1. Tillett, Jackie ND, CNM, FACNM
  2. Clinical Professor

Article Content

The current issue of The Journal of Perinatal & Neonatal Nursing shares articles and information on the high-risk pregnancy. Nurses on perinatal and neonatal units often perceive that the number of patients with a high-risk pregnancy is increasing and that patients are sicker than in the past. The difficult and challenging patient is recalled with more clarity than the patient with a normal, low-risk pregnancy and birth. Are there more women with high-risk pregnancies? Are those pregnant women sicker than in the past?


If we look at trends in maternal morbidity and mortality in the United States, the answer to these questions is yes. Severe maternal morbidity rates have increased in the United States. Using ICD-9 (International Classification of Diseases, Ninth Revision) codes, Callaghan et al1 found that the rate of severe maternal morbidity increased from 0.6% in 1998 to 1.6% in 2011, nearly tripling. Severe maternal morbidity was defined by this group as pregnant patients with a diagnosis of acute renal failure, cardiac arrest, sepsis, shock, disseminated intravascular coagulation, myocardial infarction, transfusion, ventilation, pulmonary edema, and eclampsia.1 Patients could have more than 1 of these diagnoses.


Berg et al2 looked at all maternal morbidities and compared 5-year spans. The combination of 5 years of data in the comparison points creates a statistically reliable picture of trends and rates of morbidities. The researchers found statistically significant changes in the rates of morbidities, both increases and decreases.2 Hospitalizations for birth showed increases in the rate of pregnant women with severe preeclampsia, gestational diabetes, preexisting diabetes mellitus, and asthma by as much as 20%.2 The rates of postpartum hemorrhage increased from 3 per 1000 births to 5 per 1000 births in the time period. The incidences of third- and fourth-degree lacerations and the rate of maternal infections decreased during these time spans.2


If we consider the causes of maternal morbidity separately, we can discern the trends in the health of the prepregnant and pregnant populations in the United States. The occurrence of hypertensive disorders among women hospitalized for childbirth increased from 67.2 per 1000 births to 81.4 per 1000 births in 2006.3 These women have a significantly greater risk of experiencing severe obstetrical complications than those women without hypertensive disorders.


The same trends are seen in pregnant women presenting with diabetes. The rate of women hospitalized for childbirth with a diagnosis of diabetes increased from 3.49% in 1994 to 5.47% in 2004, a 56.3% increase.4 These data are from 2004, but the trend has held.5 The biggest increase in diabetes in pregnant women was the proportion of women with type 2 diabetes, but increases were also seen in the proportion of women with gestational diabetes and women with type 1 diabetes. Women admitted to a hospital for childbirth with a diagnosis of diabetes had a significantly greater proportion of cesarean births and longer lengths of stay even with vaginal births.4 The most alarming trend seen in this study was the increase in the diabetes rate among younger women, for all 3 types of diabetes. Pregnant women with pregestational diabetes have a higher risk for complications, including preeclampsia and fetal anomalies, than pregnant women without diabetes. The proportion of American women (and men) with diabetes and metabolic syndrome is increasing in the United States. However, even without the increase, the ability of women with diabetes to become pregnant and maintain the pregnancy has been enhanced with newer treatment modalities. Universal testing for diabetes in pregnancy has led to earlier identification of diabetic conditions in pregnant women, with earlier and more comprehensive surveillance for both the fetus and the mother. As these women carry more pregnancies for longer gestations, the nurse on the labor and delivery unit will be providing care for more of these women during labor and birth.


Cardiac conditions in pregnant women can be either congenital or acquired.6 The number of women with acquired cardiac disease is decreasing in the United States. However, the number of pregnant women with congenital cardiac disease is increasing in the United States.6 This increase is due to enhanced diagnosis and treatment of women with cardiac disease, which has led to increasing survival rates and improved overall health. Women with congenital cardiac disease live long enough and are healthy enough now to get pregnant. As with diabetic patients, the nurse on the labor and delivery unit will be providing care for women with cardiac anomalies who were not seen on these units in the past.


