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Introduction

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Grace the wyffe of William Baxter, beinge aboute three weeks before her tyme, was brought in bed the first day of December of two children, their bellies were growne and joyned together, from their breastes to their navells, and their faces were together.

John Richardson, giving details of Siamese twins, born in 1655

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Definition1

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A high-risk pregnancy is one in which the fetus is at increased risk of stillbirth, neonatal morbidity or death, and/or the expectant mother is at increased risk for morbidity or mortality.

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High-risk pregnancies may be predicted before conception in some women, especially those with serious medical problems and a poor obstetric history. Others at high risk can be identified at the first antenatal visit; other high-risk pregnancies develop during the course of pregnancy. The first antenatal visit is the most important visit and demands time and care to make an accurate assessment.

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The primary goal in obstetric care is to avoid maternal and perinatal morbidity and mortality (in particular) wherever possible through appropriate risk management, including proactive strategies.

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Maternal mortality

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The WHO definition of maternal mortality is the death of a woman during pregnancy, childbirth or in the 42 days of the puerperium, irrespective of duration or site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management. This excludes deaths from assisted reproductive technology where pregnancy has not resulted, but includes incidental causes of deaths. In Australia the classification comprises direct maternal deaths, indirect obstetric deaths (where diseases such as diabetes, cardiovascular and kidney are complicated by pregnancy) and incidental deaths such as road accidents, suicide and malignancy.2

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The maternal mortality ratio is the number of deaths per 100 000 confinements. In first world countries it is approximately 10. The latest triennium statistics for Australia was 8.4 deaths per 100 000 confinements—8 for non-Indigenous Australians and 21.5 for ASTI people (c.f. Africa approx. 900).2

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The main causes of direct maternal deaths in Australia are (in order):

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  • amniotic fluid embolism

  • thrombosis and thromboembolism

  • haemorrhage

  • hypertensive disorders of pregnancy

  • cardiac conditions

  • anaesthetic-associated deaths

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Contributing factors among those who died from haemorrhage are delays in diagnosis, treatment to arrest the haemorrhage and giving blood transfusion. Intracerebral haemorrhage was the main cause of death in hypertensive disorders.

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Some Australian obstetric statistics for 2003:

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  • average age of all mothers was 29.5 years

  • spontaneous vaginal births—60.3%

  • caesarean section (CS) rate—28.5%

  • instrumental delivery rate—10.7%

  • multiple pregnancies—1.7%

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Perinatal mortality

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The perinatal mortality is the total number of deaths of children within 28 days of birth (early neonatal deaths) plus fetal deaths at a minimum gestation period of 20 weeks or a minimum fetal weight of 400 g expressed ...

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