Quick (unscientific) poll - early induction due to maternal age...

(33 Posts)
PlinkertyPlonk Mon 28-Nov-11 22:23:08

I posted some time ago on this topic and the variety of answers got me wondering...

If you were of 'advanced maternal age' when you were due ie over-40's (or over-35's in some areas):
1. Were you told you would be induced early, due to your advanced maternal age (ie not for any other reason)?
2. Which healthcare trust was it (if you are happy to share this)?
3. If you were told you'd be induced early, what was your decision and the final outcome?

I understand that some consultants recommend early induction before due date because of a slightly increased risk of early placental failure in older mothers, but I can't find the research to support this (based on age alone) and it seems many consultants don't even mention it. It's not mentioned in the NICE guidelines.

So I'm just curious to see if it's something that's common only in 'the provinces'.

My answers:
1. Yes (age 41. No 'other' complications)
2. Taunton
3. Have yet to decide

AgnesBligg Mon 28-Nov-11 22:28:29

I had my dd aged 42 and my age was never mentioned by anyone, MW or consultant. Easy pregnancy apart from an unfounded concern for 'small for dates' about wk 36.
My answers:
1. No
2. South Kent
3. N/A

BikeRunSki Mon 28-Nov-11 22:34:00

No (37 and 40)
Sheffield and South Yorkshire
N/a

Chynah Mon 28-Nov-11 22:49:20

1. Not told but asked if I would agree to it at 40 wks (age 39)
2. Surrey
3.N/A had an ELCS as was never wanted a VB in the first place.

1. Told I'd be induced by EDD - my age (41) has been mentioned at every consultant appointment I've had with various different recommendations.
2. camden & islington
3. Due next week but am negotiating possible induction at 41 weeks instead (with regular monitoring ) - I'll let you know how I get on

tiokiko Tue 29-Nov-11 10:00:57

I was 36 with DD1 (Northamptonshire) and 39 with DD2 (Edinburgh) - age not mentioned in either case. When I raised it with MW1 she said it didn't even come into the equation until I was 40+ and when I mentioned it to a consultant at a scan with DD2 she said the same and that even then there would have to be other issues before it became a concern.

I went overdue in both cases and was offered/encouraged to be induced purely for that reason; refused both times as no other issues and had healthy DDs with easy labours at 40+11 and 40+8 respectively.

vinchaud Tue 29-Nov-11 10:42:20

I live abroad and early induction was not mentioned with previous baby (I was 38), though you do have monitoring/scans here every 3 days from due date onwards.

Now expecting again age 40 and I'm worried about increase in stillbirth in older mums. As I've had a previous cs I've been offered one again at 38/39 weeks which I'm tempted to take purely to get the baby out safely. This article discusses increased stillbirth in older mothers.

http://www.medscape.com/viewarticle/721313_5

PlinkertyPlonk Tue 29-Nov-11 14:49:40

Thanks for your responses, it all seems pretty random so far smile Nice to hear no one's been forced down the the induction route against their will.

Vinchaud - thanks for the link, some good info in there. Are you able to interpret any of the stats? A key finding is:

an OR for stillbirth of 1.8–2.2 for women between 35 and 39 years of age and an OR of 1.8–3.3 for women over 40 years of age

Do you know what OR (assume it means 'odds ratio') means or how they calculate it?

This also stood out to me, from one of the referenced papers:

The risk of IUFD for women 40 to 44 years of age at 39 weeks is comparable with that of 42 weeks in those 25 to 29 years of age. We concluded that AMA (Advanced Maternal Age) is an independent predictor of IUFD, and a strategy of antenatal testing in those >= 40 years of age beginning at 38 weeks may be considered.

Can anyone translate these results into "x out of 1000 40+ year olds suffered stillbirth past x weeks" figure? Stats never was my strength!

TheBightyMoosh - let us know how you get on - good luck!

i'm 42, in dublin and have been told they'll sweep me at my next antenatal - 39+6. i imagine they'll want to induce earlier than normal if i go over - but i am 39+3 today and i don't think it's going to be an issue. feeling grim, discharge increasing, randomly contracting, and have had what is sometimes known on here as a 'clearout'....

juuule Tue 29-Nov-11 15:02:55

1. No (40 and almost 44)
2. Northwest England
3. N/A

Last was induced at 42w which I was quite happy about. I personally would be reluctant to go longer than 42w.

vinchaud Tue 29-Nov-11 16:34:35

I presume the 25-29 year old group have an OR of 1, so women 40-44 have a stillbirth risk of 1.8-3.3 that of the younger group. I don't know absolute numbers but the final paragraph talks about the risk for 40-44 year olds at 39 weeks being equivalent to 25-29 year olds (the least risky group I think) at 42 weeks.

