Older gravidas are more likely to have preexisting medical conditions and are more prone to both chronic and pregnancy-related diabetic and hypertensive disorders.² As well, older gravidas are more likely to experience high-order multiple gestations. Approximately 5 percent of pregnancies among women ages 35 to 44, and more than 20 percent in women age 45 and older, result in multiple gestations, thereby increasing the risk of complications.¹ Furthermore, women in their thirties are also more likely than younger women to conceive multiples. Overall, an increasing number of pregnancies (approximately 1 in 100) occur later in the childbearing years and are achieved using assisted reproductive technology (ART), which increases the likelihood of multi-fetal gestations.⁴ Perinatal morbidity and mortality are significant threats arising from multiple gestation and evidence suggests that the impact on maternal health, in particular, is significant and may result in the need for maternal critical care exceeding three times that for women with a singleton pregnancy.⁵ As familiarity with ART increases and media attention continues to focus on high-order multiple gestations, it is reasonable to anticipate that these numbers will continue to rise, along with the numbers of expectant mothers requiring more intensive care.

Not only is the childbearing population affected by obesity in disproportionate numbers, but recent data show that weight gain during pregnancy is well beyond recommended amounts. In 2009, the Institute of Medicine issued updated guidelines for weight gain during pregnancy.⁶ The maximum recommended weight gain of 40 pounds was intended for the minority of pregnant women who begin their pregnancies underweight; however, this recommendation is currently exceeded by 21 percent of the total gravid population.¹ There are significant clinical and logistical implications in caring for overweight or obese pregnant women in a manner equivalent to the care of gravid women of normal weight. Under ordinary circumstances, an obese patient’s size
may present challenges as basic as finding a bed suitable to accommodate increased maternal body habitus and having other properly sized equipment readily available to monitor maternal and fetal status. Additional personnel may be needed to carry out procedures or assist in safe transfers. A complete discussion of obesity in pregnancy is presented in Chapter 22.

Since 1996—when trial of labor (TOL) and vaginal birth after Cesarean (VBAC) were most widely utilized, induction rates had not yet reached current levels, and with a near-complete cessation of attempts at vaginal breech delivery—Cesarean birth rates have increased 54 percent.¹ Factors that have contributed to this increase include the rising rate of repeat Cesarean delivery, Cesarean birth by patient request, and population demographics. Maternal age is a compounding factor due to issues discussed previously and also because breech/malpresentation increases proportionately with maternal age (occurring almost twice as often in those age 40 and older as compared with pregnant women younger than age 20).¹ Despite the fact that Cesarean delivery has become commonplace, there continue to be risks with this procedure. Two of the four most common preventable errors related to maternal deaths include failure to pay sufficient attention to alterations in maternal vital signs following Cesarean delivery and hemorrhage following the procedure.⁷

Patient safety and the importance of collaboration, communication, and teamwork among professional staff are “high-visibility” topics in perinatal care. Although it specifically addressed factors influencing infant death and injury during delivery, the Joint Commission Sentinel Event Alert, Issue 30, in 2004 brought increased attention to issues related to patient safety in a manner that no longer allowed them to be overlooked by institutions. These patient safety–related topics are particularly applicable to high-risk and critical care obstetrics, where there is even greater need for collaboration and effective communication and less of a margin for error. Collaboration in clinical practice is discussed further in Chapter 2.

In January 2010, the Joint Commission issued Sentinel Event Alert 44: Preventing Maternal Death.⁷ Based on the 2008 Hospital Corporation of America (HCA) study, which evaluated causes of maternal death among 1.5 million births within 124 hospitals over 6 years, the Alert noted that most maternal deaths were not preventable. Further, it suggested that, although some deaths might have been prevented by improved individual care, precise figures indicating the frequency of preventable deaths should be examined carefully and with caution. According to this study, the most common preventable causes of maternal death include: