Iowa Administrative Code
Agency 641 - PUBLIC HEALTH DEPARTMENT
Chapter 150 - IOWA REGIONALIZED SYSTEM OF PERINATAL HEALTH CARE
Rule 641-150.7 - Levels of maternal care
Universal Citation: IA Admin Code 641-150.7
Current through Register Vol. 46, No. 19, March 20, 2024
The levels of maternal care include basic obstetrical care Level I, specialty care Level II, subspecialty care Level III and regional perinatal health care Level IV. The levels reflect the overall evidence for risk-appropriate care in a hospital through the availability of appropriate personnel, physical space, equipment, technology, and organization. Each level reflects the minimal capabilities, provider type and functional criteria required.
(1) Level I maternal care hospital.
a.
Provider
of basic obstetrical care. ALevel I maternal care hospital provides
care to women who are low risk and are expected to have an uncomplicated
birth.
b.
Capabilities. A Level I maternal care hospital has the
following capabilities:
(1) To perform
routine intrapartum and postpartum care that is anticipated to be
uncomplicated. Care of uncomplicated pregnancies includes the 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 that provides
specialty maternal care.
(2) To
begin an emergency cesarean delivery within a time interval that best
incorporates maternal and fetal risks and benefits with the provision of
emergency care.
c.
Types of health care providers. A Level I maternal care
hospital will have:
(1) Maternity care
providers, including certified nurse-midwives, family practice physicians, or
obstetrician-gynecologists, available to attend all births.
(2) Every birth attended by at least two
professionals, including the primary maternal care provider and a person
competent to provide neonatal resuscitation and postnatal care to stabilize the
infant.
(3) Adequate numbers of
registered nurses available who have completed orientation and demonstrated
competence in the care of obstetric patients, including women and fetuses,
consistent with Level I care criteria and who are able to stabilize and
transfer high-risk women and newborns.
(4) Nursing leadership with expertise in
perinatal nursing care.
(5) A
provider with privileges to perform an emergency cesarean delivery, available
to attend all deliveries. The provider may be a general surgeon, an
obstetrician-gynecologist, or a family practice physician with
certification.
(6) A provider of
anesthesia services available to provide labor analgesia and surgical
anesthesia.
d.
Functional criteria of support services. Support services
include, but are not limited to, access to obstetric ultrasonography,
laboratory testing, and blood bank supplies at all times. A Level I maternal
care hospital will:
(1) Have protocols and
capabilities in place for:
1. Massive
transfusion,
2. Emergency release
of blood products (before full compatibility testing is complete),
3. Management of multiple component
therapy.
(2) Ensure
optimal care of all pregnant women by having formal transfer plans established
in partnership with a higher-level receiving hospital. These plans will
include:
1. Risk identification,
2. Determination of conditions necessitating
consultation,
3. Referral and
transfer, and
4. A reliable,
accurate, and comprehensive communication system between the participating
hospital and the transport team.
(3) Have education and quality improvement
programs to maximize patient safety, provide such programs through
collaboration with facilities with higher levels of care that receive
transfers, or both.
(4) Have data
collection, storage and retrieval to support quality improvement.
(2) Level II maternal care hospital.
a.
Provider of specialty care. In addition to meeting the
criteria of a Level I maternal care hospital, a Level II maternal care hospital
provides care of appropriate high-risk pregnant women, both those directly
admitted to the hospital and those transferred from another hospital.
b.
Capabilities. In addition
to having the capabilities of a Level I maternal care hospital, a Level II
maternal care hospital has the following capabilities:
(1) The infrastructure for continuous
availability of adequate numbers of registered nurses who have demonstrated
competence in the care of obstetric patients (women and fetuses).
(2) Orientation and demonstrated competence
consistent with Level II care criteria and the capability to stabilize and
transfer high-risk women and newborns who exceed Level II care
criteria.
c.
Types of health care providers. In addition to meeting the
health care provider requirements of a Level I maternal care hospital, a Level
II maternal care hospital will have:
(1)
Health care providers, including certified nurse-midwives or family
physicians.
(2) Nursing leaders and
staff with formal training and experience in the provision of perinatal nursing
care who can coordinate with respective neonatal care services.
