Obstetric Care Consensus #9: Levels of Maternal Care
2019; Elsevier BV; Volume: 221; Issue: 6 Linguagem: Inglês
10.1016/j.ajog.2019.05.046
ISSN1097-6868
AutoresSarah J. Kilpatrick, M. Kathryn Menard, Christopher M. Zahn, William M. Callaghan,
Tópico(s)Cardiovascular Issues in Pregnancy
ResumoMaternal mortality and severe maternal morbidity, particularly among women of color, have increased in the United States. The leading medical causes of maternal mortality include cardiovascular disease, infection, and common obstetric complications such as hemorrhage and vary by timing relative to the end of pregnancy. Although specific modifications in the clinical management of some of these conditions have been instituted, more can be done to improve the system of care for high-risk women at facility and population levels. The goal of levels of maternal care is to reduce maternal morbidity and mortality, including existing disparities, by encouraging the growth and maturation of systems for the provision of risk-appropriate care specific to maternal health needs. To standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care, this classification system establishes levels of maternal care that pertain to basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). 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. State and regional authorities should work together with the multiple institutions within a region, and with the input from their obstetric care providers, to determine the appropriate coordinated system of care and to implement policies that promote and support a regionalized system of care. These relationships enhance the ability of women to give birth safely in their communities while providing support for circumstances when higher level resources are needed. This document is a revision of the original 2015 Levels of Maternal Care Obstetric Care Consensus, which has been revised primarily to clarify terminology and to include more recent data based on published literature and feedback from levels of maternal care implementation. Maternal mortality and severe maternal morbidity, particularly among women of color, have increased in the United States. The leading medical causes of maternal mortality include cardiovascular disease, infection, and common obstetric complications such as hemorrhage and vary by timing relative to the end of pregnancy. Although specific modifications in the clinical management of some of these conditions have been instituted, more can be done to improve the system of care for high-risk women at facility and population levels. The goal of levels of maternal care is to reduce maternal morbidity and mortality, including existing disparities, by encouraging the growth and maturation of systems for the provision of risk-appropriate care specific to maternal health needs. To standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care, this classification system establishes levels of maternal care that pertain to basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). 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. State and regional authorities should work together with the multiple institutions within a region, and with the input from their obstetric care providers, to determine the appropriate coordinated system of care and to implement policies that promote and support a regionalized system of care. These relationships enhance the ability of women to give birth safely in their communities while providing support for circumstances when higher level resources are needed. This document is a revision of the original 2015 Levels of Maternal Care Obstetric Care Consensus, which has been revised primarily to clarify terminology and to include more recent data based on published literature and feedback from levels of maternal care implementation. Levels of maternal care. Obstetric Care Consensus No. 9. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;134:e41–55. Levels of maternal care. Obstetric Care Consensus No. 9. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;134:e41–55. 