accommodation, where appropriate. NHS boards should ensure women and their babies who require inpatient, high-dependency or intensive care also receive appropriate postnatal assessment and care, regardless of the clinical setting in which they are treated. Providing compassionate, clear, coordinated support when a baby requires end of life care ensures that women (and, where appropriate, their care partners) receive timely information and are able to make informed decisions that reflect their needs and preferences and that are in the best interest of her baby.

Note: the standards apply to the care of newborn babies up to six weeks of age.

Deteriorating mental health is covered in Standard 10.

Criteria

9.1

Women and their babies can access immediate care that is:

  • right for them
  • in the right place
  • at the right time.
9.2

Whenever and wherever women require immediate care, staff ensure women:

  • are fully informed about what is happening
  • feel empowered to ask questions and know how to raise concerns
  • are listened to and taken seriously
  • continue to be actively involved in decision making
  • are supported to review and update their care plans.

Where appropriate, the care partner’s concerns are listened to and taken seriously.

9.3

NHS boards ensure timely and equitable access to immediate care for all women and their babies (up to six weeks of age) 24 hours a day, seven days a week.

9.4

Women can access unscheduled and emergency maternity care through:

  • self-referral
  • referral by a community healthcare professional, including community midwife, GP or health visitor, or prison healthcare staff
  • referral from ambulance clinicians, paramedics and the Scottish Ambulance Service
  • referral or signposting from a community centre or third sector support agency.
9.5

NHS boards have systems and processes in place to ensure women can access appropriate immediate care:

  • at any stage of their pregnancy, including early pregnancy
  • during birth
  • in the immediate postnatal period
  • up to six weeks after birth
  • wherever they live or choose to receive maternity care (for example home birth).
9.6

Women who require immediate care receive tailored information and are supported to make informed decisions and provide consent for any recommended interventions and treatment.

Where a woman is unable to consent, for example because of loss of consciousness or lack of capacity, clinical decisions should be based on her best interests. Involvement of the woman’s care partner should be in line with relevant guidance.

9.7

NHS boards ensure that staff are enabled to deliver evidence-based immediate care, which includes:

  • prioritising care appropriately based on clinical presentation, risk assessment and the urgency of the woman’s or her baby’s needs
  • recording observations accurately and following local escalation pathways using nationally recommended and validated assessment tools such as MEWS
  • interpreting and responding to assessment results within appropriate timeframes
  • recognising and acting on clinical prioritisation in line with clearly defined local and national referral and escalation policies
  • referring women to other appropriate services, such as early pregnancy services
  • requesting clinical investigations and accessing advice and support, when required
  • supporting the safe transfer of care of women or their babies who require immediate care in a different setting or service
  • accessing evidence-based guidance relevant to the assessment and management of unscheduled, emergency and critical maternity care.
9.8

NHS boards have systems and processes in place for telephone assessments of women, that ensure:

  • women know who to contact and when
  • women receive a timely response
  • midwives are appropriately trained and educated and use a structured tool to assess, identify, escalate and refer appropriately
  • midwives can access the woman’s case notes during the call
  • women receive the right advice or support based on clinical need, including appropriate management of time critical emergencies
  • women receive tailored, evidence based and accurate information to support informed decision making
  • accurate and contemporaneous records of discussions, decisions and referrals are maintained and shared appropriately
  • there is clinical oversight and assurance of the service, with improvement plans developed and implemented as appropriate..
9.9

NHS boards have systems and processes in place to ensure that women who do not attend a hospital appointment following a triage call are promptly identified, contacted, and offered appropriate follow-up care.

9.10

NHS boards provide early pregnancy assessment services for all pregnant women who are under 12 weeks pregnant. The service provides:

  • same-day information and holistic assessment by an appropriately trained member of the maternity team
  • onward referral, where appropriate, in line with relevant pathways.
9.11

Women who require immediate care within any clinical care setting have their care coordinated by an obstetrician. Continuity of care, and where appropriate of midwifery carer, should be supported and prioritised, wherever possible.

9.12

Women who are assessed as requiring emergency surgical interventions, including assisted or Caesarean birth:

  • have a timely assessment by appropriately trained staff from across the multidisciplinary team
  • are triaged for theatre appropriately, in line with local clinical pathways and national guidance
  • are reviewed by an anaesthetist to plan appropriate anaesthesia
  • receive care from appropriately trained theatre staff within theatres that are well equipped, safely maintained and ready for emergency use.
9.13

NHS boards ensure timely, safe and effective transfer of care between clinical settings and healthcare teams for all in-utero transfers.

9.14

NHS boards have clear pathways and protocols to ensure women who require critical care have the same high-quality evidence-based care as:

  • non-maternity patients in critical care settings
  • patients in maternity settings, regardless of where they are cared for.
9.15

Where a woman or her baby requires emergency or critical care in a non-maternity setting, NHS boards enable them to remain together and to receive all the postnatal parenting support that is offered in a maternity setting, including support for early attachment and bonding (see Criterion 10.9).

9.16

NHS boards have clear pathways and protocols for babies under six weeks who require emergency or critical care including admission to a neonatal unit. This ensures babies:

  • are appropriately and safely transferred, with accurate and accessible handover of case notes
  • have their care coordinated by the multidisciplinary teams, with the consultant neonatologist leading and managing the care
  • have regular clinical assessments using validated tools (such as NEWTT2) with clear escalation pathways
  • are discharged with appropriate follow-up and support, including referral to relevant community and specialist services
  • are enabled to have their parents and families attend wherever possible and appropriate.
9.17

NHS boards have oversight and assurance of the timeliness of assessing women who require unscheduled, emergency and critical care. This includes reviewing and monitoring data and developing action plans where appropriate.

