You're welcome. I'm glad I've been able to assist you in making
I poked around the medical research to see what studies I
could find that address older women and stillbirth. The best of the
bunch was this one, which,
if you want a copy for yourself or your midwives and consulting OB,
can be downloaded for free if you follow the link. The strengths of
this study are that it is big enough to detect differences in rates
of rare outcomes; it is based on data collected prospectively, not
after the fact; it is a U.S. study of recent vintage, which
means results are more likely to apply to you then results from
another country or from years ago; and it reports stillbirth
rates after reaching term.
The key finding for you is that fetal death rates go up
with advancing maternal age compared with women with no risk
factors (white non-Hispanic, 25-29 years old, normal weight, prior
birth, no chronic hypertension or pre-existing diabetes), but
the increase is very small. The risk of fetal death in the
risk-free group at 37-42 weeks of gestation was 0.8 per 1000
pregnancies. Maternal age of 35 or more in isolation from these
other factors increased this risk to 1.3 per 1000. Having a
first baby in women with no other risk factors increased risk of
fetal death to 0.9 per 1000 pregnancies, so I doubt whether your
being a first-time mom adds appreciably to your risk. The study's
Maternal age > 35 years by itself
was associated with a relatively low risk of stillbirth. This low
risk may not apply to women > 40 years old because of the small
number of women > 40 years old reaching term in our cohort. . .
. In addition, there is no evidence that by performing antepartum
fetal testing the occurrence of stillbirth will be averted as the
mechanism associated with advanced maternal age is unknown and may
be unrelated to detection of placental
The study doesn't tell us, though, whether the fetal death rate
goes up or the gap between women with no risk factors and women
with no risk factors other than maternal age widens. I can tell you
study of U.S. national data that the fetal mortality rate in
the general population pretty much holds constant at about 1
per 1000 until you get to 42 weeks when it becomes 1.7 per
Now let's look at the other side of the ledger. Tests of fetal
wellbeing have a high false-positive rate. This means that if the
test says there is a problem, it is very likely to be wrong and the
baby is fine. But once you have a test that says there may be a
problem, you can't simply ignore it. This means that antenatal
testing isn't harmless because it leads to unnecessary inductions
and cesareans. Inducing labor isn't harmless either. Studies show
that elective induction, that is, inductions for other than medical
indications, roughly double the likelihood of cesarean in
first-time mothers compared with labor starting on its own. Studies
also show that measures to ripen an unfavorable cervix, such
as Cervidil, don't reduce the excess cesarean rate associated with
Where does this leave you? One option is to exercise your right
to informed refusal and refuse antenatal testing and
induction of labor at a predetermined date. If you go this
route, I suggest you have a conversation about the circumstances
under which you would revisit the issue or change your mind. The
other is to agree to testing, induction of labor at 41 weeks, or
both. To help you if you agree to induction, I'm going to
paste in the relevant section of "Strategies for Optimal Care" from
the induction chapter of my new book (co-author Amy Romano),
Optimal Care in Childbirth: The Case for a Physiologic
Approach, a book for childbirth professionals published last
year. All of these statements are supported by the
obstetric evidence presented in the chapter.
When induction is necessary:
• If possible, wait for
• With a favorable cervix,
proceed directly to oxytocin: cervical ripening agents are not
needed and introduce unnecessary risk.
• Do not use vaginal
misoprostol: other methods produce similar cesarean rates at
reasonable cost with less likelihood of adverse effects.
• With an unfavorable cervix,
ripen with a balloon catheter followed by a gentle, slow oxytocin
induction with a fall-back to PGE2 [Cervidil] or possibly low-dose
oral misoprostol if catheter insertion fails.
• Use an evidence-based
oxytocin dosing interval and dose.
• Conduct a leisurely, serial
induction with meticulous attention to achieving cervical ripeness
and maintaining maternal wellbeing.
• Refrain from rupturing
• Turn off the oxytocin drip
once in active labor: in most cases, labor will continue to
progress without it, and it may reduce the likelihood of
• Refrain from vaginal exams if
membranes are ruptured.
• Have patience: induced labors
may take longer especially in nulliparous women [first-time
mothers] and in women requiring cervical ripening, but longer
labors do not result in worse maternal or neonatal outcomes.
I would love to hear how everything goes.