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golden Caring for clients of advanced age in an out-of-hospital care setting: Evidence, management options and practice guidance by rachel cipryk

he mean age of childbearing is rising in the they are ready to have a , or to use someone United States and in all other high-income else’s eggs, sperm, or to have a child. These countries.1 Since 1970, for example, the technological advances extend the childbearing mean age at first birth in the United States years by overcoming at least some of the biological Thas increased by more than five years.2 This change barriers to and birth at advanced mater- is due to a range of social, economic, and techno- nal age (AMA). logical factors. Women are much more likely than The increase in the mean age of childbearing has ever before to be educated, to work, and to support sparked a discussion of the risks and the complica- themselves financially, which has led many to- pri tions associated with pregnancy and birth at AMA. oritize their professions in their early years.3 Numerous studies find that the >35 age group is Further, advances in reproductive technology now more likely to experience a wide range of pregnancy allow people to store younger, healthier eggs until and birth complications (see Table 1).

TABLE 1. ODDS RATIO FOR PREGNANCY AND BIRTH COMPLICATIONS BY AGE GROUP4

Complication Age Odds ratio (99% CI) Complication Age Odds ratio (99% CI) dreamstime Gestational diabetes 35-40 2.63 (2.40–2.89) Emergency cesarean 35-40 1.59 (1.52–1.67) | >40 3.98 (3.38–4.68) >40 2.17 (1.97–2.39) images Preeclampsia 35-40 1.19 (1.01–1.40) Elective cesarean 35-40 1.77 (1.68–1.87) >40 1.25 (0.88–1.79) >40 2.67 (2.42–2.95) previa 35-40 1.93 (1.58–2.35) Postpartum 35-40 1.14 (1.09–1.19) business >40 3.09 (2.19–4.36) hemorrhage >40 1.27 (1.15–1.39) Breech presentation 35-40 1.37 (1.28–1.47) Birth before 32 weeks 35-40 1.41 (1.24-1.61)

>40 1.72 (1.50–1.98) >40 1.64 (1.25-2.14)monkey 35-40 0.92 (0.78–1.08) 0.83 Birth before 37 weeks 35-40 1.18 (1.11–1.25) >40 (0.56–1.22) >40 1.42 (1.26–1.60) Pulmonary embolism 35-40 1.28 (0.75–2.18) Birth after 42 weeks 35-40 1.14 (0.8-1.61) >40 2.38 (1.03–5.47) >40 1.19 (0.57-2.50) Operative vaginal birth 35-40 1.50 (1.43–1.57) Delta* 35-40 1.28 (1.20-1.36) >40 1.60 (1.43–1.78) <5th % >40 1.49 (1.29-1.71) Prolonged postpartum 35-40 1.52 (1.44–1.60) Delta* birth weight 35-40 1.20 (1.13-1.27) stay >40 2.10 (1.87–2.36) >95th % >40 1.29 (1.14-1.45) Induction of labor 35-40 1.04 (1.00–1.08) Stillbirth 35-40 1.41 (1.17–1.70) >40 1.19 (1.10–1.29) >40 1.83 (1.29–2.61) Source: Adapted from Jolly et al Notes: The comparison group for the odds ratio is the 18-34 age group, which has a ratio of 1.0 for each complication *Birthweight expressed as a delta value, i.e. the number of SD by which the observed birthweight differed from the mean for males and females for each week of