1.To reaffirm the need for levels of maternal care, as initially presented in the 2015 Obstetric Care Consensus, which includes uniform definitions, a standardized description of maternity facility capabilities and personnel, and a framework for integrated systems that addresses maternal health needs.2.To reaffirm that the goal of levels of maternal care is to reduce maternal morbidity and mortality, including existing disparities, by encouraging the growth and maturation of systems for the provision of risk-appropriate care specific to maternal health needs. Central to systems is the development of collaborative relationships between hospitals of differing levels of maternal care in proximate regions, which ensures that every maternity hospital has the personnel and resources to care for unexpected obstetric emergencies, that risk assessment is judiciously applied, and that consultation and referral are readily available when high-risk care is needed. These relationships enhance the ability of women to give birth safely in their communities while providing support for circumstances when higher-level resources are needed.3.To clarify definitions and revise criteria by applying experience from jurisdictions that are actively implementing levels of maternal care. Maternal mortality and severe maternal morbidity, particularly among women of color, have increased in the United States. The Centers for Disease Control and Prevention (CDC) reported that pregnancy-related deaths increased from 7.2 per 100,000 live births in 1987 to 18.0 in 2014, and non-Hispanic black women had a 3.3 times greater pregnancy-related mortality ratio compared with non-Hispanic white women.1Centers for Disease Control and PreventionPregnancy Mortality Surveillance System. CDC, Atlanta (GA)2018https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htmDate accessed: April 15, 2019Google Scholar, 2Petersen E.E. Davis N.L. Goodman D. et al.Vital signs: pregnancy-related deaths, United States, 2011–2015, and strategies for prevention, 13 states, 2013–2017.MMWR Morb Mortal Wkly Rep. 2019; 68: 423-429Crossref PubMed Scopus (387) Google Scholar Furthermore, severe maternal morbidity increased by nearly 200% between 1993 and 2014.1Centers for Disease Control and PreventionPregnancy Mortality Surveillance System. CDC, Atlanta (GA)2018https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htmDate accessed: April 15, 2019Google Scholar, 3Callaghan W.M. Creanga A.A. Kuklina E.V. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States.Obstet Gynecol. 2012; 120: 1029-1036Crossref PubMed Scopus (544) Google Scholar, 4Main E.K. Maternal mortality: new strategies for measurement and prevention.Curr Opin Obstet Gynecol. 2010; 22: 511-516Crossref PubMed Scopus (44) Google Scholar, 5Centers for Disease Control and PreventionSevere maternal morbidity in the United States. CDC, Atlanta (GA)2017https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.htmlDate accessed: April 15, 2019Google Scholar, 6Centers for Disease Control and PreventionRates in severe morbidity indicators per 10,000 delivery hospitalizations, 1993–2014. CDC, Atlanta (GA)2017https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/rates-severe-morbidity-indicator.htmDate accessed: April 15, 2019Google Scholar In addition, data shared by 13 maternal mortality review committees showed that as many as 60% of pregnancy-related deaths during 2013–2017 were potentially preventable.2Petersen E.E. Davis N.L. Goodman D. et al.Vital signs: pregnancy-related deaths, United States, 2011–2015, and strategies for prevention, 13 states, 2013–2017.MMWR Morb Mortal Wkly Rep. 2019; 68: 423-429Crossref PubMed Scopus (387) Google Scholar These data underscore the need to focus on the quality and safety of maternal care systems. Implementation of levels of maternal care has been identified as a common theme when identifying actionable opportunities to prevent maternal mortality.2Petersen E.E. Davis N.L. Goodman D. et al.Vital signs: pregnancy-related deaths, United States, 2011–2015, and strategies for prevention, 13 states, 2013–2017.MMWR Morb Mortal Wkly Rep. 2019; 68: 423-429Crossref PubMed Scopus (387) Google Scholar, 7Association of Maternal and Child Health ProgramsBuilding US capacity to review and prevent maternal deaths. Report from nine maternal mortality review committees. Association of Maternal and Child Health Programs, Washington (DC)2018http://reviewtoaction.org/sites/default/files/national-portal-material/Report%20from%20Nine%20MMRCs%20final_0.pdfDate accessed: April 15, 2019Google Scholar The leading medical causes of maternal mortality include cardiovascular disease, infection, and common obstetric complications such as hemorrhage and vary by timing relative to the end of the pregnancy.2Petersen E.E. Davis N.L. Goodman D. et al.Vital signs: pregnancy-related deaths, United States, 2011–2015, and strategies for prevention, 13 states, 2013–2017.MMWR Morb Mortal Wkly Rep. 2019; 68: 423-429Crossref PubMed Scopus (387) Google Scholar Although specific modifications in the clinical management of some of these conditions have been instituted (eg, the use of thromboembolism prophylaxis and development of hemorrhage and hypertension practice management bundles), more can be done to improve the system of care for high-risk women at facility and population levels.8Main E.K. Cape V. Abreo A. et al.Reduction of severe maternal morbidity from hemorrhage using a state perinatal quality collaborative.Am J Obstet Gynecol. 