Reducing Obstetric Risk Factors Through Management

April 1, 2021
April 1, 2021

As recently as the 1980s, pregnant women over the age of 35 were routinely described as elderly mothers. During that time, these patients were also relatively rare. Today, many women are delaying childbearing, and pregnancy in women over the age of 35 is considerably more common.

Advanced maternal age (AMA) still comes with increased risks for pregnant women and their babies, but improvement in technology and the management of labor and delivery has resulted in better outcomes for them. Additionally, AMA is now more frequently defined in medical literature as 40 to 45 years old.

So how did we get here, to a place where we need to put much more effort into high risk obstetrics? What are the changes that led to improved outcomes for older pregnant women?

Addressing Safety Issues in High-Risk Maternity Patients

Appropriate management of high-risk patients is essential to making pregnancy, labor and delivery safer for patients in this cohort. An obstetric risk assessment is key in many situations. Where should we focus our attention when planning training and education for providers? OB clinical competency is a good place to start.

Consider the following when planning to maintain clinical skills for obstetrical providers.

  1. Electronic Fetal Monitoring (EFM) - What kinds of skills and knowledge does your team really need to be able to consistently identify the early warning signs of fetal and maternal distress? EFM provides the best insight to providers and is the optimal way to reduce stillbirths and neonatal convulsions.
  2. Postpartum Hemorrhage (PPH) – PPH is a rare, but serious complication. Recognition of the signs and symptoms of PPH is important as is an understanding of the conditions that tend to increase the risk for PPH.
  3. Hypertension in Pregnancy – Both chronic and pregnancy-induced hypertension is associated with advanced maternal age. The risks associated with hypertension during pregnancy are serious and, in some cases, life-threatening. They include preeclampsia, placental and fetal growth abnormalities, pre-term delivery and placental abruption.
  4. Shoulder Dystocia – Estimates of incidence rates for shoulder dystocia vary quite widely, but the condition is believed to be present in 0.02 to 2.1% of all births (although some estimates are as high as 10%). The condition is associated with fetal macrosomia, maternal hypertension and maternal diabetes, but in many cases, none of these conditions will be present making shoulder dystocia somewhat difficult to predict. Helping staff to recognize the presentation of shoulder dystocia and to understand the diagnostic methods and optimal interventions are essential for a safe birth.
  5. Trial of Labor After Cesarean (TOLAC) – While a successful outcome of a TOLAC may be safer overall for laboring women, the risks of TOLAC include uterine rupture which can have serious maternal and fetal implications. Providers need training on the identification of the best candidates for TOLAC, the optimal setting for TOLAC, and the signs and symptoms that would indicate a need for a cesarean delivery.
  6. Effective Communication and Event Disclosure – At this point, the benefits of disclosing information about adverse events for patients, physicians, and healthcare organizations are well known. Best practices in effective communication are essential to the success of the dialogue. Understanding what information should be communicated and the optimal way in which to communicate that information is key for your staff.

Improving Perinatal Outcomes – The Must Haves

Improving perinatal outcomes means safer pregnancy and delivery for all women including the increasing numbers of women of advanced maternal age has long been a goal in healthcare. So what is the best way to support providers facing high risk obstetrics who are striving to provide safe and effective obstetrical care?

Make sure your program includes the following:

  • Pre-assessment of provider knowledge to help customize educational focus and goals thus saving time and training costs
  • Use competency-based training that focuses on high-risk patient safety issues
  • Right-size the learning modules to insure higher levels of learner engagement, retention and focus on the key learning objectives
  • Use virtual microsimulations to enhance the critical thinking that is essential in managing high risk pregnancy, labor and delivery
  • Use a learning performance dashboard to enable efficient and informed decision-making
  • Build an inter-disciplinary approach that is accredited by the ANCC and the ACCME to insure understanding of best practices and the latest clinical information

Lastly, build an inclusive program for physicians, nurses, nurse midwives and anesthesiologists so that all disciplines are adequately prepared to manage obstetrical risk.


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