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Williams Obstetrics 24th Ed Used more commonly, but less accurately, are the terms Maternal Mortality

Section 1: Overview Rate or Maternal Death Rate


Chapter 1: Overview of Obstetrics The term ratio is more accurate because it includes in the numerator the
number of deaths regardless of pregnancy outcome, live births,
Obstetrics stillbirths, and ectopic pregnancies, whereas the denominator includes
Concerned with human reproduction the number of live births.
The specialty promotes health and well-being of the pregnant woman and her fetus (27) Pregnancy-Associated Death
through quality perinatal care The death of a woman, from any cause, while pregnant or within 1 calendar
Entails appropriate recognition and treatment of complications, supervision of labor year of termination of pregnancy, regardless of the duration and the site of
and delivery, ensuring care of the newborn, and management of the puerperium. pregnancy.
Postpartum care promotes health and provides family planning options. (28) Pregnancy-Related Death
The importance of obstetrics is reflected by the use of maternal and neonatal outcomes as A pregnancy-associated death that results from:
an index of the quality of health and life among nations. (1) Complications of pregnancy itself
Indices that reflect poor obstetrical and perinatal outcomes would lead to the (2) The chain of events initiated by pregnancy that led to death
assumption that medical care for the entire population is lacking. (3) Aggravation of an unrelated condition by the physiological or
pharmacological effects of pregnancy and that subsequently caused
VITAL STATISTICS death.
Definitions
Definitions recommended by the National Center for Health Statistics and the Center for MEASURES OF OBSTETRICAL CARE
Disease Control and Prevention are as follows: Perinatal Mortality
(1) Perinatal Period There are a number of indices among the vital statistic definitions that are used as a yardstick
The interval between the birth of an infant born after 20 weeks gestation of obstetrical and perinatal outcomes to assess quality of care.
and the 28 completed days after that birth. The perinatal mortality rate includes the numbers of stillbirths and neonatal deaths
When perinatal rates are based on birthweight, rather than gestational age, it is per 1000 total births.
recommended that the perinatal period be defined as commencing at 500 g.
(2) Birth Infant Deaths
The complete expulsion or extraction from the mother of a fetus after 20 The three leading causes of infant death
weeks gestation. (a) Congenital malformations
In the absence of accurate dating criteria, fetuses weighing < 500 g are usually (b) Low birthweight
not considered as births but rather are termed Abortuses for purposes of vital (c) Sudden infant death syndrome
statistics. Accounted for almost half of all deaths
(3) Birthweight Infants born at the lowest gestational ages and birthweights add substantively to these
The weight of a neonate determined immediately after delivery or as soon mortality rates.
thereafter as feasible.
It should be expressed to the nearest gram. Maternal Mortality
(4) Birth Rate The deadly obstetrical triad of accounted for a third of all deaths
The number of live births per 1000 population. (a) Hemorrhage
(5) Fertility Rate (b) Preeclampsia
The number of live births per 1000 females aged 15 through 44 years. (c) Infection
(6) Live Birth Thromboembolism, cardiomyopathy, and other cardiovascular disease together accounted
The term used to record a birth whenever the newborn at or sometime after for another third
birth breathes spontaneously or shows any other sign of life such as a heartbeat Other significant contributors in this group were
or definite spontaneous movement of voluntary muscles. (a) Amnionic fluid embolism (7.5 percent)
Heartbeats are distinguished from transient cardiac contractions (b) Cerebrovascular accidents (6.3 percent)
Respirations are differentiated from fleeting respiratory efforts or gasps. Anesthesia-related deaths were at an all-time low of only 1.2 percent.
(7) Stillbirth or Fetal Death It is also important to consider the role that the increasing cesarean delivery rate has on
The absence of signs of life at or after birth. maternal mortality risks
(8) Early Neonatal Death
Death of a live born neonate during the first 7 days after birth.
(9) Late Neonatal Death
Death after 7 days but before 29 days.
(10) Stillbirth Rate or Fetal Death Rate
The number of stillborn neonates per 1000 neonates born, including live births
and stillbirths.
(11) Neonatal Mortality Rate
The number of neonatal deaths per 1000 live births.
(12) Perinatal Mortality Rate
The number of stillbirths plus neonatal deaths per 1000 total births.
(13) Infant Death
All deaths of live born infants from birth through 12 months of age.
(14) Infant Mortality Rate
The number of infant deaths per 1000 live births.
(15) Low Birthweight
A newborn whose weight is < 2500 g.
(16) Very Low Birthweight
A newborn whose weight is < 1500 g.
(17) Extremely Low Birthweight
A newborn whose weight is < 1000 g.
(18) Term Neonate
A neonate born any time after 37 completed weeks of gestation and up until 42
completed weeks of gestation (260 to 294 days)
The American College of Obstetricians and Gynecologists (2013b) and the
Society for Maternal-Fetal Medicine endorse and encourage specific gestational
age designations.
(a) Early Term
Refers to neonates born at 37 completed weeks up to 386/7 weeks
(b) Full Term
Denotes those born at 39 completed weeks up to 406/7 weeks
(c) Late Term
Describes neonates born at 41 completed weeks up to 416/7
weeks.
(19) Preterm Neonate
A neonate born before 37 completed weeks (the 259th day).
(20) Postterm Neonate
A neonate born any time after completion of the 42nd week, beginning with
day 295.
(21) Abortus
A fetus or embryo removed or expelled from the uterus during the first half of
gestation 20 weeks or less, or in the absence of accurate dating criteria, born
weighing < 500 g.
(22) Induced Termination of Pregnancy
The purposeful interruption of an intrauterine pregnancy that has the
intention other than to produce a live born neonate and that does not result in
a live birth.
This definition excludes retention of products of conception following fetal
death.
(23) Direct Maternal Death
The death of the mother that results from obstetrical complications of
pregnancy, labor, or the puerperium and from interventions, omissions,
incorrect treatment, or a chain of events resulting from any of these factors.
Maternal death from exsanguination after uterine rupture.
(24) Indirect Maternal Death
A maternal death that is not directly due to an obstetrical cause. Death results
from previously existing disease or a disease developing during pregnancy,
labor, or the puerperium that was aggravated by maternal physiological
adaptation to pregnancy.
Maternal death from complications of mitral valve stenosis. Severe Maternal Morbidity
(25) Nonmaternal Death Because maternal deaths have become so uncommon, the practice of analyzing severe
Death of the mother that results from accidental or incidental causes not maternal morbidity evolved as a surrogate to improve obstetrical and perinatal care.
related to pregnancy Because avoidance of medical errors serves to decrease the risks for maternal mortality or
Death from an automobile accident or concurrent malignancy. severe maternal morbidity, the concept of Near Misses or Close Calls was also introduced.
(26) Maternal Mortality Ratio These are defined by the Joint Commission and the Institution for Safe Medication
The number of maternal deaths that result from the reproductive process per and Practices (2009) as unplanned events caused by error that do not result in patient
100,000 live births. injury but have the potential to do so.
These are much more common than injury events, but for obvious reasons, they are
more difficult to identify and quantify.

