What do you think makes for high or low risk?

[lizziebits]

The terms high risk and low risk are thrown around a lot when discussing birth/midwifery/obstetrics and so on but I don't so often see these terms fleshed out.

What do you think makes for high or low risk?

If I was making a list, for high risk I'd include (off the top of my head): pre-e, multiples, GD, history of hemorrhage, history of shoulder dystocia, placenta issues, breech, <37 weeks or >42 weeks. Not saying this risk is definitive or anything, just what I'm thinking of at the moment.

Anyone have any thoughts?

[CI Mama]

I'm curious about this as well...

Another piece of the question is: at risk for what?

At risk for maternal and/or infant death?

At risk for complications during pregnancy and/or delivery? What kinds of complications?

At risk for c-section?

At risk for not having a pain free, peaceful, unmedicated vaginal birth?

[Jane93]

I would include:

(1)  Differences from typical anatomy (problems like a heart shaped uterus)

(2)  A whole host of pre-existing conditions -- anything from certain disabilities (like having cerebral palsy) and other issues (like problems with kidney or heart function) to issues like entering your pregnancy with drug/alcohol addiction.

(3)  maternal age -- supposed to increase your risks for certain issues (placenta previa, for example)

[GoBecGo]

It depends on what one is going to do with the information that one has labelled someone "high risk".

I think that i wouldn't label a person or a pregnancy "high risk" based purely on external factors if all it means is a sweeping restriction or treatment which ignores the individual.

For example maternal age CAN be irrelevant.  Well-controlled diabetes can be harmless.  Pre-e is a problem once diagnosed, so to me it's pointless to make it a "risk" - previous pre-e does not mean future pre-e and current pre-e should be treated according to what it is doing, not what it did last time or might do next time.

This is why i'm hugely in favour of one-to-one midwifery care for every pregnant woman, with full continuity.  When one has a dedicated partner in one's care monitoring how everything is going one has little need for labels and sweeping responses to them.

[Gena 22]

These terms seem meaningless and harmful to me.  What are the practical differences?  There's at least one study I know that shows that "high" risk moms have better outcomes with first a midwife, then a GP, and last of all, an OB.  That's the same for "low" risk moms, and has to do with individualized care (ie fewer routine interventions) leading to better outcomes.

My experience bears that out.  I was a young-ish, healthy, first time mom who at 19 weeks was surprised to find out I was carrying twins.  That catapulted me into a high intervention class, despite having no other issues over the entire course of my pregnancy and birth.  Turned out my twins were di-amniotic / di-chorionic (the safest configuration) and were both head down at full term.  Granted, there are some increased risks with multiples.  So I was OK with some amount of increased monitoring of my pregnancy.  But I was not OK with an automatic induction, nor the inevitable c/s that would follow.  So I found an experience midwife, far more experienced in natural twin births than my doctors, and I stayed home.  I didn't start the pregnancy as a homebirther, but I ended it as an advocate.

High risk = more liability concerns for caregivers, which = more non-individualized interventions, and then worse outcomes.  High risk becomes a self-fulfilling cycle.  Not something that has a place in evidence based practice.

[Serenity Now]

To me, being high risk means that you are at high risk of a maternal or fetal death. And low risk means that you are at a low risk of maternal or fetal death. Off the top of my head I would consider someone with certain heart conditions, certain genetic fetal syndromes, mothers with juvenile diabetes, incompetent cervix, certain clotting disorders, and so on to be high risk.

Unfortunately, I think the term is bandied about so much that high risk loses some of its intended meaning. There is a population of mothers to be who want to be high risk. They like the attention, sympathy, and martyrdom. Of course there are moms who are not like that at all, and I've noticed that in the natural community you have more women who are proud to be low risk, or fighting for the low risk distinction, than I have seen in mainstream communities. I have no back up for that, it's just an observation. But I can't tell you how many times I've seen moms on mainstream boards talking about how they had a low lying placenta at 8 weeks, so they are very high risk their whole pregnancy. It's a bit of a slap in the face to a mom who has an incompetent cervix and has had 4 or 5 stillbirths, for instance. It's unfortunate that the wannabe high risk pregnant moms make the truly high risk moms' experiences less serious.