Perseo Tue 29-Nov-11 18:24:43

I'm in Berkshire and was sent by my midwife to see a consultant at 36 weeks because of my age (40) - my pregnancy was normal though. The rule here is that you're induced on your due date if you're over 40 irrespective of any other factors, the consultant was very clear about the risks of going over - I managed to agree with her that I'd come in a week before my due date and decide then what to do but she was very reluctant to let me go over at all. I don't think that it was a case of being obliged to be induced, although I was also told that due to being 40 I should have been in consultant care from the start of my pregnancy.

As it was I went into labour a week early on the day I was due to see the consultant again and so the final decision never happened anyway!

vinchaud Tue 29-Nov-11 20:32:22

This article has a graph showing risk of foetal death by gestational age and age of mother
http://www.ajog.org/article/S0002-9378(05)02280-5/fulltext

PlinkertyPlonk Wed 30-Nov-11 09:39:43

Thanks vinchaud. The graph is quite convincing!

Has anyone been offered monitoring as an alternative to early induction? It seems a preferable alternative (although I may well be ready for an induction by 39wks!), but the reading I've done seems to suggest that it isn't necessarily a reliable prediction of placental failure, although it clearly detects some cases.

I should stop reading research because I just go into analytical mode and find myself asking more questions than I started with!

MonaPomona Thu 01-Dec-11 09:41:43

my answers are:
1 yes, the hospital said their policy is to induce at 40 wks if you are >=40 years of age (I am 40)
2 Kingston
3 I said no way, luckily we managed to move area a month before ds2 was born so I did not have to have any stressful conversations about it

we moved to surrey and the mws there said they would never induce for age only. I went on to have a lovely home birth at 40 +5 and the mw said the placenta was perfect and healthy, and the baby still had vernix on him so he was born at exactly the right time for him.

I had estimated my due date was 5 days over what the hospital said because my cycle is 33 days not the 28 days standard that they use to calculate their due date - so according to me he was born at 40 weeks exactly

PlinkertyPlonk Thu 01-Dec-11 11:07:49

Mona, you make an interesting point about cycle length. I hadn't thought about that and it would of course make a difference to whether the baby is ready or not, although not necessarily about placental health.

I wonder why there is such a dichotomy in approach between hospitals. Is it based on their personal experience, approach to risk management or opinion of the research done to date?

IssyStark Thu 01-Dec-11 13:40:50

1. It has never been mentioned to me (aged 40 and currently 38w)

2. Southampton

3. Induction would be risky for me as it would be a vbac (previous c-section due to failure of induction at 42w2d)

Me again - I saw my consultant yesterday who agreed not to induce me until 40+10, which is their standard recommendation for under 40s. The only condition was that I have to go in for monitoring twice a week to check on fluid levels, placenta position & general health of the baby. All of which is fine - it's quite reassuring to have so much monitoring really - so my age does have some advantages!!

mejon Thu 01-Dec-11 20:50:44

1. It was never mentioned - I was 42 when DD2 arrived in February.
2. Hywel Dda Health Board (Ceredigion/mid-Wales)
3. Was induced at 40+12 - hospital norm is +10 but they couldn't fit me in on the day.

I was quite relaxed about the whole thing - I wasn't aware that early or term induction is advised for over 40s in so many places until after I'd had DD2. It is strange that the advice to induce or not isn't across the board. I wonder why some consider it to be a risk when others don't mention it? What is the NICE position? I was under consultant care throughout my pregnancy and had more scans than is normal as I also had fibroids that needed keeping an eye on, low-lying placenta and baby was breech until 33 weeks or so but I wasn't even offered extra monitoring when I went over 40 weeks so the whole thing is quite odd.

PlinkertyPlonk Thu 01-Dec-11 21:02:36

Thanks for the update Bighty, that's good to hear. I hope all goes smoothly, keep us posted!

Mejon - there are no NICE guidelines on this. I'm wondering what persuades a consultant to opt one way or the other. From the google-ing I'd done previously, it seemed that there wasn't conclusive evidence based on age alone and that monitoring couldn't predict placental failure (only tell you when it's happening/happened) - it just seems to be a bit of a grey area needing more research.