2017; 216: 298.e1-298.e11Abstract Full Text Full Text PDF Scopus (135) Google Scholar, 9Burgansky A. Montalto D. Siddiqui N.A. The safe motherhood initiative: the development and implementation of standardized obstetric care bundles in New York.Semin Perinatol. 2016; 40: 124-131Crossref PubMed Scopus (22) Google Scholar This document is a revision of the original 2015 Levels of Maternal Care Obstetric Care Consensus, which has been revised primarily to clarify terminology and to include more recent data based on published literature and feedback from levels of maternal care implementation. In the 1970s, most states developed coordinated regional systems for perinatal care that were predominantly focused on neonatal outcomes.10March of DimesToward improving the outcome of pregnancy III: enhancing perinatal health through quality, safety and performance initiatives. March of Dimes, White Plains (NY)2010https://www.marchofdimes.org/toward-improving-the-outcome-of-pregnancy-iii.pdfDate accessed: April 2, 2019Google Scholar The designated regional or tertiary care centers provided the highest levels of obstetric and neonatal care and served smaller facilities’ needs through education and transport services. Numerous studies validated the concept that improved neonatal outcomes were achieved through the application of risk-appropriate maternal transport systems.11Paneth N. Kiely J.L. Wallenstein S. Marcus M. Pakter J. Susser M. Newborn intensive care and neonatal mortality in low-birth-weight infants: a population study.N Engl J Med. 1982; 307: 149-155Crossref PubMed Scopus (212) Google Scholar, 12Gortmaker S. Sobol A. Clark C. Walker D.K. Geronimus A. The survival of very low-birth weight infants by level of hospital of birth: a population study of perinatal systems in four states.Am J Obstet Gynecol. 1985; 152: 517-524Abstract Full Text PDF PubMed Scopus (97) Google Scholar A comprehensive meta-analysis showed an increased risk of neonatal mortality for very low-birthweight infants (less than 1500 g) born outside of a neonatal intensive care unit level III hospital (38% vs 23%; adjusted odds ratio [adjusted OR], 1.62; 95% confidence interval [CI], 1.44–1.83).13Lasswell S.M. Barfield W.D. Rochat R.W. Blackmon L. Perinatal regionalization for very low-birth-weight and very preterm infants: a meta-analysis.JAMA. 2010; 304: 992-1000Crossref PubMed Scopus (255) Google Scholar Similarly, neonatal mortality was higher for very low-birthweight infants born in hospitals staffed by neonatologists in the absence of a more complete multidisciplinary team (level II), compared with those born in level III centers.14Menard M.K. Liu Q. Holgren E.A. Sappenfield W.M. Neonatal mortality for very low birth weight deliveries in South Carolina by level of hospital perinatal service.Am J Obstet Gynecol. 1998; 179: 374-381Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar However, although regionalized systems that promote maternal transfer to improve neonatal outcomes are well established, similar safety networks focused on maternal medical risk-based needs are not well defined and, thus, not established in many areas of the United States. Importantly, accredited birth centers and hospitals that offer basic and specialty maternity services provide needed obstetric care for most women who are giving birth in the United States.15American Hospital AssociationAHA guide to the health care field. 2014. AHA, Chicago (IL)2013Google Scholar Furthermore, they often provide maternity care in rural and underserved communities, which offers the benefit of keeping women with low- or moderate-risk pregnancies in their local communities. Closing hospitals with low-volume obstetric services could have counterproductive adverse health consequences16Kozhimannil K.B. Hung P. Henning-Smith C. Casey M.M. Prasad S. Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States.JAMA. 2018; 319: 1239-1247Crossref PubMed Scopus (130) Google Scholar, 17Kozhimannil K.B. Hardeman R.R. Henning-Smith C. Maternity care access, quality, and outcomes: a systems-level perspective on research, clinical, and policy needs.Semin Perinatol. 