> For the complete documentation index, see [llms.txt](https://docs.sygnal.network/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://docs.sygnal.network/use-cases/uc2-upward-mnch-danger-sign.md).

# UC2 — Upward MNCH danger-sign referral

A campaign worker spots a danger sign in a pregnant mother. Emergency referral, with the household's routine health worker looped in as an observer.

|                    |                                                                                                                                                            |
| ------------------ | ---------------------------------------------------------------------------------------------------------------------------------------------------------- |
| **Status**         | Draft                                                                                                                                                      |
| **Direction**      | Upward (campaign → clinical)                                                                                                                               |
| **Transactions**   | T1 only (single on-network hop)                                                                                                                            |
| **Contract**       | `HealthReferral` (v2.1)                                                                                                                                    |
| **Consent**        | Class A                                                                                                                                                    |
| **Reference flow** | [`reference-flows/UC2-upward-mnch-danger-sign/`](https://github.com/Medtronic-LABS/sygnal/tree/main/reference-flows/UC2-upward-mnch-danger-sign/README.md) |

## Actors

| Party                                   | Role on the network                     | Platform             |
| --------------------------------------- | --------------------------------------- | -------------------- |
| Community health worker (campaign mode) | Referrer                                | DIGIT HCM, as seeker |
| ComEMR                                  | Care coordinator **and** provider       | ComEMR, as provider  |
| Peripheral health unit (PHU)            | Internal target of ComEMR               | ComEMR               |
| The household's routine health worker   | **Observer** on the notification roster | —                    |

## Trigger

During net distribution, the health worker identifies a maternal, newborn and child health (MNCH) danger sign in a pregnant mother. A check against the records layer finds her antenatal care (ANC) record. The danger sign requires an **emergency** referral to the PHU.

## What crosses the network

DIGIT HCM raises an emergency referral to ComEMR (**T1**). ComEMR runs its MNCH workflow with the PHU as the target. Crucially, it also brings in the household's **routine health worker**, who can help with transport and follow-up.

ComEMR handles this routing to two parties **internally**, using the referral's notification roster: the routine health worker is listed with `partyRole: OBSERVER` and `notificationScope: LIFECYCLE_ONLY`. The only on-network transaction is still T1.

```mermaid
sequenceDiagram
  participant HCM as DIGIT HCM (seeker)
  participant EMR as ComEMR (coordinator / provider)
  Note over HCM,EMR: net distribution, reconciliation finds ANC record (records layer)
  Note over HCM: health worker identifies a danger sign
  HCM->>EMR: select / init / confirm — EMERGENCY referral (HealthReferral, T1)
  EMR-->>HCM: on_confirm — accepted (ACTIVE)
  Note over EMR: MNCH workflow, PHU = target, routine health worker = OBSERVER
  EMR->>HCM: on_status / on_update — evaluation and outcome
```

## What's different from UC1

Only two things: `clinicalUrgencyTier = EMERGENCY`, and the `notificationRoster` carries an extra `OBSERVER` entry. Consent basis and topology are the same as [UC1](/use-cases/uc1-upward-fever-referral.md). The lifecycle differs slightly: the PHU is notified as the target rather than booked.

**Lifecycle states exercised:** `DRAFT → ACTIVE → TARGET_NOTIFIED → ATTENDED → OUTCOME_RECEIVED → CLOSED`, plus a `PATIENT_CANCELLED` deviation branch for when the family declines transfer.

## Where the Sygnal APIs come in

* **Emergency SLA.** An SLA (service-level agreement) sets time limits. Emergency urgency typically maps to a short acceptance window in the policy's `SlaSection`. If the window is breached, the referrer raises it through `deviation/flag`.
* **Referral-response-time visibility.** Aggregate reporting shows programme managers the time to acceptance for emergency referrals, by area.

## Scope

**In scope:** the T1 referral lifecycle, with the observer roster entry shown at `confirm`.

**Out of scope:** the MNCH clinical workflow, which is internal to ComEMR; records-layer sync; policy-governed reporting.

## Notes and gaps

* `specialty` / `subSpecialty` use `OBSTETRICS` / `MNCH`, which are additions in the network's [code lists](/specification/coded-values.md).


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