However vinchaud has found some research that appears on the face of it to be pretty clear about the increased risks - except I still don't understand what the OR values mean. Am going to ask a health economist friend to translate!

rufusnine Fri 02-Dec-11 23:24:44

offered induction at 38 weeks due to maternal age and size of baby.I was almost 45 so i was a geriatric mother- baby was 8 and a half pounds at birth. I agreed to induction cos i wanted the baby out as quickly and safely as possible - HOWEVER it was not the best experience of my life and took much longer than i thought - 28 hours from 1st pessary. In hindsight i wish i'd let nature take its course like my others but she came into the world healthy and is our absolute mid life crisis delight! Not many have a baby for their 26th wedding anniversary!

PlinkertyPlonk Sat 03-Dec-11 12:00:29

smile rufusine, I know of 2 women that had healthy babies aged 47 - bit of a shock to both women as neither were trying or expected to get pregnant!

Flisspaps Sat 03-Dec-11 12:33:12

Not being of 'advanced maternal age' but having noticed some of the phrases that some of you have been using as per the health professionals I just wanted to remind you (and others who may stumble across this thread in the future) that:

You cannot be told that you will be induced early. If you are told then please feel free to remind your consultant/MW that they can only advise you to be induced or to undergo any kind of medical intervention or testing - it is entirely the mother's decision. This includes membrane sweeps, or even having an appointment with a consultant.

This means that even if it is the Trust's "rule" to induce at X days over, you are not in any way obliged to follow that rule and if you do not want to be induced (or have a sweep, or examinations) then you are absolutely within your rights to say 'No'.

As Mary Cronk (IM) says - 'ALLOWED is not an appropriate word to use when talking to a mentally competent adult' smile

If you choose to accept any kind of medical intervention then it is exactly that - your choice.

PlinkertyPlonk Sat 03-Dec-11 12:59:46

Thanks for all your replies. The results so far show:

18 births in total:
- 13 births to mothers aged >40, of which 7 were recommended or offered an induction at or before EDD.
- 5 births to mothers aged 35-39, of which 1 was recommended or offered an induction at or before EDD.

Of those 8 mothers who were offered an induction before or on EDD:
- 1 was induced early (but with an additional factor, baby size)
- 2 chose ELCS
- 1 birth prior to induction date
- 1 negotiated monitoring
- 3 unknown results

Looking at region:
- inductions were not recommended/offered North of Berkshire/London or in Wales
- inductions were offered to about half of mothers in the South
- Surrey had conflicting results

Hardly statistical evidence, but very interesting <prods geeky glasses back onto nose>. I wouldn't want to draw any conclusions but I am surprised there is such a split in mothers being offered induction and those that aren't. I suspect that it differs by consultant (hence Surrey result) and whether it is a 1st or later baby.

MonaPomona Sat 03-Dec-11 22:57:50

can i just add that I have never seen a consultant for either of my pgs, one birth at 37 and one at 40; both were totally mw care as I booked for homebirths - perhaps consultants are more wary of older mothers

I think what flisspaps says is important, when i was 8 days over with my 1st i scoured MN for induction stories and these coupled with all my reading about birth convinced me induction was not for me. It's your body/baby/birth and the inconsistencies this thread has revealed prove that there is no right or wrong across the board.

PlinkertyPlonk Sun 04-Dec-11 18:58:25

Fliss, Mona, you are absolutely right, ultimately it's a personal choice. But it can be difficult to decide what your personal choice should be when you are receive advice that isn't in line with other consultants; it can shake your confidence in sticking with your instincts.

Some consultants are clearly more concerned than others about the risks associated with older mothers, but there doesn't seem to be strong evidence to back up their concerns. In my case, it wasn't presented as a rounded recommendation - it was stated as if there was solid evidence and other options and their risks were not offered.

I asked a couple of friends in the research/stats/healthcare world to give their view on one of the research papers referenced in vinchaud's link. It's the one I quoted above with ORs etc. From the paper, they couldn't tell if there was an increased risk based purely on age and the study didn't say how large the sample was. This raised questions in their minds about the authority of the study. Of course, maybe the link didn't publish all the relevant info.