2017; 41: 367-374Crossref PubMed Scopus (28) Google Scholar and potentially increase health care disparities18Hung P. Casey M.M. Kozhimannil K.B. Karaca-Mandic P. Moscovice I.S. Rural-urban differences in access to hospital obstetric and neonatal care: how far is the closest one?.J Perinatol. 2018; 38: 645-652Crossref PubMed Scopus (39) Google Scholar, 19Hung P. Henning-Smith C.E. Casey M.M. Kozhimannil K.B. Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004–2014 [published erratum appears in Health Aff 2018;37:679].Health Aff (Millwood). 2017; 36: 1663-1671Crossref PubMed Scopus (146) Google Scholar by limiting access to maternity care. Women with complex high-risk conditions often benefit from giving birth in hospitals that offer a broad array of specialty and subspecialty services. Perhaps the most direct evidence that caring for the sickest women in higher acuity centers is associated with improved outcomes is that women with a high comorbidity index had a significantly higher adjusted relative risk of severe maternal morbidity when they gave birth in hospitals of low acuity (adjusted OR, 9.55; 95% CI, 6.83–13.35) compared with hospitals of high acuity (adjusted OR, 6.50; 95% CI, 5.94–7.09).20Clapp M.A. James K.E. Kaimal A.J. The effect of hospital acuity on severe maternal morbidity in high-risk patients.Am J Obstet Gynecol. 2018; 219: 111.e1-111.e7Abstract Full Text Full Text PDF Scopus (21) Google Scholar Additional recent data suggest that hospital delivery volume, health care provider patient volume, and hospital level or rating can all affect maternal outcomes.20Clapp M.A. James K.E. Kaimal A.J. The effect of hospital acuity on severe maternal morbidity in high-risk patients.Am J Obstet Gynecol. 2018; 219: 111.e1-111.e7Abstract Full Text Full Text PDF Scopus (21) Google Scholar, 21Kyser K.L. Lu X. Santillan D.A. et al.The association between hospital obstetrical volume and maternal postpartum complications.Am J Obstet Gynecol. 2012; 207: 42.e1-42.e17Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar, 22Janakiraman V. Lazar J. Joynt K.E. Jha A.K. Hospital volume, provider volume, and complications after childbirth in US hospitals.Obstet Gynecol. 2011; 118: 521-527Crossref PubMed Scopus (70) Google Scholar, 23Kilpatrick S.J. Abreo A. Greene N. et al.Severe maternal morbidity in a large cohort of women with acute severe intrapartum hypertension.Am J Obstet Gynecol. 2016; 215: 91.e1-91.e7Abstract Full Text Full Text PDF Scopus (35) Google Scholar, 24Guglielminotti J. Deneux-Tharaux C. Wong C.A. Li G. Hospital-level factors associated with anesthesia-related adverse events in cesarean deliveries, New York State, 2009–2011.Anesth Analg. 2016; 122: 1947-1956Crossref PubMed Scopus (24) Google Scholar, 25Eller A.G. Bennett M.A. Sharshiner M. et al.Maternal morbidity in cases of placenta accreta managed by a multidisciplinary care team compared with standard obstetric care.Obstet Gynecol. 2011; 117: 331-337Crossref PubMed Scopus (322) Google Scholar, 26Sullivan S.A. Hill E.G. Newman R.B. Menard M.K. Maternal-fetal medicine specialist density is inversely associated with maternal mortality ratios.Am J Obstet Gynecol. 2005; 193: 1083-1088Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 27Ananth C.V. Lavery J.A. Friedman A.M. Wapner R.J. Wright J.D. Serious maternal complications in relation to severe pre-eclampsia: a retrospective cohort study of the impact of hospital volume.BJOG. 2017; 124: 1246-1253Crossref PubMed Scopus (18) Google Scholar Furthermore, data indicate that outcomes are better if women with certain conditions, such as placenta previa or placenta accreta, are managed in hospitals with high delivery volume.28Wright J.D. Herzog T.J. Shah M. et al.Regionalization of care for obstetric hemorrhage and its effect on maternal mortality.Obstet Gynecol. 2010; 115: 1194-1200Crossref PubMed Scopus (91) Google Scholar, 29Olive E.C. Roberts C.L. Algert C.S. Morris J.M. Placenta praevia: maternal morbidity and place of birth.Aust N Z J Obstet Gynaecol. 2005; 45: 499-504Crossref PubMed Scopus (47) Google Scholar This information should not be interpreted to imply that hospitals with low delivery volumes are not safe for care of women with low-risk pregnancies, or as a call to close hospitals with a lower volume or acuity. In remote or rural areas, hospitals with low delivery volumes are often the only local delivery option. Rather, these data, combined with the fact that 59% of hospital births in the United States occur at hospitals where fewer than 1000 newborns are delivered annually,15American Hospital AssociationAHA guide to the health care field. 