Professional Documents
Culture Documents
tertiary care hospital runs simu- Through a Maternal Health the referring hospitals and partner
lations of obstetrical emergencies Compact, physicians and nurses with them to create such site-
and assists with quality-improve- made available to lower-resource specific algorithms, including use
ment activities such as implemen- hospitals through a video link can of emergency-release blood, fresh
tation of hemorrhage-treatment help manage on-site obstetrical frozen plasma, shock garments,
algorithms. Such collaborative emergencies. Physicians make rec- and tranexamic acid. The work-
work can be done in person or ommendations regarding care, flow for patients requiring trans-
through telemedicine connections. while nurses support the nurse port should be as efficient and
National efforts at improving in the field by documenting the seamless as possible.
obstetrical care have stopped short patients course and care in the Pregnant woman in rural com-
of addressing rare emergencies medical record and facilitating munities cannot afford to lose
that can occur in a lower-resource communication with the local access to local hospitals; rather,
hospital. In 2015, for example, the pharmacy to obtain necessary we need to make the care they
American Congress of Obstetri- medications. The telehealth pro- receive as safe as possible. Team
cians and Gynecologists and the gram developed at Avera, for ex- training and simulation of emer-
Society for MaternalFetal Medi- ample, houses under one roof a gencies are common tools of the
cine released the Obstetric Care variety of medical departments patient-safety movement, and elec-
Consensus on Levels of Maternal ICU, pharmacy, emergency, and tronic connectivity and broad
Care, which delineates criteria for others to provide continual implementation of a Maternal
identifying women at consider- specialty care to partner care fa- Health Compact are the next log-
able health risk (such as those cilities. This kind of coordination ical steps for improving patient
with placenta previa, placenta ac- is invaluable to patients. care, retaining rural care facili-
creta, or preeclampsia with severe The development and imple- ties, and recruiting and support-
features) who should be cared for mentation of national standards ing practitioners in the field.
at a hospital with appropriate supports the consistency of ob- Disclosure forms provided by the authors
staffing and resources to avert stetrical care. The National Part- are available at NEJM.org.
obstetrical complications and re- nership for Maternal Safety, an This article was updated on April 6, 2017, at
NEJM.org.
lated deaths.4 Unfortunately, the initiative aimed at reducing ma-
consensus statement does not ad- ternal morbidity and mortality, From the Department of Obstetrics and Gy-
necology, Beth Israel Deaconess Medical
dress the situation of an 18-year- released a Consensus Bundle on Center, Boston (S.M.); the Obstetric Ser-
old with an unexpected severe Obstetric Hemorrhage, in conjunc- vice Line, Avera Health, Sioux Falls, SD
hemorrhage. Yet with better prepa- tion with the Alliance for Innova- (K.M.); the American College of Obstetrics
and Gynecology, Washington, DC (H.B.);
ration and planning through a Ma- tion in Maternal Heath (AIM), and the Duke University School of Medi-
ternal Health Compact, hospitals which recommended that all hos- cine, Durham, NC (H.B.).
could be ready for these crises. pitals that provide obstetrical care 1. Lisonkova S, Haslam MD, Dahlgren L,
Telehealth is already used in develop a standard treatment Chen I, Synnes AR, Lim KI. Maternal morbid-
ity and perinatal outcomes among women
many disciplines in which there is protocol for postpartum hemor-
in rural versus urban areas. CMAJ 2016;
a mismatch between patient needs rhage.5 The challenge for the 188(17-18):E456-E465.
and specialty expertise, such as smaller, often rural, hospital has 2. Callaghan WM, Creanga AA, Kuklina
EV. Severe maternal morbidity among deliv-
dermatology, geriatrics, and men- been to determine what the pro- ery and postpartum hospitalizations in the
tal health, but to our knowledge, tocol should be for a massive United States. Obstet Gynecol 2012; 120:
there has been no telehealth transfusion when their blood bank 1029-36.
3. Hung P, Kozhimannil KB, Casey MM,
model for obstetrical care for an carries only a fraction of the blood Moscovice IS. Why are obstetric units in rural
acutely high-risk pregnant woman products considered essential for hospitals closing their doors? Health Serv
in a lower-resource hospital. In most hemorrhage-treatment pro- Res 2016;51:1546-60.
4. Obstetric care consensus no. 2: levels of
the case of the Minnesota patient, tocols. Lower-resource hospitals maternal care. Obstet Gynecol 2015; 125:
a coordinated telehealth team in- need site-specific protocols for 502-15.
tervened quickly and effectively; managing the care of patients 5. Main EK, Goffman D, Scavone BM, et al.
National Partnership for Maternal Safety
they worked with the rural hos- with massive hemorrhage. The ter- consensus bundle on obstetric hemorrhage.
pital to stabilize the patient, ar- tiary care physicians who accept Obstet Gynecol 2015;126:155-62.
ranged transport, and prepared transfers of such patients should DOI: 10.1056/NEJMp1700485
the tertiary care hospital. help identify resources available at Copyright 2017 Massachusetts Medical Society.
The Maternal Health Compact