Posted By on 21 Mar 2011 04:51 PM
Henci, you somewhat addressed this in a previous message I wrote
to you about maternal age and placentas aging and doctors
suggesting induction. I now have a client who is older and
her doctor suggests induction at 40 weeks because she is at greater
risk for stillbirth.
I have done some checking on line with various studies and
found a systematic review from nbci. and they conclude that older
women are at risk for stillbirth.
An excerpt from this link:
'INTERPRETATION: Women with advanced maternal age have
an increased risk of stillbirth. However, the magnitude and
mechanisms of the increased risk are not clear, and prospective
studies are warranted.'
As well there is this
which discusses a very large Norwegian study done that came to the
same conclusion regarding maternal age and increased risk of
Based on this information it would appear that induction
should be undertaken. Is there any other more recent study or
studies that have given a clearer interpretation, reducing the
variables to rule out factors such as diet, whether a first or
subsequent pregnancy, previous C-sec, etc..... ????
My client wants to avoid unnecessary interventions, a C-section
and induction but in light of this research, how can she say no?
She is also aware of the risk of induction increasing her chances
of a Cesarean. Caught between a rock and a hard place. Any other
information would be greatly appreciated so she can be fully
informed prior to making a decision.
Thanks very much. Debra Woods
I could take a look at the studies, and I'm willing to bet there
are weaknesses--indeed, Kimmelin points out some in the Norwegian
study in her Science and Sensibility post. One I've found before is
that investigators fail to take "prior cesarean" into account,
which a number of studies have found to be associated with
unexplained stillbirth. (The placental attachment complications
associated with prior cesarean increase risk of stillbirth as well,
although these may be accounted for by excluding women with
antenatal hemorrhage.) Older women are, of course, more likely to
have a prior child or children. However, I think the best that
can be done here if your client is feeling anxious is to
minimize the risk of an induction ending in a preventable cesarean.
This she can do by refusing induction unless the cervix is ripe
(Bishop score of at least 6 on a scale of 1-10 and higher is
better). Cervical ripening does a great job of ripening the cervix,
but it doesn't reduce the excess c/section rate. If her cervix
isn't ready for labor, the risks of cesarean for her and her
baby and any future babies will surely outweigh the
miniscule risk of a sudden antenatal demise in a healthy woman
carrying a healthy baby. If she is induced, refuse rupture of
membranes. That way, if the induction doesn't take, she can go
home and try again another day, but once membranes are
ruptured, she is committed to delivery by one route or the
other. She should also request a physiologic oxytocin
(Pitocin) dosing regimen, as opposed to an "active management" one.
This will minimize the chance of fetal distress, and it will get
the job done, although it may take longer. The dosing regimen comes
with the Pitocin package. A gentle, serial oxytocin induction
is actually a good way to go, although I doubt it will ever catch
on because it isn't as cost effective for the hospital.