Walking into the PACU following an appendectomy on a Saturday afternoon, the on-call obstetrician pages you about a pregnant patient in the ED. You work at a 50-bed hospital in a mountain town that provides basic obstetric services but has no ICU and a limited blood bank. The patient is a 32-year-old G1P0 healthy woman at 29 weeks gestation who was hiking when she felt lightheaded and generally unwell. In the ED, her blood pressure is 190/100, she has protein in her urine and mildly elevated LFTs, and is complaining of a headache. She is diagnosed with preeclampsia with severe features, and you have concerns about progression to HELLP syndrome.

You and the obstetrician quickly determine that the patient needs transfer to a facility with a higher level of care for both maternal and fetal indications. You work together to manage her blood pressure; the headache resolves with BP control to the 150s/90s and magnesium therapy. You call the anesthesia team at the receiving hospital and give a brief handoff about the patient as you anticipate their obstetrics team may move toward delivery upon patient arrival.

Maternal mortality and severe maternal morbidity have increased in the United States over the past two to three decades (asamonitor.pub/39bIjeh; asamonitor.pub/3FzKZy8). These outcomes also have profound disparities, with non-Hispanic Black women having a significantly higher maternal mortality ratio than non-Hispanic white women (Obstet Gynecol 2017;130:366-73). One unified strategy to improve outcomes for all pregnant women and eliminate disparities among racial and ethnic groups is the implementation of regionalized maternal care systems, similar to the well-established system of neonatal levels of care. Levels of Maternal Care have been developed by the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (Obstet Gynecol 2019;134:883). As of January 2022, institutions can voluntarily obtain a Maternal Levels of Care verification from The Joint Commission.

The Levels of Maternal Care range from Levels 1-4. There are many criteria for each level, which include equipment, laboratory and blood bank capabilities, radiologic and critical care facilities, and availability of various health care providers. The Table summarizes the requirements for type and availability of anesthesia care providers. Detailed criteria can be found in ACOG’s Levels of Maternal Care Obstetric Care Consensus document (Obstet Gynecol 2019;134:883).

Anesthesiologists have many opportunities to improve maternal mortality within the framework of Levels of Maternal Care, beginning with the risk stratification of obstetric patients both antepartum and on the labor floor. Risk stratification should address both risk-appropriate delivery location and patient optimization. Significant value can be added to obstetric patient care by establishing systems for consultation between the obstetrician and the anesthesiologist. One example of a formal consultative process is the cardio-obstetrics team; however, in lower-risk settings, informal discussions between the obstetric and anesthesiology teams may be more appropriate (Clin Obstet Gynecol 2020;63:791-8). The last several years have also seen the advent and success of telehealth obstetric consultations (J Matern Fetal Neonatal Med 2021:1-8). As perioperative physicians, anesthesiologists can offer expertise in assessing need for advanced hemodynamic monitoring, airway management, resuscitation and transfusion, and intensive care unit or other increased monitoring postpartum, all of which may impact the choice of risk-appropriate delivery location.

“While ACOG Levels of Maternal Care designations focus on the relative availability, experience, and formal training background of the anesthesia provider, there is an additional opportunity for anesthesia-specific policies designed to optimize the safety and quality of maternal care within this framework. Our patients and communities deserve an explicit method of appraising the quality of care provided by the facilities they choose for their delivery, including the implementation of policies and practices associated with greater quality and safety in maternal care.”

The required availability for subspecialty consultation and intensive care services increases with each level of care. Level 3 facilities must have medical and surgical ICUs that can accept obstetric patients and a “full complement of subspecialists available for consultation.” Ideally, obstetric-specific critical care should be available at Level 4 facilities, and intensivists and subspecialists should be on site at all times. While the levels of care do not specifically address the availability of anesthesiology subspecialists, we expect such availability to correlate well with the increasing levels of care. At Level 1 and 2 facilities, there may be cardiac or critical care-trained anesthesiologists available to help stabilize or care for obstetric patients. At Level 3 facilities, the anesthesiology group will almost certainly include members with that subspecialty training, and at Level 4 facilities it is not unusual for there to be on-site anesthesiologists with critical care, cardiac, neurosurgical, transplant, and other subspecialty training who can collaborate with the obstetric anesthesiologist and others as a multidisciplinary team. It will be increasingly important to demonstrate the value diverse anesthesiology training brings to the care of pregnant patients.

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Once the decision is made to pursue transfer, anesthesiologists have a second opportunity to improve care by communicating (either in the chart or directly) concerns to the receiving institution. We recommend establishing systems by which transfer pathways include anesthesiologist-to-anesthesiologist communication. Finally, when the decision is made to continue care at the presenting institution, anesthesiologists serve a vital role in the maternal levels of care by collaborating with the obstetrics team to medically optimize the patient, including but not limited to decisions about vascular access, fluids, timing, and type of anesthetic and analgesic, airway management, delivery location, and postpartum care plan.

While ACOG Levels of Maternal Care designations focus on the relative availability, experience, and formal training background of the anesthesia provider, there is an additional opportunity for anesthesia-specific policies designed to optimize the safety and quality of maternal care within this framework. Our patients and communities deserve an explicit method of appraising the quality of care provided by the facilities they choose for their delivery, including the implementation of policies and practices associated with greater quality and safety in maternal care. The Society for Obstetric Anesthesia and Perinatology (SOAP) has sought to address this deficiency in site designation through their “Centers of Excellence for Anesthesia Care of Obstetric Patients” designation. While this system of designation also addresses the anesthesia providers’ level of training and availability, specific indicators of quality in clinical practice based on current evidence are detailed as well (Anesth Analg 2019;128:844-6).

Protocols specified by the Center of Excellence designation provide anesthesiologists an outline for implementing high-yield systems of care, including a massive transfusion protocol, multidisciplinary rounds or huddles, an obstetric emergency response system, and simulation-based drills for team training. Specific equipment and medications on site and even the capability for an open and available OR and staffing at all times (in addition to those in use) are detailed. These specifications further detail evidence-based approaches to the provision of labor analgesia (low-concentration solution, patient-controlled epidural analgesia, flexible catheter use, etc.) and anesthesia for cesarean delivery (enhanced recovery pathways, use of pencil point spinal needles, multimodal analgesic approaches, prophylaxis for spinal-induced hypotension, etc.).

While the ACOG Levels of Maternal Care offer delineation based on the availability and training of anesthesiologists, we see this framework as an opportunity for anesthesiologists to bring value to their patients and hospitals by substantively improving the care provided (and ultimately improving maternal and fetal outcomes and reducing disparities). Anesthesiologist involvement in the risk stratification, triage, transfer, and implementation of best practices confers the most benefit to maternal and fetal outcomes. As the levels of care evolve, we envision specific benchmarks that reflect the practices, not just the people, involved in the provision of care on a labor and delivery unit to better characterize the level of care provided.