Delays or improper handling of maternal near miss (MNM) referrals are closely associated with maternal mortality. Establishing a sound MNM referral system and maintaining its effective operation are crucial for reducing maternal mortality, ensuring the safety of MNM patients, and achieving favorable prognosis. This consensus establishes standards covering 9 aspects: definition of MNM, purpose of referral, classification, principles, referral process, transfer implementation, emergency management, handling process in receiving hospitals, and summary evaluation. It aims to safeguard maternal and fetal safety and improve adverse pregnancy outcomes.

The World Health Organization (WHO) defines maternal near miss (MNM) as a pregnant woman who survives a life-threatening condition occurring during pregnancy, childbirth, or within 42 days after delivery. Its identification includes clinical symptoms, signs, laboratory examinations, and treatment measures. The organization has uniformly renamed "Severe Acute Maternal Morbidity (SAMM)" to MNM.

Due to significant differences in the coverage of perinatal health services across countries, collecting statistical data on MNM faces substantial challenges. Limited domestic and international statistical data indicate an incidence rate of approximately 0.4% to 1%.

Combined with clinical obstetric practice in China, the incidence of MNM is on the rise due to the growing trend of advanced maternal age and the increasing prevalence of metabolic diseases and other comorbidities. Comprehensive assessment enables more accurate identification of MNM cases and timely referral under safe conditions. This is of great significance for reducing maternal mortality, improving pregnancy outcomes, and protecting maternal and fetal health.

If the receiving medical institution lacks the capability to provide appropriate diagnosis, treatment, and rescue for MNM patients with pregnancy complications or comorbidities, the patient should be immediately referred by a professional medical team trained in emergency medical rescue skills to a tertiary general hospital with maternal critical care qualifications. This ensures that pregnant women receive more professional multidisciplinary medical services and timely treatment, rationally utilizes medical resources, effectively reduces maternal and fetal risks, improves the success rate of treatment, and effectively safeguards maternal and fetal health.

It includes two types: maternal-fetal referral and postpartum referral. For preterm pregnancies where the fetal condition permits, maternal-fetal transfer is preferred. The MNM patient is transferred to a hospital with maternal and neonatal treatment capabilities before termination of pregnancy (Evidence quality: A; Recommendation strength: Strong).

Safety is the core of MNM referral. Referral should be implemented only when medical safety is fully guaranteed to avoid the risks of blind referral (Evidence quality: B; Recommendation strength: Strong).

The competent unit shall form a professional medical team consisting of doctors from obstetrics, gynecology, emergency medicine, neonatology, anesthesiology, interventional radiology, critical care medicine, internal medicine, surgery, and other departments. This team conducts a comprehensive assessment of the severity of the maternal condition, transfer risks, and the treatment capacity of the receiving hospital. It predicts the transportation time and the maternal tolerance to the disease. Pregnant women with transfer contraindications are prohibited from blind referral (Evidence quality: B; Recommendation strength: Strong).

Fully communicate with the pregnant woman and her family members (spouse, adult children, etc.), explain the necessity of transfer, potential risks, and possible outcomes, and obtain their informed consent with signature on relevant documents (Evidence quality: C; Recommendation strength: Strong).

The diagnosis should be confirmed based on the pregnant woman's demographic information, medical history, clinical symptoms, signs, and auxiliary examinations. When the attending physician and hospital assess that the treatment of the pregnant woman exceeds the medical capacity of the unit, they should immediately report to the superior maternal critical care center and the Obstetric Safety Management Office of the Medical Affairs Department via telephone, video, information, and other instant communication tools to seek support. After considering referral, the primary task is to assess whether the maternal and fetal conditions are stable, closely monitor for signs of deterioration during referral, and confirm the presence of referral contraindications. If referral is deemed necessary after weighing the pros and cons but the patient has unstable conditions or other transfer contraindications, the medical staff requesting the referral should document the reasons why transfer to another medical institution is more beneficial to the mother and fetus. The receiving unit should conduct active pre-treatment to reduce transfer risks (such as rescue under the guidance of the superior hospital or active blood transfusion, blood pressure reduction treatment for the patient's condition) (Evidence quality: A; Recommendation strength: Strong).