[Jane93]

Better that that falsely trying to be low-risk.   Midwives have (or should have) a particular scope of practice for a reason, and refusing to do testing so that you remain "low-risk" is disingenious at best and potentially life-threatening at worst.

[lizziebits]

So, I am just getting back to this thread. I was originally thinking that the terms were important because I think when discussing location of birth and choice of attendent, that the qualifications for midwife/homebirth are "low risk" woman.
 

Originally Posted by Gena 22 

These terms seem meaningless and harmful to me.  What are the practical differences?  There's at least one study I know that shows that "high" risk moms have better outcomes with first a midwife, then a GP, and last of all, an OB.  That's the same for "low" risk moms, and has to do with individualized care (ie fewer routine interventions) leading to better outcomes.

My experience bears that out.  I was a young-ish, healthy, first time mom who at 19 weeks was surprised to find out I was carrying twins.  That catapulted me into a high intervention class, despite having no other issues over the entire course of my pregnancy and birth.  Turned out my twins were di-amniotic / di-chorionic (the safest configuration) and were both head down at full term.  Granted, there are some increased risks with multiples.  So I was OK with some amount of increased monitoring of my pregnancy.  But I was not OK with an automatic induction, nor the inevitable c/s that would follow.  So I found an experience midwife, far more experienced in natural twin births than my doctors, and I stayed home.  I didn't start the pregnancy as a homebirther, but I ended it as an advocate.

High risk = more liability concerns for caregivers, which = more non-individualized interventions, and then worse outcomes.  High risk becomes a self-fulfilling cycle.  Not something that has a place in evidence based practice.

I'm not familiar with that study, do you have any more information about it? I'd love to look at it.

And in the second bolded part, are you saying you don't think women should ever be labeled high or low risk?
 

Originally Posted by Serenity Now 

To me, being high risk means that you are at high risk of a maternal or fetal death. And low risk means that you are at a low risk of maternal or fetal death. Off the top of my head I would consider someone with certain heart conditions, certain genetic fetal syndromes, mothers with juvenile diabetes, incompetent cervix, certain clotting disorders, and so on to be high risk.

Unfortunately, I think the term is bandied about so much that high risk loses some of its intended meaning. There is a population of mothers to be who want to be high risk. They like the attention, sympathy, and martyrdom. Of course there are moms who are not like that at all, and I've noticed that in the natural community you have more women who are proud to be low risk, or fighting for the low risk distinction, than I have seen in mainstream communities. I have no back up for that, it's just an observation. But I can't tell you how many times I've seen moms on mainstream boards talking about how they had a low lying placenta at 8 weeks, so they are very high risk their whole pregnancy. It's a bit of a slap in the face to a mom who has an incompetent cervix and has had 4 or 5 stillbirths, for instance. It's unfortunate that the wannabe high risk pregnant moms make the truly high risk moms' experiences less serious.

That's interesting, I hadn't seen that so much. I feel like I've seen a lot more of people who I would consider high risk who don't consider themselves high risk.
 

Originally Posted by Jane93 

Better that that falsely trying to be low-risk.   Midwives have (or should have) a particular scope of practice for a reason, and refusing to do testing so that you remain "low-risk" is disingenious at best and potentially life-threatening at worst.

Yeah, I see this a lot too.

[Jane93]

"It's unfortunate that the wannabe high risk pregnant moms make the truly high risk moms' experiences less serious. "

Right -- I mean, how do you know who to really judge for having a c-section unless you can be really sure that the high-risk women are high-risk? 

I kid, but only a little, after seeing how women who have had a c-section or claim they are high risk have to justify that either the c-section was really "necessary" or the pregnancy is really high risk.  I mean, the only way to REALLY know whether a c-section was necessary is when there isn't one and you end up with a dead baby, a dead mother or both.

Edited by Jane93 - 3/27/11 at 7:09pm

[CI Mama]

Originally Posted by Serenity Now 
There is a population of mothers to be who want to be high risk.

I don't know any women who want to be high risk, but I don't frequent any mainstream boards. I only know women who want to be low risk because they want natural births. I have a hard time understanding why a woman would want to be high risk, if the meaning of the term is "statistically likely to experience complications that could lead to infant or maternal death."

I agree that the meaning of the terms is not clearly understood and that it's problematic. No one wants a bad birthing experience or a bad outcome. But how the "low risk" or "high risk" label helps women (regardless of their interest in a natural birth) have better experiences or better outcomes is not at all clear to me.

