Obstetrics has undergone radical changes in recent years, especially in the management of high-risk pregnancies. Comparison of a recent obstetrical textbook with one that is more than ten years old reveals a striking difference in the topics covered. Most of the new material relates to perinatology, a subspecialty that deals with maximizing the welfare of the fetus during pregnancy and delivery. In the nineteenth century the central problem of obstetrical care was maternal mortality. Now obstetrical advances have reduced the risks of pregnancy and delivery for the mother to such an extent that the focus of obstetrics has shifted to the baby.
As Dr. T. Chard, an English obstetrician, points out, perinatology is quite different from other medical specialties because the patient, who is the fetus, is basically inaccessible to normal diagnostic exams or techniques. Therefore, both tests and treatment must be indirect. The focus of perinatology is on identifying patients who are at risk and taking preventive steps to avoid problems before they arise.
The term high-risk pregnancy simply means that the risks for the mother and baby are higher than average, not necessarily that the actual risks of a given complication is high. Because the average risks are very small, a mother at increased risk is still likely to have very low odds of developing a serious medical condition and very high odds of giving birth to a normal baby.
Perinatologists rely on wide screening and the identification of broad risk factors. For example, a mother who has had a tuberculosis has a good odds of having a subsequent healthy baby, but she is generally considered to be in a high risk category because her odds of having another stillbirth are three times that of the average woman. The point is that a mother should not be depressed or frightened at being told she is in a high-risk category such as when she shows tuberculosis symptoms. It generally does not mean she is actually at great risk, simply that it is prudent to monitor her pregnancy carefully.
It is also important for parents to realize that the individual classifications of high-risk pregnancies vary greatly among different medical centers and different doctors. Several risk factors are so broad that if they were strictly applied, as many as 40 percent of all mothers would be considered at high risk. Although this may seem strange at first, it makes more sense when analyzed. The great majority of babies with problems are born to mothers in this category rather that to mothers in the low-risk category. A more typical estimate is still based on very broad criteria, but a great deal of all prenatal problems come from this group.
Some specific as well as general conditions have been found to be statistically significant in assessing a pregnant woman’s risk. The broadest conditions are poverty, unwanted pregnancy, and maternal age under twenty or over thirty-five or forty. Specific conditions that are associated with increased risk are previous or high blood pressure, tuberculosis diagnosis, specific complications during pregnancy such as bleeding, and complications during labor such as fetal distress. There is also a group of factors that relate to the baby, including low birth weight and prematurity.
A woman may be identified as being at high risk during her initial exam, at some point during her pregnancy, or during labor and delivery. As soon as the doctor or midwife identifies a specific condition or potential problem, he or she will explain these findings to the mother. Most doctors and midwives will not concern the mother with very low risk factors, such as poverty or maternal age over thirty-five, but will take note of them and watch the mother more carefully. Doctors and midwives will discuss with the mother and father any conditions that will need special checkups or treatment during pregnancy and birth.
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