The MNM screening criteria proposed by WHO include severe maternal complications, critical interventions or admission to the intensive care unit (ICU), and life-threatening conditions. In 2020, China added criteria for screening severe pregnancy complications and comorbidities on the basis of WHO's standards.

(1) Unstable maternal vital signs (such as continuous bleeding, refractory hypertension, heart failure, etc.).(2) Inevitable delivery before the completion of referral.(3) Unstable fetal condition, where delayed delivery would lead to adverse neonatal prognosis.(4) Patient refusal of referral.(5) Lack of appropriate routes for safe maternal-fetal transfer.(6) Extremely dangerous weather and road conditions that prevent safe transfer (Evidence quality: B; Recommendation strength: Strong).

Before referral, a comprehensive assessment should be completed based on the pregnant woman's medical history, symptoms, signs, adverse pregnancy and childbirth history, pregnancy-complicated underlying diseases, pregnancy complications, laboratory examinations, and imaging examinations. Potential or impending clinical critical states should be predicted, close monitoring and timely effective intervention should be conducted, active preparations for referral should be made, and the comprehensive assessment content should be completed.

High-quality communication and information exchange between medical institutions are necessary to prevent adverse events during transfer and promote the continuity of MNM treatment. A designated person is responsible for detailing the patient's condition, potential risks and benefits during transfer, and treatment costs to the patient and her family. After the initiation of referral, the transferring hospital should implement the negotiated transfer plan and sign a written informed consent form. The transfer team should carry the maternal and child health manual, MNM referral form, and medical condition introduction to the receiving hospital. Self-referral by the pregnant woman and her family or referral to a hospital without MNM rescue conditions should be avoided to prevent delayed treatment (Evidence quality: C; Recommendation strength: Strong).

Before the MNM patient arrives at the receiving hospital, the transferring hospital and doctors are responsible for the treatment of the MNM patient, unless the receiving hospital takes the initiative to dispatch a transfer team. Each hospital should clarify responsibilities before, during, and after referral. The medical treatment during transfer is the responsibility of the transferring hospital, and the receiving hospital may provide consultation and guidance if necessary (Evidence quality: C; Recommendation strength: Strong).

The transfer team must consist of professional and technical personnel who meet the needs of MNM treatment to ensure the safety of the transfer. Given the particularity of the maternal clinical process, it is recommended that the MNM transfer team include at least 1 physician with emergency experience (obstetrics, emergency critical care, or anesthesiology specialty) and a nurse/midwife with emergency experience. For severe conditions, senior professional and technical personnel with corresponding qualifications should be added. When the transfer distance is 400km or more or the transfer time is 5h or more, it is recommended to arrange 2 accompanying drivers with 5 years or more of long-distance driving experience. In the future, air transfer may be considered (Evidence quality: A; Recommendation strength: Strong).

MNM faces the dual risk of safeguarding maternal and fetal health. In addition to commonly used emergency equipment, items, and medications, the transfer must be equipped with midwifery and neonatal rescue-related items. Due to differences in reserved medications and equipment among different units, emergency equipment, items, and medications are recommended (Evidence quality: B; Recommendation strength: Strong).

After the initiation of the transfer process, the transferring hospital and the participating transfer physicians need to reassess the patient's condition and maintain the maternal vital signs in a relatively stable state. If blood transfusion, fluid infusion, mechanical ventilation, or other needs are predicted during the transfer, pre-treatment should be performed before the transfer. Check the transfer plan and ensure that the equipment and items provided during the transfer are sufficient.

Medical staff should closely monitor the progress of the MNM patient's condition, including continuous blood pressure, heart rate, and blood oxygen saturation measurement, as well as timely fetal heart rate monitoring, electrocardiogram, and other examinations. It is recommended to record the maternal vital signs, fetal heart rate changes, uterine contraction frequency, and other monitoring indicators in writing on the transfer form every 15 minutes, which can be increased or decreased according to specific conditions. Emergencies during transfer and their handling measures should also be recorded in detail. During transfer, the pregnant woman is recommended to take a left lateral position or sitting position to minimize the compression of the aorta by the uterus (Evidence quality: B; Recommendation strength: Strong).