I was one who was (much to my relief as a first time mama at the age of 38) labeled "low risk." I took that to mean not just "statistically not likely to experience complications that could lead to infant or maternal death" but also "no reason not to have a natural birth."

Well, there were some reasons not to have a natural birth, and perhaps those reasons are clearer now that I'm on the other side of my long, difficult labor and subsequent c-section. They weren't necessarily "medical" reasons, and perhaps the idea of "risk" was not the right way to identify what kind of birth complications to expect or how to deal with them. For example, how do you assess the risk that comes with being a full-time working mom with limited maternity leave, thus under tremendous pressure to work up until the moment labor begins, at which point there is a good chance of being exhausted before the thing even begins?

What I've concluded at this point is that I could have had a non-traumatic vaginal birth if circumstances had been ideal and I'd had a perfect support team. But I went into things knowing that I didn't have ideal circumstances and knowing that my support was not perfect. I used the "low risk" label to reassure myself that in spite of the challenges I could see, a natural birth would be possible, perhaps even inevitable. So I suppose I mis-used the low risk label. I should have understood that it only referred to risk of infant and maternal death and had no bearing on how easy or natural my labor & delivery would be.

I guess my biggest concern is that by assigning a label that isn't well understood, the opportunity for conversation and individualized approach gets cut off. If it's assumed that "high risk" means that interventions should be used indiscriminately or "low risk" means there's no need to even consider possible interventions, that doesn't leave much room for figuring out an individual woman's actual challenges and what might realistically help her have the best experience available to her.

[msmiranda]

I guess I think of low-risk and high-risk as the dividing line between being able to choose midwifery care and needing OB care.  So I would not include GD or maternal age as automatic high-risk categories.  Perhaps insulin-dependent GD, but not mild GD that can be controlled with diet or oral meds.  I'm not sure I would classify someone with a history of something (pre-e, shoulder dystocia, etc.) as automatically high-risk either.  Obviously you would watch certain things more closely for those patients, but there is no reason why a mama with a previous hemorrhage or shoulder dystocia or pre-eclampsia should not be able to use a midwife if she chooses.  If she did develop pre-e again, the midwife would refer her, but that's not a foregone conclusion.  I guess for that reason I wouldn't necessarily put twins into high-risk either, as there are many midwives who will see a twin mama.  Same with some breech presentations (e.g. frank).   

I do agree that Type 1 diabetes, placenta previa, preterm, some breech presentations such as footling breech or "stargazing" breech, transverse lie, uterine anomalies such as bicornuate uterus, and some preexisting conditions are rightly classified high-risk.  I'm sure I'm forgetting some others.

ETA: I have encountered mamas who seem to want to be high-risk on mainstream boards.  It's not that they *want* to be high-risk per se, but they are quick to embrace the label and tell everyone about it.  There is one popular local mainstream board that I frequent, and there are plenty of NCB types there, but a more numerous and equally vociferous contingent of pro-c-section, listen-to-your-doctor-no-matter-what, why-would-anyone-have-a-natural-birth, healthy-baby-is-the-only-thing-that-matters, women-who-want-natural-births-are-selfish-and-value-their-experience-over-their-baby's-health moms.  The contrast between asking a question on that forum and here is quite striking. 

[Jane93]

"I guess for that reason I wouldn't necessarily put twins into high-risk either, as there are many midwives who will see a twin mama. "

I'm not sure that who a midwife will and will not deliver is a good rationale for whether someone is high risk or not.  Maybe for some midwives, but certainly not for all.

I believe the recommendations for vertex/vertex twins are vaginal delivery, however evidently twin pregnancies have 2x the risk of pre-e, 4X the risk of eclampsia, 2x the risk of PPH and 6x the risk of preterm delivery as a singleton pregnancy.   So I would certain put 2x the singleton risk of PPH due to twin pregnancy as higher risk.

[AlexisT]

Not all twins are created equal, though. A shared placenta raises the risks quite a bit, and a shared sac (monoamniotic twins) is extremely high risk.

