JESS MCMICKINGITP TRAINEE

LIVERPOOL HOSPITAL

Advanced age nulliparous women and labour outcomes – should we forewarn of the murky water that

lies ahead?

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

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

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

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

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

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

The Audit - Findings

Maternal age Total births = 8495

Total ≥ 35 years = 1368 = 15.3% ≥ 35 years + nulliparous = 196

Advanced age + nulliparous = 2.3%

<35 years≥35 + multiparous≥35 + nulliparous

Compared to Australian data2,5

Very low rate 2008 = 14.5% advanced age + nulliparous

Reasons – private health care option, patient demographics

The Audit - Findings

Maternal age 2 age groups

35 – 39 years ≥ 40 years

Steady increase for ≥ 40 years

2011 2012 2013 20140

5

10

15

20

25

30

35

40

45

35 - 3940+

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

The Audit - Findings

Mode of delivery

Overall CS rate = 46%

Compared to own hospital data (2014) Overall CS rate = 21.8%

Emergency = 8.2%, elective = 13.6% Vaginal birth = 70.9%

Vaginal Complicated vaginal

Elective CS Emergency CS0

10

20

30

40

50

60

70

28% 25% 15% 31%

The Audit - Findings

Mode of delivery Overall CS rate = 46%

% of total for age group - 35-39yo = 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%

The Audit - Findings

Indication for caesarean section Emergency – fetal distress 28%, failure to progress 20.7% Elective request – 8%

0

10

20

30

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…”

The Audit - Findings

Post-dates induction 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

1 2 3 40123456789

The Audit - Findings

Post-dates induction Total number = 26 Delivery outcome

NVB = 8 per 100Emergency CSComplicated vaginalNormal vaginal

8%

57%35%

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%

The Audit - Findings

Patient’s verbal concerns 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”

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

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

References

1. Rowlands C, Rowlands I, Nguyen M. The contribution of maternal age to increasing caesarean section rates. ANZJOG. 2012; 52: 308-309.

2. Ludford I et al. Pregnancy outcomes for nulliparous women of advanced maternal age in South Australia, 1998-2008. ANZJOG. 2012; 52, 235-241.

3. Biro MA et al. Advanced maternal age and obstetric morbidity for women giving birth in Victoria, Australia: A population-based study. ANZCOG. 2012; 52: 229-234.

4. Callaway L, Lust K, McIntyre D. Pregnancy outcomes in women of very advanced maternal age. ANZJOG. 2005; 45: 12-16.

5. 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: 24-29.

6. Dulitzki M et al. Effect of very advanced maternal age on pregnancy outcome and rate of caesarean delivery. Obstetrics and Gynaecology. 1998; 92: 935-939.

7. Roberts C, Rowlands I, Nguyen M. Letter to the Editor – The contribution of maternal age to increasing caesarean section rates. ANZJOG. 2012; 52: 308-309.

8. Carolan M. Health literacy and the information needs and dilemmas of first-time mothers over 35 years. Journal of Clinical Nursing. 2007; 16 (6), 1162-1172.

9. Beckmann M. Older mothers. O&G Magazine. 2013; 15: 34-35.10. RANZCOG. Cobs 39 – Caesarean section at Maternal Request. 2013.