2014. AHA, Chicago (IL)2013Google Scholar underscore the importance of adequately staffed and equipped level I and II hospitals; regionalized care with defined relationships between different level facilities; continuous risk assessment; and the potential benefit of caring for women with high risk of maternal morbidity in centers with higher-level, acuity-focused resources and specialty and subspecialty personnel. Regionalized maternal care is intended to maintain and increase access to care by developing, strengthening, and better defining relationships among facilities within a region. In turn, this should facilitate consultation and transfer of care when appropriate so that low- to moderate-risk women can stay in their communities while pregnant women with high-risk conditions receive care in facilities that are prepared to provide the required level of specialized care. Each facility should have a clear understanding of its capability to handle increasingly complex levels of maternal care and should have a well-defined threshold to transfer women to health care facilities that offer a higher level of care. In emergency situations, the nearest level-appropriate hospital should be used if added travel to a farther level-appropriate hospital increases risk. An important goal of regionalized maternal care is for level III or IV facilities to provide training for quality improvement initiatives, support for education, and severe morbidity and mortality case review for hospitals in their regional system. These recommendations should be considered guidelines, not mandates, and it should be acknowledged that geographic and local issues will affect systems of implementation for regionalized maternal and neonatal care. Development of levels of maternal care programs are increasing. Several states, including Georgia, Indiana, Texas, and Iowa, passed legislation or changed their administrative codes to establish a specific maternal level of care designation for all hospitals that provide maternity care. An essential component of all of these programs is the concept of an integrated system in which level III or IV maternal centers provide education and consultation, including training for quality improvement initiatives and severe morbidity and mortality case review, to level I and II facilities and provide for a streamlined system for maternal transport when necessary. The CDC developed the Levels of Care Assessment Tool (LOCATe)30Centers for Disease Control and PreventionCDC Levels of Care Assessment Tool (CDC LOCATe). CDC, Atlanta (GA)2019https://www.cdc.gov/reproductivehealth/maternalinfanthealth/LOCATe.htmlDate accessed: April 15, 2019Google Scholar in 2013 to address a need identified by states and national partners for a simple, web-based tool that standardizes the assessment of maternal and neonatal care capabilities of facilities. It is in alignment with the national guidelines published by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine and the national guidelines published by the American Academy of Pediatrics.31Catalano A. Bennett A. Busacker A. et al.Implementing CDC’s Level of Care Assessment Tool (LOCATe): a national collaboration to improve maternal and child health.J Womens Health (Larchmt). 2017; 26: 1265-1269Crossref PubMed Scopus (24) Google Scholar The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, in collaboration with the CDC, the Arizona Perinatal Trust, and the National Perinatal Information Center, expanded on the work achieved with LOCATe to develop the Levels of Maternal Care verification program. The verification program involves an on-site survey to assess levels of maternal care in an obstetric facility according to the Levels of Maternal Care Obstetric Care Consensus criteria. A multidisciplinary team that represents organizations with expertise in maternal risk-appropriate care piloted this program with 14 facilities across 3 states (Georgia, Illinois, and Wyoming). The team performed an on-site comprehensive review of the maternal services available in each facility using the hospital’s LOCATe results as the initial step in the verification process.32Zahn C.M. Remick A. Catalano A. Goodman D. Kilpatrick S.J. Menard M.K. Levels of maternal care verification pilot: translating guidance into practice.Obstet Gynecol. 