High-risk Pregnancy Care Research Articles

Humanized birth in high risk pregnancy: barriers and facilitating factors

The medical model of childbearing assumes that a pregnancy always has the potential to turn into a risky procedure. In order to advocate humanized birth in high risk pregnancy, an important step involves the enlightenment of the professional's preconceptions on humanized birth in such a situation. The goal of this paper is to identify the professionals' perception of the potential obstacles and facilitating factors for the implementation of humanized care in high risk pregnancies. Twenty-one midwives, obstetricians, and health administrator professionals from the clinical and academic fields were interviewed in nine different sites in Japan from June through August 2008. The interviews were audio taped, and transcribed with the participants' consent. Data was subsequently analyzed using content analysis qualitative methods. Professionals concurred with the concept that humanized birth is a changing and promising process, and can often bring normality to the midst of a high obstetric risk situation. No practice guidelines can be theoretically defined for humanized birth in a high risk pregnancy, as there is no conflict between humanized birth and medical intervention in such a situation. Barriers encountered in providing humanized birth in a high risk pregnancy include factors such as: the pressure of being responsible for the safety of the mother and the fetus, lack of the women's active involvement in the decision making process and the heavy burden of responsibility on the physician's shoulders, potential legal issues, and finally, the lack of midwifery authority in providing care at high risk pregnancy. The factors that facilitate humanized birth in a high risk include: the sharing of decision making and other various responsibilities between the physicians and the women; being caring; stress management, and the fact that the evolution of a better relationship and communication between the health professional and the patient will lead to a stress-free environment for both. Humanized birth in a high risk pregnancy is something that goes beyond just curing women of their illnesses. It can be considered as a token of caring, and continued support, which positively consolidates the doctor-patient relationship. As yet, it has not been described as a practiced guideline, due to its ever-changing complexities.

Towards understanding the concept of risk for pregnant women: some nursing and midwifery implications

This paper aims to explore the concept of risk in pregnancy. Notions of risk and 'not knowing' have always surrounded pregnant women, although in the last two decades trends of increased consumer confidence and midwifery activism have together promoted a greater appreciation of pregnancy as a normal life event. At the same time, advances in pregnancy-related technologies have contributed new levels of concern related to an increasing ability to detect minor abnormalities by ultrasound. This, in turn, causes a concordant rise in the number of women referred to high-risk pregnancy care to monitor suspect findings. Overall, it seems likely that this increasing emphasis on abnormality detection and risk may have serious implications for women. Concept analysis. In this paper, I undertake an exploration of the concept of risk as understood by health professionals and pregnant women. Then, using Deborah Lupton's understanding of a 'discourse of risk', I discuss the ways pregnant women both contribute to and are enmeshed in, this discourse. In the final section, I consider how nurses act informally to shield vulnerable women. Health professionals and pregnant women understand risk differently. Women employ a subjective appraisal of risk, measuring it against their personal values and prior experience, while health professionals evaluate risk in an objective manner. As increasing numbers of women are referred to 'at risk' care, it is important that health professionals understand and respond to maternal understandings of risk. Nurses and midwives particularly, have a role to play in assisting women to make sense of risk calculations. In this way, they can act to ameliorate the growing concept of risk for pregnant women.

Care of high risk pregnancy

Care of high risk pregnancy

Asthma and pregnancy

In 1972, a report from the Norway Birth Registry1 suggested that asthmatic women were at increased risk of adverse perinatal outcomes, including neonatal death, preterm birth, low birthweight, and pre-eclampsia (panel). The data published over the subsequent 26 years have been conflicting,2 but the hope has been that, with improvements in the management of asthma and in the care of high-risk pregnancies, as well as better control for confounding factors, a similar contemporary analysis would not show this increased risk.

Maternity care in The Netherlands: the changing home birth rate.