So from a personal perspective, I will not be requesting an early induction (unless my risk of complication changes of course). From a wider perspective however, I am concerned that some consultants are trying to steer women to a course of action that isn't sufficiently supported by medical research.

vinchaud Sun 04-Dec-11 19:23:48

I think it's well documented that older mums have an increased risk of stillbirth
http://news.bbc.co.uk/2/hi/health/6347239.stm
Though the risk is still very low and the article above suggests increased monitoring of older mums from 38 weeks (not induction).

The study I gave a link to looked at 6 million pregnancies ( don't know if the link came up correctly) I think it's the same one referred to in the BBC article above.

I haven't been offered early induction but have the option of elcs which I may take up to get the baby out safely (I also know an older mum who had a stillbirth at term which is no doubt influencing my decision).

brandysoakedbitch Sun 04-Dec-11 19:39:36

I was 40 when I had dc4 and the consultant sanctioned sweeps from 37 weeks because I always have homebirths - she did mention that they like to induce at 40 weeks for women of my age but I told her very politely to get stuffed - I have never got to 40 weeks pregnant yet and certainly not going to line myself up for a hospital birth if I can avoid it. Am pregnant with dc5 and have not seen the consultant yet but I expect she will offer the same thing. I am in West Sussex.

PlinkertyPlonk Sun 04-Dec-11 19:41:26

Ok, different link, same study. It's possible my friends didn't access the whole research paper, or only read one of the referenced contributing papers.

The researchers also found that foetal checks at 38 weeks of pregnancy had the greatest impact on reducing stillbirth rates in older women.

So now i'm wondering, if this was their finding, why aren't we being offered monitoring from 38wks?

vinchaud Sun 04-Dec-11 19:41:32

Here's the text of the article in case the link wasn't clear. The last paragraph talks about delivery at 39 weeks for older mothers.

Advanced maternal age is associated with an increased risk of stillbirth. In one of the largest studies to evaluate the influence of maternal age on stillbirth risk, Reddy et al. conducted an analysis of more than 5 million singleton deliveries. In this analysis, advanced maternal age was associated with a higher rate of stillbirth, with a peak risk period for stillbirth occurring among older mothers between 37 and 41 weeks of gestation.

Smith and Fretts presented data from a literature search. They presented an OR for stillbirth of 1.8–2.2 for women between 35 and 39 years of age and an OR of 1.8–3.3 for women over 40 years of age. Other epidemiological risk factors were nulliparity (OR: 1.2–1,4), smoking (OR: 1.7–3.0), obesity (BMI &#8805;30; OR: 2.1–2.8), having had a previous SGA infant (OR: 2.0–4.6), multiple gestations compared with singleton gestations and black compared with white race (OR: 2.0–2.2).

A total of 6,239,399 singleton pregnancies in the USA were analyzed by Bahtiyar et al. in order to evaluate the influence of advancing maternal age on stillbirth. The ORs were referred to the group of 25–29-year-old mothers who had the lowest stillbirth risk. When compared with this group, the odds of stillbirth at term increased significantly with advancing maternal age (OR for mothers aged 30–34 years: 1.24; OR for mothers aged 35–39 years: 1,45; and OR for mothers aged 40–45 years: 3.04).

Interestingly, the risk of stillbirth for women aged 40–44 years at 39 weeks of gestation is comparable with women aged 25–29 years at 42 gestational weeks.

Therefore, the authors concluded that a strategy of antenatal testing beginning at 38 gestational weeks for women over the age of 40 years may be considered. According to the authors, delivery by 39 weeks may also be considered for women over 40 years of age since the cumulative risk of stillbirth in women aged 40–44 years at 39 weeks is nearly identical to the risk in those aged 25–29 years at 42 weeks.

PlinkertyPlonk Sun 04-Dec-11 19:52:09

Ok, that explains why my friends couldn't find the sample size - they only looked at the Smith & Fretts paper.

vinchaud Sun 04-Dec-11 20:02:07

Increased monitoring would be a good alternative. It's not easy to make a decision. I'm not a fan of inductions - I've only had one and it resulted in emcs. This time it will be elcs or natural start to labour for me, though I am lucky to be monitored at the hospital from due date onwards.

didoreth Sun 04-Dec-11 20:11:09

I was 46 when I had ds. My age wasn't really raised as an issue, until I mentioned I wanted a home birth.

1. No, was booked for an induction at their standard date - 40+10 I think.
(ds came one day before this, so I was saved an argument as I had no
intention of going along with induction, and every intention of staying at home.)

2.Derby City

The chances of placental failure and subsequent stillbirth may three times higher in women over 40, but its three times a very small number.

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