2018; 132: 1401-1406Crossref PubMed Scopus (20) Google Scholar Experience from LOCATe and the pilot verification program have informed the revisions of this document to better enable implementation. To standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care, this classification system establishes levels of maternal care that pertain to basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). Definitions, capabilities, and health care providers for each of the 4 levels of maternal care and for birth centers are delineated in Table 1. Maternal care refers to all aspects of antepartum, intrapartum, and postpartum care. Table 1 also refers to low-, moderate-, and high-risk care; defining what constitutes these levels of risk should be individualized by facilities and regions, with input from their obstetric care providers. Accredited birth centers (freestanding facilities that are not hospitals) (see Accredited Birth Centers section for more information) are an integral part of many regionalized care systems and are, therefore, included in the table; however, capabilities and health care providers are not delineated in the table because well-established standards governing birth centers in the United States are already available.33American Association of Birth CentersStandards for birth centers. AABC, Perkiomenville (PA)2017http://www.birthcenters.org/resource/resmgr/AABC-STANDARDS-RV2017.pdfDate accessed: April 2, 2019Google ScholarTable 1Levels of maternal care: definitions, capabilities, and health care providers∗These guidelines are limited to maternal needs. Consideration of fetal or neonatal needs and the appropriate level of care should occur following existing guidelines. In fact, levels of maternal care and levels of neonatal care may not match within facilities. Additionally, these are guidelines, and local issues will affect systems of implementation for regionalized maternal care, perinatal care, or bothAccredited birth centerDefinition•Care for low-risk women with uncomplicated singleton term vertex pregnancies who are expected to have an uncomplicated birthCapabilities and health care providers•Refer to birthcenters.org for American Association of Birth Centers’ Standards for Birth CentersLevel I (basic care)Definition•Care of low- to moderate-risk pregnancies with ability to detect, stabilize, and initiate management of unanticipated maternal-fetal or neonatal problems that occur during the antepartum, intrapartum, or postpartum period until the patient can be transferred to a facility at which specialty maternal care is availableCapabilities•Capability and equipment to provide low-risk and appropriate moderate-risk maternal care and a readiness at all times to initiate emergency procedures to meet unexpected needs of women and newborns within the center. This includes:○Ability to begin emergency cesarean delivery within a time interval that best incorporates maternal and fetal risks and benefits○Limited obstetric ultrasonography with interpretation readily available at all times†Readily available at all times: the specific person should be available 24 hours a day, 7 days a week, for consultation and assistance, and able to be physically present onsite 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○Support services readily available at all times†Readily available at all times: the specific person should be available 24 hours a day, 7 days a week, for consultation and assistance, and able to be physically present onsite 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, including laboratory testing and blood bank○Capability to implement patient safety bundles‡Available at https://safehealthcareforeverywoman.org/patient-safety-bundles for common causes of preventable maternal morbidity, such as management of maternal venous thromboembolism, obstetric hemorrhage, and maternal severe hypertension in pregnancy§See also Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. ACOG Committee Opinion No. 767. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e174-80○Ability at all times†Readily available at all times: the specific person should be available 24 hours a day, 7 days a week, for consultation and assistance, and able to be physically present onsite 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 to initiate massive transfusion protocol, with process to obtain more blood and component therapy as needed•Stabilization and the ability to facilitate transport to a higher-level hospital when necessary. This includes:○Risk identification and determination of conditions necessitating consultation, referral, and transfer○A mechanism and procedure for transfer/transport to a higher-level hospital available at all times†Readily available at all times: the specific person should be available 24 hours a day, 7 days a week, for consultation and assistance, and able to be physically present onsite 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 facil
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