Tiered Care Centers Proposed for High-Risk Pregnancies

Troy Brown, RN

January 29, 2015

A new consensus document proposing the establishment of levels of care for perinatal and postnatal women has been developed by the American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine. The document was published in the February issue of Obstetrics & Gynecology.

In 1976, a March of Dimes report proposed the establishment of an integrated system for regionalizing perinatal care. "This report included criteria that stratified maternal and neonatal care into three levels of complexity, and recommended referral of high-risk patients to higher-level centers with the appropriate resources and personnel needed to address their increased complexity of care," the authors write.

Most states followed these recommendations, and the model resulted in improved neonatal outcomes. More recently, however, the emphasis has shifted to the newborn, and maternal mortality rates have increased in the last 14 years.

"It is essential to remember that when we are addressing obstetrical outcomes, we have two very important patients: mother and child," Sarah J. Kilpatrick, MD/PhD, a lead author of the document, said in an American College of Obstetricians and Gynecologists news release. "Our goal for these consensus recommendations is to create a system for maternal care that complements and supplements the current neonatal framework in order to reduce maternal morbidity and mortality across the country." Dr Kilpatrick is chair of the Department of Obstetrics and Gynecology at Cedars-Sinai Medical Center in Los Angeles, California.

The consensus document establishes standardized designations for levels of maternal care that complement but are distinct from neonatal levels of care, provides uniform definitions and nomenclature for healthcare facilities that offer each level of maternal care, offers consistent guidelines for use in quality improvement and health promotion, and encourages the development and balanced geographic distribution of the full range of maternal care.

The authors note that levels of maternal care and neonatal care may not match at all facilities; therefore, the pregnant woman should be cared for at the facility best prepared to care for her and her baby.

The proposed designations are:

  • Birth centers that care for low-risk women with uncomplicated, single-baby, term pregnancies in which no complications are expected: Birth centers do not offer cesarean and operative vaginal deliveries.

  • Level 1, or basic care, facilities that care for low-risk women who are anticipated to have an uncomplicated birth: They are capable of performing routine antepartum, intrapartum, and postpartum care. Examples of appropriate patients include term twin gestation, trial of labor after cesarean delivery, uncomplicated cesarean delivery, and preeclampsia without severe features at term.

  • Level 2, or specialty care, facilities that provide care to high-risk pregnant women who are admitted there or transferred from another facility: Level 2 facilities must have an attending obstetrician-gynecologist at all times and have a maternal-fetal medicine subspecialist available for consultation on site, by telephone, or by telemedicine. Examples of appropriate patients include those with severe preeclampsia and placenta previa without prior uterine surgery.

  • Level 3, or subspecialty care, facilities that have maternal-fetal medicine services available 24/7 that are led by a maternal-fetal subspecialist: These facilities must have an obstetrician-gynecologist on site at all times, a full complement of subspecialists available for inpatient consultations, and an intensive care unit on site that is equipped to care for pregnant women. Level 3 facilities should have the demonstrated experience and capability to comprehensively manage severe maternal and fetal complications and should function as regional care centers in areas without level 4 facilities. Examples of appropriate patients include those with suspected placenta accreta or placenta previa with prior uterine surgery, suspected placenta percreta, adult respiratory syndrome, and expectant management of early severe preeclampsia at less than 34 weeks of gestation.

  • Level 4, or regional perinatal health care centers, that have demonstrated experience caring for "the most complex and critically ill pregnant women throughout antepartum, intrapartum, and postpartum care. This includes maternal-fetal medicine care teams with the expertise to assume care of pregnant and postpartum women in critical condition or with complex medical conditions...[including] comanagement of [intensive care unit]-admitted obstetric patients," according to the news release: Examples of appropriate patients include those with severe maternal cardiac conditions, severe pulmonary hypertension or liver failure, pregnant women requiring neurosurgery or cardiac surgery, and pregnant women in unstable condition and in need of an organ transplant.

The consensus document was endorsed by the American Association of Birth Centers; the American College of Nurse-Midwives; the Association of Women's Health, Obstetric and Neonatal Nurses; and the Commission for the Accreditation of Birth Centers. In addition, the leadership of the American Academy of Pediatrics, the American Society of Anesthesiologists, and the Society for Obstetric Anesthesia and Perinatology have reviewed and support the recommendations.

Obstet Gynecol. 2015;125:502-515. Abstract

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