Maternity Care for Older Women

Decision Making Package B

Q1: The issue of a birthing woman's age as it relates to pregnancy, birth and midwifery work.

Amanda is 39 years old having her first baby. Literature shows that pregnancy can evoke a broad range of feelings for older women (Bewley, Davies, & Braude, 2005).Today women, particularly those in professional occupations, are having children later than 35 years of age. This is simply life in the early 21st century (Bewley et al, 2005). Seeking information and a desire for knowledge about pregnancy is important to Amanda and her partner John. Using principals of adult learning I continue to provide and educate her with information that is current and evidenced based.

Most women over 35 years of age have healthy pregnancies and healthy babies (Baby centre website, 2010). However, there is good evidence to show this group of women are more likely to have or develop certain medical conditions that can have serious consequences to their pregnancy and birth. Medical conditions include high blood pressure, diabetes and placenta praevia. (Baby centre website, 2010). According to Heffner (2004, cited in Pairman, Pincombe, Thorogood & Tracy, 2008), Effects of maternal age on the outcome of pregnancy might be best assessed by examining factors that can negatively affect the desired outcome of mother and baby. Factors include declining fertility, miscarriage, chromosomal abnormalities, hypertensive complications and stillbirth (Pairman et al, 2008).

Most pregnant women over 35 years old have issues and concerns to which midwives and other healthcare workers must pay attention to (Nichols & Humenick, 2000). As a midwife, I am aware that the biggest obstacle for women over the age of 35 is getting pregnant. A woman hits her peak fertility between the ages of 20 and 24. In women aged 35 to 39, fertility is at least one quarter less (Baby centre website, 2010). This may be due to less frequent ovulation, or to problems such as endometriosis where tissue similar to that lining the uterus attaches itself to the ovaries or fallopian tubes and interferes with conception (Pairman et al, 2008). Amanda has conceived naturally, and while women over the age of 35 may have more difficulty conceiving, they also have a greater chance of bearing twins. Likelihood of naturally conceived twins without fertility treatment peaks between ages 35 and 39 and then declines (Pairman et al, 2008).

Before 20 week gestation, a spontaneous pregnancy loss is called a miscarriage (Pairman et al, 2008). Heffner(2004, cited in Pairman et al, 2008) states that a test that helps to find genetic problems (karyotyping) from the products of conception after miscarriage indicates that about two-thirds are chromosomally abnormal. The relationship between maternal age and miscarriage exists. It is 12% to 15% in women 20 years of age and rises to about 25% for women up to age 40 (women.webmd website, 2010). Miscarriage rate contributes significantly to decreasing fertility among older women. In support of this, success rate using donor eggs from women younger than the age of 35, in vitro fertilisation supports the hypothesis that deterioration occurs in the quality of the ova with advancing maternal age (Heffner (2004), cited in Pairman et al, 2008).

It is normal and expected that blood pressure changes during pregnancy, because pregnancy hormone progesterone relaxes the walls of your blood vessels and this can make a woman's blood pressure to drop (Baby centre website, 2010). Blood pressure is at its lowest between 18 and 20 week gestation. However, high blood pressure (Hypertension) and diabetes can develop for the first the time in pregnancy and women over the age of 30 are at increased risk of developing the complication. Hypertension usually occurs during the second half of a pregnancy. In Amanda's antenatal appointments, I will be checking and monitoring her Blood pressure and urine analysis regularly which will help identify anything outside the norm. Urine analysis is carried out to test protein in the urine (Proteinuria). Protein present in urine and high blood pressure can indicate a woman is developing pre eclampsia. Pre eclampsia is thought to happen when the placenta is not working properly. If not treated it can cause Amanda and her baby to be ill (Baby centre website, 2010).

Pre eclampsia can restrict foetal growth and cause premature birthing when the health of either mother or baby is threatened (Pairman, et al, 2008). I will explain to Amanda, the symptoms of Pre eclampsia include sudden severe swelling of the face, hands or feet, severe headaches, problems with vision such as blurring or flashing, pain below the ribs and a general feeling of being unwell (Baby centre website, 2010). If she experiences any of the symptoms above to immediately inform me or seek medical attention.

Risks of bearing a child with certain chromosomal disorders increases s a woman ages, and the most common is Down syndrome. When a woman is 25 years old she has a 1 in 1250 chances of having a baby with down syndrome, at 30 years of age she has 1 in 1000 chance, at age 35 a 1 in 400 chance, at 40 a 1 in 100 chance and at 45 she has a 1 in 30 chances. Women who are 35 or older are offered the option of prenatal testing. During my first visit with Amanda I discussed the issue of prenatal screening that included blood tests, nuchal translucency and serum analytes. Screening tests are conducted to give an indication or calculated risk for certain abnormalities (ZIndler, 2005).

I offered and discussed the option of having an Ultrasound screening (nuchal translucency) test to check for chromosomal abnormalities with Amanda. This ultrasound is used to visualise and measure the fluid filled sac located at the back of her unborn baby's neck between 11 and 13 weeks gestation (Pairman et al, 2008). Together with a blood test for the hormone hCG (human chorionic gonadatrophin) and PAPP-A (Pregnancy Associated Plasma Protein) helped to assess the risk of Amanda having a baby with Down's syndrome or any other chromosomal abnormality. Other diagnostic tests included amniocentesis which involved sampling cells in amniotic fluid (Pairman et al, 2008). All test results came back negative and Amanda is looking forward to having a healthy normal baby.

Another common problem that is faced by women over the age of 35 is placenta praevia (Pairman et al, 2008). This is where the placenta covers part or all of the opening of the cervix Women of this age have an eight times more likely to have this problem than women in their twenties (Pairman et al, 2008). According to the literature, when prenatal screening results from older women like Amanda, come back negative and rule out chromosomal abnormalities and the mother is healthy, the baby probably is at no greater