(3) An attending obstetrician-gynecologist
available at all times.
(4) A
board-certified or board-eligible obstetrician-gynecologist with special
interest and experience in obstetric care as the director of obstetric
services.
(5) Access to a
maternal-fetal medicine subspecialist for consultation, available on site, by
telephone, or by telemedicine as needed.
(6) A provider of anesthesia services
available at all times to provide labor analgesia and surgical
anesthesia.
(7) A board-certified
or board-eligible anesthesiologist with special training or experience in
obstetric anesthesia, available for consultation.
(8) Medical and surgical consultants
available to stabilize obstetric patients who have been directly admitted to
the facility or transferred from other hospitals.
d.
Functional criteria of support
services. In addition to meeting the support services requirements of
a Level I maternal care hospital, a Level II maternal care hospital will have:
(1) Computed tomography scan and, ideally,
magnetic resonance imaging with interpretation available.
(2) Basic ultrasonographic imaging services
for maternal and fetal assessment at all times, either in house or on
call.
(3) Special equipment needed
to accommodate the care and services needed for obese women. In addition, based
on the patient's BMI and other risk factors, a consultation with an
obstetrician-gynecologist or a maternal fetal medicine specialist should be
considered.
(4) The ability to
provide high-risk obstetrical care, but efforts should be made to transfer
women whose newborns are likely to need a higher level of care than a Level II
maternal care hospital can provide, or when the pregnancy has risk factors that
require the consultation or care of a maternal-fetal medicine
specialist.
(3) Level III maternal care hospital.
a.
Provider of subspecialty
care. A Level III maternal care hospital provides care to women that
includes all Level I and Level II services and has subspecialists available on
site, by telephone, or by telemedicine to assist in providing care for more
complex maternal and fetal conditions.
b.
Capabilities. A Level III
maternal care hospital functions as the regional perinatal health care center
for some areas of Iowa if there are no Level IV maternal care hospitals
available. In these areas, a Level III maternal care hospital will be
responsible for the leadership; facilitation of transport and referral;
educational outreach; and data collection, storage and retrieval to support
quality improvement. Designation of Level III maternal care hospital should be
based on the demonstrated experience and capability of the facility to provide
comprehensive management of severe maternal and fetal complications.
c.
Types of health care
providers. In addition to meeting the health care provider
requirements of a Level II maternal care hospital, a Level III maternal care
hospital will have:
(1) An
obstetrician-gynecologist with inpatient privileges, available on site at all
times.
(2) A maternal-fetal
medicine subspecialist with inpatient privileges, available at all times,
either on site, by telephone, or by telemedicine.
(3) A director of the maternal-fetal medicine
service who is a board-certified or board-eligible maternal-fetal medicine
subspecialist.
(4) A
board-certified or board-eligible obstetrician-gynecologist with special
interest and experience in obstetric care directing obstetric
services.
(5) A provider of
anesthesia services available at all times on site.
(6) A board-certified or board-eligible
anesthesiologist with special training or experience in obstetric anesthesia
who is in charge of obstetric anesthesia services.
(7) A full complement of subspecialists,
available for inpatient consultations, including subspecialists in:
1. Critical care,
2. General surgery,
3. Infectious disease,
4. Hematology,
5. Cardiology,
6. Nephrology,
7. Neurology, and
8. Neonatology.
(8) Nursing leaders and adequate numbers of
registered nurses who have completed orientation and demonstrated competence in
the care of obstetric patients (women and fetuses) consistent with Level III
care criteria, including the transfer of high-risk women who exceed Level III
care criteria, and who have special training and experience in the management
of women with complex maternal illnesses and obstetric complications. Nursing
personnel will be continuously available.
d.
Functional criteria of support
services. In addition to meeting the support services requirements of
a Level II maternal care hospital, a Level III maternal care hospital will
have:
(1) An on-site intensive care unit to
accept pregnant women.
(2) Critical
care providers on site to actively collaborate with maternal-fetal specialists
at all times.
(3) Equipment and
personnel with expertise available on site to ventilate and monitor women in
the labor and delivery unit until they can be safely transferred to the
intensive care unit.
(4) The
ability to provide the following imaging services, with interpretation
available at all times:
1. Basic
interventional radiology,
2.