4 / midwifery matters A recent study by Sheen et al looks at a composite somal abnormalities, rises with maternal age (see of severe maternal morbidity made up of 20 admin- Table 2). There is also some research on the con- istrative conditions related to perinatal care.5 The nection between maternal and paternal age and au- study finds that, when compared to the 18-24 and tism spectrum disorders, but there is insufficient 25-29 age groups, all age groups have an increased evidence to conclusively link the two. Finally, some risk of severe morbidity, particularly the 45-54 age studies find that the risk of having a baby with group. Morbidities, however, are often related to congenital malformations increases with maternal the overall health of individual pregnant people of age. Cardiac anomalies, in particular, seem to in- AMA, since older clients are more likely than young- crease independent of aneuploidy. Studies also find er clients to have preexisting chronic illnesses that that club foot, hypospadias, craniosynostosis, and complicate pregnancy, such as obesity, diabetes, hy- congenital diaphragmatic hernia seem to increase pertension, cancer, or a history of pelvic or uterine with maternal age.9 The data are, however, inconsis- . A number of non-disease indicators, too, tent and further research is needed to fill the gaps. may affect pregnancy risk for people of advanced INCREASED RISK OF , ECTOPIC ages, such as multiparity, multiple sexual partners, 6,7 PREGNANCY, AND PLACENTA PREVIA and the use of artificial reproductive technologies. Pregnant people of advanced age are much more Increasingly, healthcare providers recommend likely to experience spontaneous (SAB), early induction or cesarean section to pregnant ectopic pregnancy, and placenta previa than their 8 people of AMA. These recommendations are based younger counterparts. on the perception of pregnancy and birth at AMA as Miscarriage: Increased rates of miscarriage are risky, complicated, and in need of medical manage- thought to be linked to the age of the oocyte, as fer- ment or intervention. While some of these concerns tility centers do not see these high rates amongst are justified, it is not a given that every pregnant clientele using younger eggs.10 One Danish study person >35 will have a complicated pregnancy and finds that, assuming only 80% of people with SAB birth, particularly if they are healthy. In a review of are hospitalized, the SAB incidence rate could be as clients >45 years of age, for example, Carolan finds high as 51.0% for the 40-44 age group and 94.5% a “trend of favorable outcomes,” even at extremely for the >45 age group (see Table 3).11 advanced maternal ages (50-65 years), when partici- Ectopic pregnancy: Hemorrhage from ectopic 6 pants are screened to exclude pre-existing disease. is the leading cause of pregnancy-relat- DEFINITIONS AND TERMINOLOGY ed maternal mortality in the first trimester.7 The risk The research defines advanced maternal age of ectopic pregnancy increases dramatically in AMA as, alternatively, >35 years or >40 years and clients. After bottoming out around 1.5% at age 22, very advanced maternal age as >45 years. the risk of ectopic pregnancy soars to 4% at age 35 Interchangeable terminology for AMA includes and to 7% at age 45 (see Figure 2).11 Researchers “later maternal age,” “mature maternal age,” and, in older literature, “geriatric pregnancy.” It is FIGURE 2: RISK OF ECTOPIC PREGNANCY BY important to note that AMA studies typically look MATERNAL AGE AT CONCEPTIONS at age groups, not specific ages. This method can make the increase in risk at ages like 35, 40, and 45 appear especially significant when, as noted by Sheen et al, age-associated risk increases gradually as a person ages.5 RESEARCH QUESTION This article seeks to answer the question: how should modify care when working with older clients? This article will explore some of the more common complications that affect pregnant people of advanced age with the aim of helping mid- wives provide safer and more appropriate care for these clients. Potential Pregnancy and Birth Complications Reproduced from Nybo Andersen AM, Wohlfahrt PC, Olsen J, THE RISK OF FETAL ABNORMALITIES Melbye M. Maternal age and fetal loss: population based register Extensive research shows that the risk of having linkage study. BMJ. 2000 Jun 24 with permission from BMJ a baby with abnormalities, particularly chromo- Publishing Group Ltd.