In 1965 two-thirds of all births in The Netherlands occurred at home. In the next 25 years, that situation became reversed with more than two-thirds of births occurring in hospital and fewer than one-third at home. Several factors have influenced that change, including the introduction of short-stay hospital birth, hospital facilities for independent midwives, increased referral rates from primary to secondary care, changes in the share of the different professionals involved in maternity care, medical technology, and demographic changes. After a decline up to 1978 and a period of relative stability between 1978 and 1988, the home birth rate started to decline further, to the extent that it might destabilize the Dutch maternity care system and the role of midwives in it. The Dutch maternity care system depends heavily on primary caregivers, midwives and general practitioners who are responsible for the care of women with low-risk pregnancies, and on obstetricians who provide care for high-risk pregnancies. Its preservation requires a high level of cooperation among the different caregivers, and a functional selection system to ensure that all women receive the type of care that is best suited to their needs. Preserving the home birth option in the Dutch maternity care system necessitates the maintenance of high training and postgraduate standards for midwives, the continued provision of maternity home care assistants, and giving women with uncomplicated pregnancies enough confidence in themselves and the system to feel safe in choosing a home birth.

Abortion and the Maternal-Fetal Medicine Physician

Madam: As a board-certified specialist in maternal-fetal medicine, trained by three other board-certified pro-life perinatologists, I believe that pro-life physicians are not only vital to the field of high risk pregnancy care, but actually belong there more rightfully thanJeffrey Blustein and Alan R. Fleischman ("The Pro-Life Maternal-Fetal Medicine Physician: A Problem of Integrity," Hastings Center Report, January-February 1995) and their pro-abortion associates. Somehow, the authors seem to have forgotten some very basic information in their field. As the most recent edition of Wil-

Prenatal determination of lung maturity from amniotic fluid--indications and new methods

Although fetal lung maturity determination is carried out more and more rarely in the German-speaking area, a reliable information about the degree of lung maturity is still very important in the care of high-risk pregnancies. The side effects and costs of a postpartal surfactant administration can be avoided if lung maturity is proved. Indications for determination of fetal lung maturity are the threatening preterm delivery and the premature rupture of membranes before the 34th week of gestation and uncertain gestational age. Furthermore, in preeclampsia resp. in diabetes mellitus, which is difficult to control, premature delivery may be necessary. To improve lung maturity testing we introduce a new "sequence scheme" containing three lung maturity tests which are easy to carry out (in the following sequence: Amniostat-FLM ultrasensitive, counting of the lamellar bodies in amniotic fluid, surfactant/albumin ratio with TDx-FLM). The principle of this scheme is, that if any of these three tests indicates lung maturity, the sequence is terminated and no further test is performed. Only if all three tests indicated immaturity, the child was at risk for RDS. In 87 amniotic fluid samples with 7 RDS-cases, we achieved high predictive values for lung maturity (specificity 90%, sensitivity 100%, predictive value of positive test 47%, predictive value of negative test 100%). In 62% only one test was needed for lung maturity determination. It is possible to use other combinations in such a scheme (e.g. the L/S ratio). This might lead to equal or perhaps better results. An advantage of this suggested "sequence scheme" is that it can be performed in any clinic.

Birthweight-specific trends in perinatal mortality by hospital category in South Australia, 1985-1990.

To investigate differences by birthweight in risk of perinatal death between level 3 hospitals (which provide care for high risk pregnancies and neonatal intensive care) and other hospitals in South Australia, using perinatal data for the 1985-1990 period. Analysis of birthweight-specific trends in risk of perinatal death by hospital category for singleton births, adjusting for risk factors. 114 725 singleton births of at least 400 g birthweight (or at least 20 weeks' gestation) born in hospitals in the 1985-1990 period and notified to the perinatal data collection. The relative odds of a perinatal death, as opposed to a live birth which survived the neonatal period. Births at level 3 hospitals had a higher crude risk of perinatal death than those at other hospitals, but this was due to the higher frequency of low birthweights at level 3 hospitals. For birthweights under 2000 g, and especially for the very low birth-weights, there was a higher risk at non-level-3 than level 3 hospitals. There was also the unexpected finding that births at level 3 hospitals in the 2500-2999 g range had a comparatively high risk of perinatal death. There was little difference in risk for births of higher birthweight. The greatly reduced risk of perinatal death in level 3 hospitals for babies with birthweights under 2000 g seems likely to be due to the specialist services in these hospitals. Further investigation is required to determine why babies in the 2500-2999 g range of birthweights had a comparatively high risk of perinatal death at these hospitals. This appears to be due, at least in part, to an excess contribution of deaths from congenital abnormalities. Also, it seems that the higher prevalence of complications in pregnancy in level 3 hospitals, and the transfers for induction of labour after intrauterine fetal death, would have made a contribution. These same factors may also have affected the risk in level 3 hospitals for higher birthweight births.