9.18

NHS boards provide triage units in an environment that is appropriately staffed and equipped (see Standard 4):

  • with access to specialist maternity, neonatal and non-maternity emergency care as appropriate
  • that is located within, or has established links to, a maternity unit.
9.19

NHS boards ensure that high-dependency care is available to women who require enhanced monitoring and support during pregnancy, labour or the postnatal period. High-dependency care should:

  • be available on or near the labour ward
  • be provided by midwives trained in providing high-dependency care
  • enable timely access to obstetric, anaesthetic and neonatal expertise, including senior decision makers
  • include access to appropriate monitoring and resuscitation equipment
  • use validated assessment and early warning tools, such as MEWS
  • provide enhanced observation in line with clinical needs and national guidance
  • support continuity of midwifery and obstetric care wherever possible
  • enable the baby to remain with the woman, where clinically appropriate, including providing support for infant feeding.
9.20

Where a baby requires end of life care, NHS boards ensure women (and, where appropriate, their care partners):

  • receive timely, compassionate and tailored information about palliative perinatal care options
  • can access multidisciplinary specialist input, including maternity, neonatal, palliative care and psychological support services
  • make informed decisions about their baby’s care, including preferred place of care and birth planning
  • experience coordinated care across settings, with clear communication between maternity, neonatal, palliative and community teams
  • can access emotional and bereavement support, including support for care partners and families
  • are offered follow-up care, including postnatal review, mental health services and referral to appropriate community resources.

What does this standard mean for...

What does the standard mean for women and their babies?

  • If you or your baby needs unplanned or emergency care, you will receive the care and support that you need.
  • You can access advice, care and support 24 hours a day, seven days a week.
  • If you (or your care partner) are concerned about you or your baby, you will be listened to and taken seriously.
  • You will have the opportunity to discuss what is happening and be supported to make decisions about your care, and the care of your baby.
  • You will continue to have the care and support of your primary midwife.
  • If you or your baby needs to be admitted, you can be confident that you are in the right place with the right team to care for you.
  • You and your baby will be kept together as much as possible.
  • If you or your baby need to be transferred to a specialist unit, you will be told what is happening.

What does the standard mean for staff?

Staff, in line with roles, responsibilities and workplace setting:

  • use nationally recommended and validated assessment tools
  • use nationally recommended education tools for telephone assessments
  • ensure appropriate escalation, referral and transfer of women and their babies
  • respond to concerns from women appropriately and within agreed timescales
  • ensure women are kept informed
  • share information and care plans with the multidisciplinary care team
  • ensure women and their babies receive the same high-quality critical care as other patients
  • support women and their babies to stay together
  • can order and review clinical investigations, information and advice from midwifery, obstetric and other specialist teams, as required.

What does the standard mean for the NHS board?

NHS boards:

  • ensure oversight and assurance of unscheduled, emergency and critical care in maternity services, including data monitoring and review of outcomes
  • have established pathways and processes for access to timely immediate or unscheduled maternity care
  • ensure appropriately staffed and equipped triage service, with access to early pregnancy services, specialist maternity, neonatal and non-maternity emergency care as appropriate, delivered in line with national guidance and pathways
  • ensure women can access a triage unit that has established links to a maternity unit
  • have clear systems and protocols for safe and timely transfer of care, including in-utero transfer.

Benchmarking and measuring performance

 

Criteria

Examples of what meeting this standard might look like

Please note this list is not exhaustive and examples may vary according to the size and scale of the service or NHS board or delivery model

9.1

Review of attendance data for immediate care, including timeliness of admission.

9.2

Evidence of informed decision making and communication with women in emergency maternity situations.

9.3

Service specifications confirming 24/7 maternity and postnatal urgent care.

9.4

Provision of local contact and referral information for unscheduled and emergency care.

9.5

Service specifications or service-level agreements outlining access to unscheduled or emergency care, including out-of-hours referral routes.

9.6

Application of consent to treatment guidance.

9.7

Demonstration of clinical care and treatment delivered in line with relevant clinical guidance, nationally recommended assessment tools and pathways.

9.8

Audit of call log data.

9.9

Local guidance to follow up women who do not attend.

9.10
9.11

Audit of patient records demonstrating obstetric coordination of care.

9.12

Provision of emergency surgical interventions.

9.13

Audit and review of referrals and admissions data for in-utero transfer.

9.14

Protocols for consistency in maternity care for women who require critical care.

9.15

Guidance to support infant bonding, including feeding in high-dependency care settings.

9.16

Local protocols for neonatal care.

9.17

Audit of timeliness of immediate care data for triage, referrals and admission.

9.18

Evidence of appropriately staffed, equipped and located triage units.

9.19

Documented observations and compliance with local escalation pathways using tools such as MEWS.

9.20

Provision of compassionate and tailored palliative care.

Editorial Information

Last reviewed: 23/03/2026

Next review date: 23/03/2031

Author(s): Maternity standards development group.

Author email(s): his.standardsandindicators@nhs.scot.

Approved By: Maternity standards development group

Reviewer name(s): Maternity standards project team.