TABLE 2: RISK OF VARIOUS ANEUPLOIDIES BY MATERNAL AGE, IN NUMBER PER 1,0009 Client Age /T21 Edwards Syndrome /T18 Patau Syndrome / T13 Total* 20 0.5-0.7 <0.1-0.1 <0.1-0.1 1.9 30 0.9-1.2 0.1-0.2 <0.1-0.2 2.6 35 2.5-3.9 0.3-0.5 0.2-0.3 5.6 40 8.5-13.7 0.9-1.6 0.5-1.1 15.8 45 28.7-52.3 2.9-6 1.5-4.1 53.7 49 75.8-152.7 7.6-17.6 3.8-11.8 149.3 Source: Adapted from Fretts 2018 *Includes the midpoint for the range by age for Down, Edwards, Patau, Turner, XXY, XYY and other clinically significant abnormalities (excluding XXX)

winter 2019 / 5 TABLE 3: ESTIMATED TABLE 4: PREVALENCE risk of having a stillbirth than younger pregnant SAB RATE BY AGE10 OF GESTATIONAL people and that this risk increases earlier in AMA pregnancies.4,9,16,17,18 Age SAB rate (%) DIABETES IN15 STATES PLUS NYC12 Studies that control for co-morbidities find that 12-19 13.3 AMA is an independent risk factor for stillbirth and 20-24 11.1 Age GDM rate (%) that older clients show an increased risk across all 25-29 11.9 <20 6.0 gestational ages. Reddy et al, for example, finds that RISK 30-34 15.0 20-24 5.9 the >40 age group has a similar risk of stillbirth at FACTORS FOR 35-39 24.6 25-29 8.2 39+0 weeks as the 25-29 age group has at 41+0 GESTATIONAL weeks. However, it also finds that a healthy 40-year- 40-44 51.0 30-34 11.1 DIABETES (GDM) old woman without comorbidities is 15.6% less >45 93.4 >35 15.5 • Physical inactivity likely than her peers to have a stillbirth. While this Source: Adapted from Nybo Source: Adapted from First-degree decreased risk is encouraging, it is still in the con- • Anderssen et at 2000 DeSisto et at 2014 relative with text of age being an independent risk factor for still- diabetes birth. Illustrating this, the data show that of clients Previous baby link increased rates of ectopic pregnancy in preg- >40 who delivered a stillborn between 37-41 weeks, • 18 with GDM nant people of AMA to an accumulation of risk fac- 73% of them reported no other maternal disease. • Previous baby tors over time, such as multiple sexual partners, tub- Interestingly, Reddy et al finds that the peak weighing 4,000g al pathologies, pelvic infection, fertility treatments, stillbirth rate for low-risk pregnant women up to or more at birth previous surgeries, and tumors that reduce the 39 years old is 40 weeks, with the risk decreasing 7 18 • History of space for an uncomplicated placental attachment. thereafter (see Figure 3). Not all studies support cardiovascular Placenta previa: Jolley et al suggest that people this finding. A more limited Norwegian study, for disease 40 and older have a relative risk for placenta pre- example, finds that the risk of stillbirth increases • Polycycstic via of 3.09 (see Table 1).4 Researchers link the in- by at term across all age groups Ovarian Syndrome creased rates of placenta previa to an accumulation (see Table 5).17 It is worth noting, however, that the • High-risk race of risk factors over time. largescale Reddy et al study contradicts the com- or ethnicity (e.g. THE RISK OF DIABETES AND GESTATIONAL African American, DIABETES Latino, Native American, Asian Gestational diabetes (GDM) stems from the pregnant body’s inability to medi- FIGURE 3: STILLBIRTH IN LOW-RISK WOMEN BY AGE AND American, Pacific WEEKS GESTATION18 Islander) ate insulin appropriately for the needs • of the pregnant person and . It (140/90 mm Hg can increase the risk of pregnancy and or on therapy for birth complications, namely macroso- hypertension mia and its sequelae (e.g. birth trauma, • High-density cesarean birth, hypoglycemia). Pre-ges- lipoprotein tational overt diabetes (DM) may also cholesterol level increase the risk of congenital anoma- less than 35 mg/ lies, perinatal morbidity, and perinatal dl (0.90 mmol/L), mortality.9 Healthcare providers con- a triglyceride sider AMA a risk factor for developing level greater than 250 mg/dL (2.82 both DM and GDM, since the incidence mmol/L) rate of both types of diabetes increases significantly with age (see Table 4). • A1C ≥5.7%, impaired glucose A number of other factors, however, tolerance, or contribute significantly to the likeli- Source: Adapted from Reddy et al, Table 1 impaired tasting hood of a person having DM or GDM. Note: This group excludes pregnancies complicated by diabetes, chronic glucose on For example, a pregnant person in the hypertension, pregnancy-associated hypertension, , and renal, previous testing US is statistically more likely to have cardiac or lung at the beginning of each gestational age interval. • Other clinical diabetes if that person has a family his- conditions tory of DM, is non-white, is obese, has associated with a lower level of education, lacks health insurance, mon assumption that the stillbirth rate continues to insulin resistance is enrolled in the Special Supplemental Nutrition increase after 41 weeks, since many healthcare pro- (e.g. pre- Program for Women, , and Children (WIC), viders use this assumption to justify transferring pregnancy body 12,13,14 mass index or is enrolled in Medicaid. Unfortunately, there care from midwives to doctors at 41 weeks. greater than is little research that ranks these disparate risk fac- Parity affects stillbirth rates across all client ages 40kg/m2, tors and none is able to disentangle causation from and gestational age groups, with women who have acanthosis correlation. It is difficult, then, for practitioners never given birth being much more likely to experi- nigricans) to assess a client’s real risk for GDM based on age ence a stillbirth than women who have given birth alone. In fact, the American College of (see Table 6). Reddy et al find that nulliparas have and Gynecologists (ACOG) does not list AMA as a an increased risk of stillbirth across all age groups, 15 reason to perform a first trimester GDM screen. and that advanced maternal age does not exacer- THE RISK OF STILLBIRTH bate this further.18 In the US, stillbirth is defined as the of a fetus Though the relative risk numbers look scary, after 20 weeks’ gestation, including intrapartum the absolute number of stillbirths is low across all . Some studies, however, define stillbirth as age groups. Almost all studies show that the risk of the death of a fetus after 24 or 28 weeks, which can stillbirth, even for the 40+ age group and even at make interpreting results across studies difficult.6 41+ weeks, is well below 1%. A study from the UK By any definition, however, stillbirth is one of the finds that the percentage of stillbirths in the 18-34, main concerns informing care for AMA clients. Evi- 35-40, and 40+ age groups are 0.47%, 0.61%, and dence consistently shows that they are at higher 0.81% respectively. A Swedish study finds that the