Remelou G. Alfelor , M.D. PLE Review Obstetrics and Gynecology Page 1 of 2


All For Jesus Through Mary Chapter 1: Overview of Obstetrics
TIMELY TOPICS IN OBSTETRICS
Rising Cesarean Delivery Rate
1. The major indication for primary cesarean delivery is dystocia
There is evidence that this diagnosis has increased
2. The sharp decline in Vaginal Births After Cesarean (VBAC) delivery is closely related to the
uterine rupture risk associated labor with a prior uterine incision
3. The controversial Cesarean Delivery on Maternal Request (CDMR) contributes to the rise
This is defined as a cesarean delivery at term for a singleton pregnancy on maternal
request in the absence of any medical or obstetrical indication
4. Near-term and term pregnancy labor induction is common place, and failed inductions
contribute to the cesarean delivery rate
It is not possible to precisely measure the contribution of each of these components to the
all-time high cesarean delivery rate.
The American College of Obstetricians and Gynecologists and the Maternal-Fetal Medicine
Units Network have addressed these in an attempt to curtail the rising rate.
The National Institute of Child Health and Human Development convened a State-of-the-
Science Conference in 2006 to provide an in-depth evaluation of the evidence regarding
cesarean delivery on maternal request.
Recognizing that repeat operations constitute a large percentage of cesarean deliveries, the
National Institutes of Health (2010) convened a consensus conference entitled Vaginal Birth
after Cesarean: New Insights
They supported a trial of labor for many selected women with a prior cesarean
hysterotomy scar and recommended that this option be made more available

Genomic Technology
Recent breakthroughs in fetal testing and diagnosis are truly stunning. In one recent issue of
the New England Journal of Medicine, there were three reports in which prenatal gene
microarray techniques were used for clinical management (Dugoff, 2012).
Wapner and coworkers (2012) compared microarray analysis of maternal blood with
karyotyping for chromosomal anomalies.
Reddy and associates (2012) applied this technology to stillbirth evaluation and reported it to
be superior to karyotyping.
The third report by Talkowski and colleagues (2012) described whole-genome sequencing of
a fetus using maternal blood.

Remelou G. Alfelor , M.D. PLE Review Obstetrics and Gynecology Page 2 of 2


All For Jesus Through Mary Chapter 1: Overview of Obstetrics