The increasing cesarean birth rate is both a reflection of the increasing number of women with prepregnancy medical conditions and a cause of postpartum morbidities and complications with subsequent pregnancies. These complications of pregnancy and birth related to cesarean delivery include postpartum hemorrhage, infection, and placental abnormalities. As the cesarean birth rate increases, the number of women requesting a trial of labor after cesarean delivery increases; also, these are higher-risk labors.


Many obstetrical units and providers are moving away from strict interpretations of the Friedman curve. There is increased use of epidural anesthesia in most settings. As a result, labors are longer. A longer labor may be a cause of increases in maternal and fetal infections, postpartum hemorrhage, and dysfunctional labor.


Maternal morbidities are not just increased by maternal illness. Women giving birth have increasing body mass indexes. A data analysis of women who participated in the Supplemental Nutrition Program for Women, Infants, and Children demonstrated that the prevalence of prepregnancy obesity increased by more than 14% from 1999 to 2008.7 Prepregnancy obesity is a risk factor for gestational diabetes, preeclampsia, cesarean delivery, and macrosomia.7


In the United States, women older than 35 years have an increasing proportion of all births.8 More than 14% of births in the United States are to women 35 years or older. These women are at risk for fetal malpresentation, dysfunctional labor, spontaneous abortion, fetal chromosomal abnormalities, preeclampsia, gestational diabetes, and prepregnancy morbidities. There is a higher cesarean birth rate that increases with the age of the mother.9


The incidence of multifetal pregnancies has increased in the United States, due to higher maternal age and the use of advanced reproductive technologies. The twin pregnancy rate in 1990 was 22.6 per 1000 births; in 2010, the rate of twin pregnancies was 33.1 per 1000 live births. Higher-order multiple gestations doubled in that time period, from 0.07 per 1000 live births to 0.14 per 1000 live births.10 Multifetal pregnancies have a higher chance for fetal anomalies, prematurity, premature rupture of membranes, and neonatal mortality.


The nurse on the labor and delivery unit and the postpartum unit will care for a higher number of women with higher-risk pregnancies and labor than in the past. Women on the unit are more likely to be older and heavier than in the past. There will be more laboring women with preexisting medical conditions and more women who have had a previous cesarean delivery than those seen on the unit 20 years ago. The nurse will be responsible for coordinating care with an increasing number of specialists, including maternal-fetal medicine, cardiology, pulmonology, and endocrine, among others. Nurses caring for pregnant women will need a widening knowledge base to provide expert nursing care for women with higher-risk labor and birth while also striving to maintain the experience of birth for the family he or she is caring for. Understanding when to stress the nature of the risk and when to emphasize the unique and extraordinary nature of all births and support the women and her family during this time can lead to difficult decisions by the nurse and the healthcare team.


The articles in this edition of the Journal can serve as reference points and lead to the development of care plans that recognize risk but maintain the special nature of all births.


-Jackie Tillett, ND, CNM, FACNM


Clinical Professor


Department of Obstetrics and Gynecology


University of Wisconsin School of Medicine and Public Health


Madison, Wisconsin




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3. Kuklina EV, Ayala C, Callaghan WM. Hypertensive disorders and severe obstetric morbidity in the United States. Obstet Gynecol. 2009;113(6):1299-1306. [Context Link]


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5. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27(5):1047-1051. [Context Link]


6. Arafeh JMR, Baird SM. Cardiac disease in pregnancy. Crit Care Nurs Q. 2006;29(1):32-52. [Context Link]


7. Hinkle SN, Sharma AJ, Kim SY, et al. Prepregnancy obesity trends among low-income women, United States, 1999-2008. Matern Child Health J. 2012;16:1339-1348. [Context Link]


8. Ventura SJ, Hamilton BE. Birth rates among women aged 15-44 years, by maternal age group-National Vital Statistics System, United States, 1961, 2007, and 2011. MMWR Morb Mortal Wkly Rep. 2012;61:978. [Context Link]


9. Luke B, Brown MB. Contemporary risks of maternal morbidity and adverse outcomes with increasing maternal age and plurality. Fertil Steril. 2007;88(2):283-286. [Context Link]


10. Hamilton BE, Hoyert DL, Martin JA, Strobino DM, Guyer B. Annual summary of vital statistics: 2010-2011. Pediatrics. 2013;131(3):548. [Context Link]