6 / midwifery matters perinatal death rate (which includes both stillbirths risk of 1.49 (1.29-1.71) over the 18-34 age group and newborn deaths up to 28 days) for the 20-29, (1.00).4 Carolan’s review of multiple studies of very 40-44, and 45+ age groups is 0.6%, 1.08%, and advanced age clients showed rates of SGA ranging 1.66% respectively.19 from 5.3% to 32% for the 45+ age group and 9% It is useful to have a sense of risk factors and how to 49% for the 50-65 age group.6 Notably, the risk they may interact to create a higher risk picture in factors for growth restriction include a number of some clients. While attempts have been made to cre- complications or conditions for which advanced age ate models that can accurately predict fetal loss, clients are at elevated risk, including chromosomal these attempts have not been successful, since evi- abnormalities, congenital abnormalities, uteropla- dence shows that “women with risk factors do not cental insufficiency, hypertension and preeclamp- account for the majority of stillbirths, and most risk sia, TORCH infection, previous SGA baby, pregnant factors do not lead to stillbirth.”20 The etiology of person having been growth restricted in utero, and increased risk of stillbirth in advanced age is un- oligohydramnios.22,23 known. While a number of factors increase the risk of stillbirth, the underlying risk associated specifi- Evidence on Management Opritons cally with age is not something that can be easily EARLY FETAL ULTRASOUND calculated. A Cochrane Review finds low-quality evidence that THE RISK OF SMALL FOR GESTATIONAL AGE AND administering fetal ultrasounds before 24 weeks re- FETAL GROWTH RESTRICTION duces the number of inductions by 40% to an aver- A fetus that is small for gestational age (SGA) is be- age risk ratio of 0.59.24. Early fetal ultrasound may low the 10th percentile for both weight and length be particularly useful with AMA clients to get a re- on the growth curve.21 When an ultrasound sug- alistic understanding of their risk of stillbirth, and gests that a fetus may be SGA, the healthcare pro- also to manage postdates appropriately and avoid a vider must determine whether the fetus is constitu- misdiagnosis of fetal growth restriction. tionally small or fetal growth restricted (FGR), since The review also finds moderate-quality evidence an FGR baby is at significantly higher risk for mor- that early fetal ultrasounds can help detect fetal mal- bidity and mortality.22 FGR, or intrauterine growth formations, thereby providing useful information restriction, does not have a specific definition in the for those considering pregnancy termination while ICD-10, but refers to a fetus that is not growing op- it is still an option. This is useful given a number timally. A diagnosis of FGR is made over time with of studies suggest that some specific malformations multiple tests to determine whether a fetus is sim- increase with age, independent of other factors (see ply constitutionally small and growing normally in Table 1). The review, however, mentions the lack of the lower range of the growth curve or has some research around uncertain ultrasound findings and abnormal physiological or environmental character- the stress these findings put families under during istics that are inhibiting optimal growth. the pregnancy. Studies show increased risk of SGA in pregnant COUNTING people of AMA, with the numbers ranging widely Many midwifery practices routinely begin fetal depending on the study. Jolly et al show that AMA movement counting at 40 weeks as an early warn- clients are at slightly increased risk of delivering ing system and an indicator of utero-placental per- babies below the 5th percentile for birthweight. formance. Studies show that when the pregnant The 35-40 age group has an increased risk of 1.28 person picks up on decreased fetal movement, inter- (1.20-1.36) and the 40+ age group has an increased vention can reduction poor outcomes like impaired

