Obstetrical Management of the Older Gravida

Maximilian B Franz; Peter W Husslein

Disclosures

Women's Health. 2010;6(3):463-468. 

In This Article

Delivery

Delaying childbearing seems to have contributed significantly to the rising rates of cesarean delivery. Gilbert et al. reported data from 24,032 women at the age of 40 years or older from a cohort of 1,160,000 women who delivered between 1992 and 1993 in California, USA.[15] The group of older gravidas aged 40 years or older was compared with gravidas at aged 20–29 years. Each group was separated into nulliparous and multiparous women. The cesarean delivery rate for older nulliparous women was 47% compared with 22.5% in the younger nulliparous women. In the older multiparous patients, the cesarean section rate was 29.6 compared with 17.8% in the younger control group.[15]

The operative vaginal delivery rate in the older group was 14.2% for nulliparous and 6.3% for multiparous women. Asphyxia (rate: 6%) and malpresentation at term (rate: 11%) occurred significantly more frequently in the older nulliparous group compared with the younger nulliparous group (4 and 6%, respectively). The rates for asphyxia and malpresentation increased similarly in the multiparous group (3.4 and 6.9%, respectively) compared with the younger multiparous group (2.4 and 3.7%, respectively).

In this study, older nulliparous women aged 40 years and over had babies of significantly lower birth weights and significantly lower gestational age.[15] In spite of these facts, cesarean delivery rates have been demonstrated to be increasing, which might be largely explained by other increasing risk factors during pregnancy in these patients.

These results were confirmed by another study of 3715 nulliparous women who were divided into age groups of younger than 25 years, 25–25 years, 35–39 years and older than 40 years of age.[18] The rate of malpresentation rose from 2.7% in those aged younger than 25 years to 5.6% in the older than 40 years age group. The increase in malpresentation was partly explained by an increase in multiple gestations among older women (>25 years of age: 0.3%; 25–35 years of age: 1.4%; 35–39 years of age: 3%; and >40 years of age: 4.1%). The cesarean delivery rates increased significantly with advancing maternal age, from 11.6% in the older than 25 years age group to 43.1% in the older than 40 years age group. Older women were more likely to undergo cesarean delivery without labor. Indications for cesarean delivery without labor that were more prevalent in the older age groups were malpresentation and prior myomectomy. However, even in women with spontaneous or induced labor, older women were more likely to have a cesarean section than younger women.

The effect of delayed childbearing on primary cesarean delivery rates has also been studied by Smith et al..[19] Among 583,843 nulliparous women in Scotland between 1980 and 2005, a linear increase in odds ratios (ORs) for cesarean delivery with advancing maternal age from 16 years upwards was demonstrated (adjusted OR for a 5-years increase in age: 1.49; 95% CI: 1.48–1.50). Furthermore, an association of longer duration of labor (0.49 h longer for a 5-year increase in age; 95% CI: 0.46–0.51) was demonstrated, as well as an increased risk of operative vaginal delivery, with advancing maternal age (adjusted OR for a 5-year increase in age: 1.49; 95% CI: 1.48–1.50). According to Smith's data, in Scotland, over the period from 1980 to 2005, the proportion of women aged 30–34 years increased threefold, the proportion of women aged 35–40 years increased sevenfold and the proportion of women aged over 40 years increased more than tenfold. In the same period, the cesarean rate among nulliparous women more than doubled. In a very interesting calculation model, the authors estimated that approximately 38% of these additional cesarean deliveries would have been avoided if the maternal age distribution had stayed at the level that it was in 1980. In the same study, the effect of advancing maternal age on the contractility of uterine smooth muscle was studied. It was shown that with increasing maternal age, spontaneous activity was reduced and the likelihood of multiphasic spontaneous myometrial contractions increased. The authors of this study concluded that the association between increasing maternal age and the rising risk of intrapartum cesarean delivery is likely to have a biological basis.[19]

Similar findings were found in many other studies from different countries (e.g., England[20] and Taiwan[21]). In all studies, advanced maternal age was associated with increased cesarean delivery rates.

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