Obstetric Evidence-Based Guidelines (Series in Maternal-Fetal Medicine)
Readily available at all times : the specified person should be available 24 hours a day, 7 days a week, for consultation and assistance, and able to be physically present on-site within a time frame that incorporates maternal and fetal or neonatal risks and benefits with the provision of care. Further defining this time frame should be individualized by facilities and regions, with input from their obstetric care providers. If referring to the availability of a service, the service should be available 24 hours a day, 7 days a week unless otherwise specified.
General Considerations Relevant for All Levels of Maternal Care All facilities need to have the capability to stabilize and provide initial care for any patient while being able to accomplish transfer if needed and, thus, must have resources to manage the most common obstetric emergencies such as hemorrhage and hypertension Table 2. Because all facilities cannot maintain the breadth of resources available at subspecialty centers, interfacility transport of pregnant women or women in the postpartum period is an essential component of a regionalized perinatal health care system.
To ensure optimal care of all pregnant women, all birth centers, basic level I , and specialty care level II hospitals should collaborate with subspecialty care and regional perinatal health facilities to develop and maintain maternal transport plans and cooperative agreements to meet the health care needs of women who develop complications. Collaborating receiving hospitals should openly accept transfers. Trauma is not integrated into the levels of maternal care because trauma center levels are already established.
Pregnant women should receive the same level of trauma care as nonpregnant patients. The appropriate care level for patients should be driven by their medical need and not limited to or governed by financial constraints. Because obesity is extremely common throughout the United States, all facilities should have appropriate equipment for the care and delivery of pregnant women with obesity, including appropriate birth beds, operating tables and rooms, and operating equipment The degree of obesity may be one of the factors that affects decisions for transfer of a woman to a higher level of care, although there are no well-established body mass index cut-off levels to determine level-specific care for pregnant women or women in the postpartum period with obesity.
Because of the importance of accurate data for the assessment of outcomes and quality indicators, all facilities should have infrastructure and guidelines for data collection, storage, and retrieval that allow regular review for trends. Although this document focuses on maternal care and does not include an in-depth discussion about risk-based neonatal care capability, optimal perinatal care requires synergy in institutional capabilities for the woman and the fetus or neonate.
Levels of maternal and neonatal care may not match within facilities. Consistent with the levels of neonatal care published by the American Academy of Pediatrics 35 , each level of maternal care reflects required minimal capabilities, physical facilities, and medical and support personnel. Each higher level of care includes and builds on the capabilities of the lower levels. All maternity facilities should have the necessary institutional support, including financial, to meet the needs of level-appropriate maternal care, including provision of health care personnel, facility resources, and collaborative relationships with perinatal hospitals within their region.
Implementation and Monitoring Regional centers, which include all level IV facilities and any level III facility that functions in this capacity, should develop relationships with level I and level II hospitals in their referral network. Measurement and Evaluation of Regionalized Maternal Care If regionalization improves care, then implementation of levels of maternal care should be associated with a decrease in preventable maternal severe morbidity and mortality. Determination and Implementation of Levels of Maternal Care The determination of the appropriate level of care to be provided by a given facility should be guided by regional and state health care entities, national accreditation and professional organization guidelines, identified regional perinatal health care service needs, and regional resources For More Information The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients.
References Centers for Disease Control and Prevention. Pregnancy Mortality Surveillance System. Retrieved April 15, Vital signs: pregnancy-related deaths, United States, , and strategies for prevention, 13 states, Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol ;— Main EK. Maternal mortality: new strategies for measurement and prevention.
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Curr Opin Obstet Gynecol ;—6. Centers for Disease Control and Prevention. Severe maternal morbidity in the United States. Rates in severe morbidity indicators per 10, delivery hospitalizations, — Building U. Capacity to Review and Prevent Maternal Deaths. Report from nine maternal mortality review committees.
Reduction of severe maternal morbidity from hemorrhage using a state perinatal quality collaborative. Am J Obstet Gynecol ; The safe motherhood initiative: the development and implementation of standardized obstetric care bundles in New York.
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Semin Perinatol ;— March of Dimes. Toward improving the outcome of pregnancy III: enhancing perinatal health through quality, safety and performance initiatives. Retrieved April 2, Newborn intensive care and neonatal mortality in low-birth-weight infants: a population study. N Engl J Med ;— The survival of very low-birth weight infants by level of hospital of birth: a population study of perinatal systems in four states.
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Am J Obstet Gynecol ;— Perinatal regionalization for very low-birth-weight and very preterm infants: a meta-analysis. JAMA ;— Neonatal mortality for very low birth weight deliveries in South Carolina by level of hospital perinatal service. American Hospital Association. AHA guide to the health care field. Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States.
Maternity care access, quality, and outcomes: a systems-level perspective on research, clinical, and policy needs. Rural-urban differences in access to hospital obstetric and neonatal care: how far is the closest one? J Perinatol ;— Access to obstetric services in rural counties still declining, with 9 percent losing services, [published erratum appears in Health Aff ;]. Health Aff Millwood ;— The effect of hospital acuity on severe maternal morbidity in high-risk patients.
The association between hospital obstetrical volume and maternal postpartum complications. Hospital volume, provider volume, and complications after childbirth in U. Obstet Gynecol ;—7. Severe maternal morbidity in a large cohort of women with acute severe intrapartum hypertension. Hospital-level factors associated with anesthesia-related adverse events in cesarean deliveries, New York State, Anesth Analg ;— Maternal morbidity in cases of placenta accreta managed by a multidisciplinary care team compared with standard obstetric care.
Maternal-fetal medicine specialist density is inversely associated with maternal mortality ratios. Am J Obstet Gynecol ;—8. This reflects the percentage of orders the seller has received and filled. Stars are assigned as follows:. Inventory on Biblio is continually updated, but because much of our booksellers' inventory is uncommon or even one-of-a-kind, stock-outs do happen from time to time. If for any reason your order is not available to ship, you will not be charged.
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Miscarriage in contemporary maternal–fetal medicine: targeting clinical dilemmas
Abnormal Orbits 23E Goiter Chapter Thoracic Imaging 24A? Congenital Diaphragmatic Hernia 24B? Congenital High Airway Obstruction 24D? Pleural Effusion Chapter Abdominal Imaging 26A? Abdominal Ascites 26B? Intestinal Atresias 26C? Gastroschisis 26D? Omphalocele 26E? Cystic Abdominal Lesions 26F? Echogenic Abdominal Lesions 26G? Limb-Body Stalk Lesions 26H?
Umbilical Vein Varix 26I? Esophageal Atresia Chapter Urogenital Imaging Chapter Skeletal Imaging Chapter Placenta and Umbilical Cord Imaging 29A? Molar Gestation 29C? Placenta Accreta-Increta-Percreta 29D? Placenta Previa 29F? Single Umbilical Artery 29G? Amniotic Fluid Volume 29H? Circumvallate Placenta 29I? Subchorionic Hematoma 29J?
Succenturiate Placenta 29K? Vasa Previa Chapter Uterus and Adnexae Imaging 30A? Adnexal Mass, Complex and Simple 30B? Uterine Anomalies 30C? Uterine Myomas Chapter First-Trimester Imaging 31A?