I think high vs low risk is overly simplistic. Partly that's because I don't fall neatly into either. I have chronic hypertension (requiring meds) with a history of superimposed preeclampsia. I am not "low risk", and few midwives will take me. I get extra monitoring, and I will be treated pretty carefully in my 3rd trimester. I've had MFM consult, and may need it again. But I am not treated as a real "high risk" patient, either. Compared to what some women I know have dealt with, my level of care is much less intensive. 

I have seen some women who almost crave the high risk label, or feel like seeing an MFM is a preventative for problems. Sometimes it's because of previous loss or IF treatment.

[mmaramba]

I actually think this is a great question to ask, and I am hoping some (more?) birth professionals come in and answer it.

When I think about this distinction, personally, I think of "low risk" as = someone for whom outcomes would be as good as or better at home vs. the hospital.  Probably because I am planning HB and have not yet been PG.

So right now, I assume I will be "low-risk," though I figure that could change when I'm PG.  Why do I consider myself "low-risk" or "likely to be low-risk" when PG?  (Again, just my very non-professional, intuitive, not at all set in stone answer to this question.)

-I am in good physical health with no pre-existing physical disabilities or diseases to speak of.

-I am <35 years old and should still be when I have my first, at least (not that I'd consider anyone 35+ to be high risk or not low risk, but <35 is pretty clearly neutral or "positive")

I also assume I am "likely to be" "low-risk" because there have been very few in my family who could be considered at all high-risk (IMO).  I know that's not everything, but it's the only thing I have at this point, where I have never even been pregnant. 

-I had one bio aunt develop pre-e during one of her three pregnancies, though she also has/had a lot of other medical problems. 

-One grandmother was suspected in retrospect of having had GD, but there's really no solid evidence of that and her births and babies were all fine (though babies were big). 

-Essentially no C/S, no VBACs and no medical emergencies for any of my 1st or 2nd degree female relatives during PG or birth, although one grandmother did have one SB in her 40s (after 5 normal births). 

-No multiples.  No preemies.  No babies in the NICU or equivalent.  No non-vertex babies.

Kind of amazing, really, considering I have the 2 grandmothers, mother, 3 bio aunts and 2 bio female cousins with kids.  Including the SB, that's out of 17 births (to bio female relatives) in my family.  Basically one SB (in the 1960s) and one case of pre-e and that's about it, not even C/S.  Pretty good luck/genes/something.

I figure I will be considered "maybe-not-so-low-risk" or "high risk" if I end up with GD, pre-e, any placental issues, multiples, breech or a rarer complication specific to pregnancy.  I don't think of GBS+ as taking you out of the "low-risk" category, but maybe that's just me.

I guess that's all off the top of my head.

[scottishmommy]

I wonder about this too. Luckily I am extremely low risk and I hope I stay that way! I think sometimes we (low riskers) take for granted how lucky we are. It is such a blessing!

[tracymom1]

Very interesting topic...

I was considered high risk during my first pregnancy, after at 22 weeks I started hemorrhaging and needed to be hospitalized because it wouldn't stop.  I kept bleeding throughout the pregnancy and it was eventually found that I had a vasa previa (see here if you are unfamiliar) with PTL and was on strict bedrest until I was again hospitalized at 32 weeks and sectioned at 35 weeks. In this case, I absolutely believe that the "high risk" label was most definitely warranted.

For my second pregnancy, the hospital-based midwives I was seeing wanted to automatically label me as high risk because of my history.  When I started refusing all of their testing and becoming "non compliant" they really tried to scare me into doing things more by the book.  Needless to say, everything was fine, I ended up ditching them and birthing at home in peace and love - nothing high risk there at all!!

I have to completely agree with GoBecGo - the only way to truly determine a high risk pregnancy is through thoughtful, one on one midwifery care.  I mean, obviously when I started bleeding like crazy I knew that bad things were to come - but up to that point everything was pretty routine.  So it just goes to show that you really never know what can happen.  The world is full of infinite possibilities and the best way to be safe and healthy is to trust your body, your care provider and then trust your body a little bit more.

[mama naturale]

Originally Posted by lizziebits 

The terms high risk and low risk are thrown around a lot when discussing birth/midwifery/obstetrics and so on but I don't so often see these terms fleshed out.

What do you think makes for high or low risk?

If I was making a list, for high risk I'd include (off the top of my head): pre-e, multiples, GD, history of hemorrhage, history of shoulder dystocia, placenta issues, breech, <37 weeks or >42 weeks. Not saying this risk is definitive or anything, just what I'm thinking of at the moment.