The transfer unit should comprehensively consider the weather and road conditions and reasonably plan the transfer route. The shorter the transfer time that various conditions can tolerate, the better.(1) Ground ambulance transportation is suitable for short-distance transportation.(2) Air transfer has the advantages of high speed and long distance, but it is expensive, has high requirements for transfer personnel and equipment, and requires a long preparation time. The actual time saved may be limited (Evidence quality: C; Recommendation strength: Weak).

The transferring hospital shall formulate emergency treatment plans for potential risks during transfer. If the MNM patient's condition changes during transfer or various force majeure factors lead to difficulties in handling during transfer, the transferring hospital and the receiving hospital should be promptly reported, and the local maternal and child health authority should be informed to obtain support (Evidence quality: B; Recommendation strength: Strong).

After determining the initiation of the MNM referral process, the receiving hospital should quickly form and activate the RRT. Through telephone, video, WeChat, and other instant communication devices, it comprehensively understands the condition of the referred patient and predicts the diagnosis and treatment plan to ensure that valuable time is not delayed during treatment and maximize the protection of maternal and fetal life safety. The RRT is composed of obstetrics and the Obstetric Safety Office of the receiving hospital, with assistance from medical staff of neonatology, anesthesiology, critical care medicine, interventional radiology, internal medicine, surgery, anesthesiology, and neonatology departments. Before the arrival of the transfer team, preparations for reception and treatment should be made, including emergency medications, equipment, beds, and corresponding medical staff. The physician of the receiving unit should again inquire in detail about the medical history, current condition, previous emergency treatment measures, fill in the transfer handover form, and record the arrival time. Relevant examinations should be completed in the emergency rescue room to reduce unnecessary intra-hospital transfer. MDT should be performed if necessary (Evidence quality: A; Recommendation strength: Strong).

Disease severity scoring is used to judge the severity of the condition. Commonly used reference scales include the Sequential Organ Failure Assessment (SOFA), Glasgow Coma Scale (GCS), and Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE-Ⅱ). In recent years, the Obstetrically Modified Quick SOFA Score (omqSOFA) has often been used for MNM, but various MNM early warning scores still need further clinical research verification (Evidence quality: C; Recommendation strength: Weak).

The receiving hospital should promptly feed back the diagnosis and treatment of the referred MNM patient to the transferring hospital and relevant management departments through China's regional three-level maternal and child health care treatment network to form a complete information closed loop. Problems arising during the MNM referral process should be summarized in a timely manner and improvement measures should be formulated. For links that temporarily cannot meet the needs of inter-hospital referral, investment in construction should be increased to gradually build a more standardized inter-hospital MNM referral plan.

Regular special training on MNM referral should be organized for personnel at all levels involved in referral, including medical staff, transfer teams, and managers of local maternal and child health management departments. Clear responsibilities of all parties should be defined to ensure referral safety. Managers need to be familiar with the referral process, actively cooperate, and coordinate to promote the rapid initiation, feedback, and improvement of the referral process. Medical staff and transfer teams should comprehensively improve their clinical skills, including early identification of maternal critical illnesses, mastery of referral-related knowledge, observation of the condition during transfer, application of first-aid skills, equipment operation, and emergency handling capabilities. Regular clinical drills should be carried out to strengthen practical skills.

In short, ensuring the safety of MNM referral is crucial for promoting the continuity of treatment between different medical institutions, advancing the management of maternal critical illnesses, and achieving the goal of "early detection and early treatment". By standardizing the inter-hospital MNM referral process and promoting effective connection of all links, referral risks can be reduced, obstetric quality can be improved, and maternal and fetal safety can be effectively safeguarded. To achieve the target of reducing maternal mortality proposed by the World Health Organization (WHO) by 2030, we will continue to make unremitting efforts.