American College of Obstetricians and Gynecologists and Society for Maternal–Fetal Medicine Release Updated Guidance to Help Hospitals Provide Risk Appropriate Maternal Care

July 25, 2019

  

Washington, D.C.—Today, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal–Fetal Medicine (SMFM) jointly released updated guidance to better prepare hospitals to provide risk-appropriate maternal care. The Obstetric Care Consensus on Levels of Maternal Care (LoMC) is part of ACOG and SMFM’s efforts to reduce maternal morbidity and mortality. 

LoMC, first published in 2015, encourages the development of collaborative relationships between hospitals that offer different levels of maternal care in proximate regions. To that end, LoMC defines the required minimal capabilities, physical facilities, and medical and support personnel for each level of care, which include birth center, level I (basic care), level II (specialty care), level III (subspecialty care), and level IV (regional perinatal health care centers). Each subsequent level of care includes and builds on the capabilities of the lower levels.

These uniform definitions provide a framework for regional hospital relationships that will enhance patient care. Collaborative relationships between hospitals of differing levels enables consultation and transfer of care, when appropriate, to maternity facilities that have the personnel and resources to care for unexpected obstetric emergencies. 

“We know that 59% of births in the United States occur at hospitals that deliver 1,000 or fewer births each year,” said Ted L. Anderson, MD, PhD, president of ACOG. “LoMC enhances the women’s ability to give birth safely in their own communities.” 

“An essential component of LoMC is the concept of an integrated and collaborative system in which care is efficiently regionalized and level III or IV maternal centers provide education and consultation to level I and II facilities,” said Brian Iriye, MD, president of SMFM. “This includes training for and implementation of quality improvement initiatives, case reviews for prevention of severe morbidity and mortality, and providing a streamlined system for maternal transport when necessary.”

In addition to reaffirming the need for levels of maternal care, the 2019 LoMC includes new evidence supporting the concept, clarification on definitions, and revisions to criteria. ACOG and SMFM applied the experiences and feedback from the 2017 LoMC pilot program conducted at 14 facilities in three states and findings from the U.S. Centers for Disease Control and Prevention’s implementation of their Levels of Care Assessment Tool with state health departments and jurisdictions. ACOG also collaborated with multiple stakeholders to review and provide feedback on the guidance.

Additionally, ACOG and SMFM are working in collaboration with the American Academy of Family Physicians and the National Rural Health Association to address rural maternal health challenges and also have included provisions for family physicians to meet the provider requirements for Level II facilities.

Several states, including Georgia, Indiana, Texas, and Iowa, passed legislation or changed their administrative code to establish a specific maternal level of care designation for all hospitals that provide maternity care. Nationwide, state health departments, regional perinatal networks, health care systems, and hospitals have expressed interest in implementing LoMC.

“With levels of maternal care defined, hospitals can identify and fill gaps in capabilities and personnel to align with national standards,” said M. Kathryn Menard, MD, MPH, one of the lead authors of LoMC. “Regions and health systems can examine capabilities of their hospitals and define criteria for care locally with designated transfer of care based on risk. In addition, states can map geographic distribution of maternity care resources to identify and address gaps.”

The revised consensus document is endorsed by the American Association of Birth Centers and the Commission for the Accreditation for Birth Centers; the American College of Nurse-Midwives; the Association of Women’s Health, Obstetric and Neonatal Nurses; and the Society for Obstetric Anesthesia and Perinatology and supported by the American Academy of Family Physicians.

Obstetric Care Consensus, Levels of Maternal Care is published in the August edition of Obstetrics & Gynecology.

Other recommendations issued by ACOG and published in the August edition of Obstetrics & Gynecology: 

Committee Opinion 783: Adnexal Torsion in Adolescents
Adnexal torsion is the fifth most common gynecologic emergency. The most common ovarian pathologies found in adolescents with adnexal torsion are benign functional ovarian cysts and benign teratomas. Torsion of malignant ovarian masses in this population is rare. In contrast to adnexal torsion in adults, adnexal torsion in pediatric and adolescent females involve an ovary without an associated mass or cyst in as many as 46% of cases. The most common clinical symptom of torsion is sudden-onset abdominal pain that is intermittent, nonradiating, and associated with nausea and vomiting. If ovarian torsion is suspected, timely intervention with diagnostic laparoscopy is indicated to preserve ovarian function and future fertility. When evaluating adolescents with suspected adnexal torsion, an obstetrician–gynecologist or other health care provider should bear in mind that there are no clinical or imaging criteria sufficient to confirm the preoperative diagnosis of adnexal torsion, and Doppler flow alone should not guide clinical decision making. In 50% of cases, adnexal torsion is not found at laparoscopy; however, in most instances, alternative gynecologic pathology is identified and treated. Adnexal torsion is a surgical diagnosis. A minimally invasive surgical approach is recommended with detorsion and preservation of the adnexal structures regardless of the appearance of the ovary. A surgeon should not remove a torsed ovary unless oophorectomy is unavoidable, such as when a severely necrotic ovary falls apart. Although surgical steps may be similar to those taken when treating adult patients, there are technical adaptations and specific challenges when performing gynecologic surgery in adolescents. A conscientious appreciation of the physiologic, anatomic, and surgical characteristics unique to this population is required.

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The American College of Obstetricians and Gynecologists (ACOG) is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, ACOG strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. www.acog.org

The Society for Maternal-Fetal Medicine (SMFM) is a non-profit, membership organization based in Washington, DC. With more than 3,500 physicians, scientists and women's health professionals around the world, the Society supports the clinical practice of maternal-fetal medicine by providing education, promoting research and engaging in advocacy to optimize the health of high-risk pregnant women and their babies. SMFM hosts an annual scientific meeting in which new ideas and research related to high-risk pregnancies are unveiled and discussed. For more information, visit www.smfm.org.