Anyone have any thoughts?

I was defined as high risk for low iron levels. :(

I am probably seen as high risk just being a woman, had 2 bubs after 42w spontaneously, getting old, this is my 5th pregnancy. Main reason I do it on my own now.

[msmiranda]

Originally Posted by AlexisT 

Not all twins are created equal, though. A shared placenta raises the risks quite a bit, and a shared sac (monoamniotic twins) is extremely high risk.

Absolutely -- I should have clarified.  I think twin pregnancies can fall anywhere on the continuum (though they will never be as fully low-risk as a singleton vertex with no other issues).  I just meant I wouldn't classify someone as *automatically* high-risk because they are carrying twins.  Obviously twin pregnancies have a  higher risk of pre-e, preterm labor, etc., but you don't know if that will happen until it does. 

[Serenity Now]

Originally Posted by msmiranda 

I guess I think of low-risk and high-risk as the dividing line between being able to choose midwifery care and needing OB care.  So I would not include GD or maternal age as automatic high-risk categories.  Perhaps insulin-dependent GD, but not mild GD that can be controlled with diet or oral meds.  I'm not sure I would classify someone with a history of something (pre-e, shoulder dystocia, etc.) as automatically high-risk either.  Obviously you would watch certain things more closely for those patients, but there is no reason why a mama with a previous hemorrhage or shoulder dystocia or pre-eclampsia should not be able to use a midwife if she chooses.  If she did develop pre-e again, the midwife would refer her, but that's not a foregone conclusion.  I guess for that reason I wouldn't necessarily put twins into high-risk either, as there are many midwives who will see a twin mama.  Same with some breech presentations (e.g. frank).   

I do agree that Type 1 diabetes, placenta previa, preterm, some breech presentations such as footling breech or "stargazing" breech, transverse lie, uterine anomalies such as bicornuate uterus, and some preexisting conditions are rightly classified high-risk.  I'm sure I'm forgetting some others.

ETA: I have encountered mamas who seem to want to be high-risk on mainstream boards.  It's not that they *want* to be high-risk per se, but they are quick to embrace the label and tell everyone about it.  There is one popular local mainstream board that I frequent, and there are plenty of NCB types there, but a more numerous and equally vociferous contingent of pro-c-section, listen-to-your-doctor-no-matter-what, why-would-anyone-have-a-natural-birth, healthy-baby-is-the-only-thing-that-matters, women-who-want-natural-births-are-selfish-and-value-their-experience-over-their-baby's-health moms.  The contrast between asking a question on that forum and here is quite striking. 

I'm glad you've seen it, too. I don't think they want the high risk outcome, such as a stillbirth, but I think they do want the "you poor thing" response. So they go on about it. And on about it. And generally it's not something that is even a big deal at all, like maybe their blood pressure was slightly elevated, but still in the normal range. Or their fluid was on the low side of the normal range. Things like that. I don't see it as often here, but I do see it a lot on other mainstream boards, and in real life in general. I think that when we are immersed in a natural parenting circle, and natural parenting boards, we forget what the population at large is like, and it's not pretty.

[scottishmommy]

Originally Posted by Serenity Now 

I'm glad you've seen it, too. I don't think they want the high risk outcome, such as a stillbirth, but I think they do want the "you poor thing" response. So they go on about it. And on about it. And generally it's not something that is even a big deal at all, like maybe their blood pressure was slightly elevated, but still in the normal range. Or their fluid was on the low side of the normal range. Things like that. I don't see it as often here, but I do see it a lot on other mainstream boards, and in real life in general. I think that when we are immersed in a natural parenting circle, and natural parenting boards, we forget what the population at large is like, and it's not pretty.

[/quot

You know, it sounds crazy, but I can kinda see why women are like this about their pregancies. I think it may be a justification for all the checkups and medical attention. Right now, I feel like I could take my own blood pressure and urine sample, and check the baby's heartbeat. I feel like I'm wasting so much money going to the midwife every month. With my last pregnancy nothing happened. Nothing. I never had a question or a concern. I didnt even get nervous or anxious or emotional. I had the most boring pregnancy ever and consequently I sort of felt like no one cared LOL. So maybe these moms just want a little attention because they feel like their pregnant and it's a big deal, yk?