1. Jess mcmicking Itp trainee Liverpool hospital
Advanced age nulliparous women and labour outcomes – should we forewarn of the murky water that lies ahead?
Jess mcmicking
Itp trainee
Liverpool hospital

2. SO we all know of Jane
One day Jane turned 35 and to Herberts horror – her biological clock started ticking
But she wasn’t the only one who was going to enter motherhood for the first time after 35years
Marcia Cross – desperate housewives beauty, 41 at her first baby
Celine Dion – in her 40s with twins. And yes that is her husband on the right
Nicole Kidman – Australian bred, also 40 years of age when she had her first own born Sunday Rose
Last Sonia Kruger – in 2014 becoming a mother at 49
Of course I am well in support of this as I am fairly sure Im heading in this direction too…

3. The Australian picture…
Delay in childbearing is becoming increasingly common, especially in developed countries such as Australia
Social, economic and educational factors
Assisted reproduction technologies
How old is “old”?
Advanced maternal age
35 years or older at time of confinement
Very advanced maternal age4
45 years or older
Represent 0.1% of Australian women giving birth

4. The Australian picture…
Statistics4,3
24% pregnant women are 35 years or older
Of the nulliparous women
Advanced maternal age
1998 – 9.1%
2008 – 14.5%
Contemporary advanced aged women5
“Fewer babies at later age…”
“…Predominantly healthier and more socially advanced…”
Higher SES, higher educational leves, lower parity, higher use of private health care
Versus previous societal trend – low SES, higher parity

5. Advanced maternal age
As clinicians we are aware of the risks associated with pregnancy in later reproductive years2
Higher intervention rate, complications and disease3,6,9
Significant difference in outcomes in comparison to younger mothers4

6. Advanced maternal age and labour
Physiological changes
Ageing and myometrial efficiency
Reduction in elasticity of pelvic joints
Patient factors
Preference of patient
Attitudes to risks
‘Precious pregnancy’ cargo
Labour outcomes2,4
Less likely to spontaneously labour
More likely to be induced
Greater risk of birth complications
Higher caesarean section rate

7. Advanced maternal age and labour – what should we do?
Women of advanced maternal age are frequently requesting specific information regarding the likely outcome of their pregnancy4,8
Advancements in technology allow information at patient’s fingertips
Want to be informed and educated by the medical staff
Helps decrease fear and tension associated with labour
The focus is on the end product
“…inability to think further ahead than birth…”
How can we optimise care?
Knowledge of the common complications
Better advice and counselling

8. The Audit – Advanced maternal age and labour outcomes
Objective
To assess the labour outcomes for advanced age nulliparous women for the purpose of counselling
Study design
Retrospective audit
January 2011 – December 2014
Secondary level hospital
Population
Nulliparous women, ≥35 years old at the time of confinement
Antenatal care and delivery at the hospital of interest
Data collection
Electronic medical records and patient medical charts

9. The Audit - Findings Maternal age Compared to Australian data2,5
Total births = 8495
Total ≥ 35 years = 1368 = 15.3%
≥ 35 years + nulliparous = 196
Advanced age + nulliparous = 2.3%
Compared to Australian data2,5
Very low rate
2008 = 14.5% advanced age + nulliparous
Reasons – private health care option, patient demographics

10. The Audit - Findings Maternal age Australian data2 2 age groups
35 – 39 years
≥ 40 years
Steady increase for ≥ 40 years
Australian data2
Average age is rising markedly – “fewer babies at later age”
Challenge of female physiology dealing with pregnancy vs. assisted reproduction beyond natural age of menopause

11. The Audit - Findings Mode of delivery
Overall CS rate = 46%
28% % % %
Compared to own hospital data (2014)
Overall CS rate = 21.8%
Emergency = 8.2%, elective = 13.6%
Vaginal birth = 70.9%

12. The Audit - Findings Mode of delivery Compared to literature
Overall CS rate = 46%
% of total for age group yo = 43.7%, ≥40 = 60.5%
Compared to literature
NSW – 20101
Baseline CS rate 30.5%
South Australia2
CS rate – 1998 to 2008
35-39yo = 45%, ≥40 = 55%

13. The Audit - Findings Indication for caesarean section
Emergency – fetal distress 28%, failure to progress 20.7%
Elective request – 8%
Evidence shows10
RANZCOG Guideline (CObs 39) - CS on maternal request
After full discussion the clinician can agree to perform CS, provided patient is able to demonstrate an understanding
“…the obstetrician should acknowledge the legitimacy of the request…”

14. The Audit - Findings Post-dates induction Evidence shows9
Total number = 26
Decline over the years
Induction earlier
Evidence shows9
Risk of stillbirth more common as women get older
Risk greatest amongst term + post-term pregnancies
Induction of labour at term is a potential strategy to reduce the risk of stillbirth in older women
RCOG Guideline – IOL at term for older mothers

15. The Audit - Findings Post-dates induction Evidence shows10
Total number = 26
Delivery outcome
NVB = 8 per 100 8%
35%
57%
Evidence shows10
It is impossible to predict which women will have a successful vaginal delivery
Risks of complication
Elective CS = 7%, emergency CS = 16.3%, instrumental delivery = 12.9%

16. The Audit - Findings Patient’s verbal concerns Evidence shows8
70% documented
Issues
Sick of pregnancy
Wanting an induction
Worried about the baby
Evidence shows8
Women over 35 are well resourced and well educated, and approach labour with a well delineated plan
Focused on birth and the end product – “I just want a healthy baby”

17. The Audit - Discussion Limitations of the study Population group
Small study cohort
Public hospital, low socioeconomic area
Missing baseline demographic data
BMI, ethnicity, conception
Retrospective data collection
Reliance on medical records for true documentation of conversations between doctor / midwife / patient
Confounding factors
Decision for delivery
Clinical judgment and decision – staffing, shift changes
Presence of co-morbidities

18. Advanced maternal age and labour – should we forewarn of the murky water?
Is there enough evidence to change how we approach the management of labour of older nulliparous women?
No…
But…
An opportunity exists to counsel advanced age nulliparous woman about labour
The pregnancy is an exceptional event – a miracle for some
Inform and empower the patient
Acknowledge the risks and potential complications
Communication

19. References
Rowlands C, Rowlands I, Nguyen M. The contribution of maternal age to increasing caesarean section rates. ANZJOG. 2012; 52:
Ludford I et al. Pregnancy outcomes for nulliparous women of advanced maternal age in South Australia, ANZJOG. 2012; 52,
Biro MA et al. Advanced maternal age and obstetric morbidity for women giving birth in Victoria, Australia: A population-based study. ANZCOG. 2012; 52:
Callaway L, Lust K, McIntyre D. Pregnancy outcomes in women of very advanced maternal age. ANZJOG. 2005; 45:
Carolan M, Davey MA, Biro M, kealy M. Older maternal age and intervention in labor: a population-based study comparing older and younger first-time mothers in Victoria, Australia. Birth. 2011; 38:
Dulitzki M et al. Effect of very advanced maternal age on pregnancy outcome and rate of caesarean delivery. Obstetrics and Gynaecology. 1998; 92:
Roberts C, Rowlands I, Nguyen M. Letter to the Editor – The contribution of maternal age to increasing caesarean section rates. ANZJOG. 2012; 52:
Carolan M. Health literacy and the information needs and dilemmas of first-time mothers over 35 years. Journal of Clinical Nursing. 2007; 16 (6),
Beckmann M. Older mothers. O&G Magazine. 2013; 15:
RANZCOG. Cobs 39 – Caesarean section at Maternal Request