Maternal echocardiography,
3.
Computed tomography,
4. Magnetic
resonance imaging, and
5. Nuclear
medicine imaging.
(5) The
ability to perform detailed obstetric ultrasonography and fetal assessment,
including Doppler studies.
(4) Level IV maternal care hospital.
a.
Provider of
services as a regional perinatal health care center. In addition to
meeting the requirements for a Level III maternal care hospital, a Level IV
maternal care hospital provides care to women with additional requirements and
has considerable experience in the care of the most complex and critically ill
pregnant women throughout antepartum, intrapartum, and postpartum care. The
particular specialty of fetal surgery, advanced neurosurgery, transplant, and
advanced cardiovascular capabilities may not all be available at an individual
Level IV maternal care hospital. In some cases, specific advanced care will
require care coordination to the Level IV maternal care hospital by
availability of specific expertise, including but not limited to fetal surgery,
advanced neurosurgery, transplant, and advanced cardiovascular capabilities.
Each hospital will have a clear understanding of the categories of perinatal
patients who can be managed appropriately in the local hospital and those who
must be transferred.
b.
Capabilities. Although Level III and Level IV maternal care
hospitals may seem to overlap, a Level IV maternal care hospital is distinct
from a Level III maternal care hospital in the approach to the care of pregnant
women and women in the postpartum period with complex and critical illnesses.
In addition to having an intensive care unit on site for obstetric patients, a
Level IV maternal care hospital must have evidence of a maternal-fetal medicine
care team that has the expertise to assume responsibility for pregnant women
and women in the postpartum period who are in critical condition or have
complex medical conditions. The matemal-fetal medicine team collaborates
actively in the co-management of all obstetric patients who require critical
care and intensive care unit services, including co-management of intensive
care unit-admitted obstetric patients.
c.
Types of health care
providers. In addition to meeting the health care provider
requirements of a Level III maternal care hospital, a Level IV maternal care
hospital will have:
(1) A maternal-fetal
medicine team member with full privileges, available at all times for on-site
consultation and management.
(2) A
board-certified maternal-fetal medicine subspecialist with expertise in
critical care obstetrics to lead the team.
(3) A maternal-fetal medicine team with
expertise in critical care at the physician level, nursing level, and ancillary
services level.
(4) Institutional
support for the routine involvement of a maternal-fetal medicine care team with
the critical care units and specialists. A key principle of caring for
critically ill pregnant and peripartum women is the hospital's recognition of
the need for seamless communication between maternal-fetal medicine
subspecialists and other subspecialists in the planning and facilitation of
care for women with the most high-risk complications of pregnancy.
(5) A commitment to having physician and
nursing leaders with expertise in maternal intensive and critical care, as well
as adequate numbers of available registered nurses in a Level IV maternal care
hospital who have experience in the care of women with complex medical
illnesses and obstetric complications; this experience includes completed
orientation and demonstrated competence in the care of obstetric patients
(women and fetuses) consistent with Level IV maternal care criteria.
(6) A director of obstetric services who is a
board-certified maternal-fetal medicine subspecialist or a board-certified
obstetrician-gynecologist with expertise in critical care obstetrics.
(7) A provider of anesthesia services
available on site at all times.
(8)
A board-certified anesthesiologist with special training or experience in
obstetric anesthesia who is in charge of obstetric anesthesia
services.
(9) Adult medical and
surgical specialty and subspecialty consultants, a minimum of those listed for
a Level III maternal care hospital, available on site at all times to
collaborate with the maternal-fetal medicine care team.
d.
Functional criteria of support
services. In addition to meeting the support services requirements of
a Level III maternal care hospital, a Level IV maternal care hospital will
have:
(1) The capability for on-site medical
and surgical care of complex maternal conditions (e.g., congenital maternal
cardiac lesions, vascular injuries, neurosurgical emergencies, and transplants)
with the availability of critical (or intensive) care unit beds.
(2) Perinatal system leadership, including
facilitation of maternal referral and transport, outreach education for
facilities and health care providers in the region and analysis and evaluation
of regional data, including perinatal complications, outcomes and quality
improvement.
This rule is intended to implement Iowa Code section 135.11(27).
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