Advnaced Maternal Age & Induction Protocols

Alison Lovejoy Spain

Advnaced Maternal Age & Induction Protocols
Hi Ms. Goer -

Thank you very much for your book, Thinking Woman's Guide.  It's made me feel a lot more confident in addressing issues with my midwives. 

I was wondering if you had any updated thoughts on Advanced Maternal Age and induction?  I've looked at the studies for AMA mothers, and done my best to decipher them, but not feeling very confident in terms of speaking with the midwives and their consultant.

I am 39.5 years old, first time mom, and have had healthy pregnancy thus far.  The consulting OB at my midwife practice requires AMA moms to deliver  by 41 weeks, and basically they start with natural inductions methods and increased monitoring (AFI and NST tests starting at 36 weeks), moving to more aggressive procedures like sweeping the membranes, castor oil, and Cervidil, to have baby by 41.  I understand that 41.1. is average for first time moms, and so am frustrated by the pressure and fear I am feeling at the end here.  I do wonder if the stress of the interventions is also interfering with labor beginning?  In weighing my choices and the midwives' new protocol, I find it coming down to these stillbirth studies and wondering if outcomes really reflect better results.  I've just undertaken my 2nd round of castor oil and am now worried about stressing out my baby. Any new thoughts you have on AMA, the recent literature, and induction vs. waiting for labor to take its course, would be very appreciated.  Do the studies apply across the board for all AMA's, or do factors like VBAC, diabetes, and IVF influence the increased stillbirth stats?  Thoughts on the risks and stress of inducion vs. risk of stillbirth?

Anyway, I know this is a long email, but I think if you  do a second edition of the book the AMA/Monitoring/Induction question would be a great update.

Thank you very much,




ALS Studio + Design 


Henci Goer

RE: Advnaced Maternal Age & Induction Protocols
(in response to Alison Lovejoy Spain)

You're welcome. I'm glad I've been able to assist you in making decisions.


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 authors write:


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 insufficiency.  


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 from another 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 1000. 


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 inducing labor. 


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 yearAll of these statements are supported by the obstetric evidence presented in the chapter.  


When induction is necessary:


• If possible, wait for cervical ripening.

• 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 membranes.

• 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 cesarean.

• 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.


~ Henci

Edited By:
Henci Goer[Organization Members] @ Aug 06, 2013 - 12:10 PM (America/Pacific)

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