Perinatal outcome in a University Hospital in Saudi Arabia

SummaryA survey of 195 perinatal deaths in the King Fahd Hospital, Al-Khobar, Saudi Arabia, revealed a perinatal mortality rate of 160/1000 total births. Lethal malformations accounted for 47 (24–1 per cent) of fetal deaths. Of the remaining 148 deaths, 81 (54–7 per cent) occurred antenatally, 28 (18–9 per cent) in labour and 39 (26–3 per cent) within the first week of delivery. Amongst the normally formed babies, low birth weight was the commonest cause of death (24–1 per cent) followed by the consequences of maternal diseases (14–4 per cent). The cause of death was unknown in 15–4 per cent of mature babies who died. Improved patient education will be necessary to reduce the deaths from congenital malformations. Skilled obstetric care of high risk pregnancies and expert neonatal care should further reduce the perinatal mortality.

Perinatal Outcome in Fetuses with Loss of End-Diastolic Blood Flow Velocities in the Descending Aorta and/or Umbilical Arteries

Continuous- and pulsed-wave Doppler velocimetry was used as an additional method of antenatal surveillance in high-risk pregnancy care. During a 30-month period with 4,169 deliveries 226 patients (5.4%) with complicated pregnancies (intrauterine growth retardation, diabetes, hypertension) were investigated. The results had only marginal influence on obstetrical management. In 38 fetuses absence of end-diastolic blood flow velocities (AEDF) was detected in the descending fetal aorta and/or umbilical arteries. Mean birth weight of these fetuses was 1,441 +/- (SD) 690 g at a mean gestational age of 31.8 +/- 6.8 weeks at birth. Twenty fetuses (53%) were growth-retarded (less than 3rd centile). Six fetuses died in utero and 7 during the perinatal period (34% mortality). There was a significant deterioration of perinatal outcome with AEDF in the umbilical arteries at the last antenatal Doppler scan. With AEDF in the descending fetal aorta the Doppler parameter Vmean and with AEDF in the umbilical arteries the pulsatility index yielded additional prognostic information. Doppler velocimetry of the fetal and umbilical vascular system could be of additional value for antenatal surveillance in high-risk pregnancies.

The obstetric perspective of neurofibromatosis

Neurofibromatosis is a complex hereditary disease involving many organs and systems. A possibility of reciprocal adverse effects exists between the disease and pregnancy. A survey of the relevant literature suggests that management of the pregnant patient with neurofibromatosis is an obstetric challenge. After appropriate genetic counseling, patients with minimal or mild neurofibromatosis who wish to conceive should receive high-risk pregnancy care. Special attention should be directed toward maternal hypertension and the aggravating features of neurofibromatosis. The fetus may inherit the disease and also be at risk for growth retardation. Patients with severe neurofibromatosis should be advised not to conceive.

Antenatal care in high-risk pregnancies.

A retrospective analysis of the antenatal records of women who gave birth to live babies was conducted in the three Districts of the East Sussex Health Area in 1977. A high-risk group was identified and the antenatal care for them was compared with that given to mothers in general. Comparison was also made between Districts. Women in the high-risk group were similar to those in the general group with respect to the number of antenatal visits. Overall this was also found with respect to when the last visit was made, but there were differences among those with short or long gestations. Pregnant women at high risk were more likely to be supervised by the hospital team exclusively during the antenatal period than those in the general group. Maternal characteristics which might have been used to identify high-risk pregnancies were often not recorded. High-risk mothers more frequently had infants with Apgar scores of less than 5 at one minute and birth weights of 2500 g or less than did women in the general group. However, it would appear that District policy on health care varied significantly since various aspects of care were found to be more dependent on the District concerned than on the risk group involved.