TABLE 5: FETAL DEATH BY MATERNAL AGE AND WEEKS’ GESTATION, IN NUMBER PER 1,00021 380-396 GA 400 – 416 GA 420 – 436 GA Though there have been no 20-24 0.65 0.84 1.7 studies done specifically on the 35-39 1.1 1.9 3.8 use of fetal movement counts >40 1.4 1.6 2.6 among clients of advanced Source: Adapted from Haavaldson et al, Table 4 (absolute numbers, 1987 -2006) age, one could surmise that such an early warning system TABLE 6: RISK OF STILLBIRTH BY MATERNAL AGE AND PARITY, IN NUMBER PER 1,000 ONGOING PREGNANCIES18 may usefully be employed Age Risk at 37+ weeks Odds ratio (95% CI) at 37 or 38 weeks–before Primiparas the point at which research <35 3.72 1.0 suggests that advanced age 35-39 6.41 1.72 (1.54-1.92) clients are at higher risk for >40 8.65 2.32 (1.89-2.86) stillbirth as younger clients. Multiparas <35 1.29 1.0 35-39 1.99 1.54 (1.38-1.72) >40 3.29 2.54 (2.14-3.03) Source: Adapted from Reddy et al, Table II

winter 2019 / 7 fetal growth, perinatal morbidity and mortality, hydrates over simple and processed carbohydrates , and emergency delivery.25 One study and recommends that pregnant people divide their finds a reduction in fetal mortality from 44/1000 to daily intake into 3 meals and 2-3 snacks, which dis- 10/1000 when perceived decreased fetal movement tributes caloric intake and allows the body to better prompts an intervention.26 Studies also show that manage its glucose.15 daily, systematic fetal movement counting reduces Note that, though studies show that exercise and pregnant people’s anxiety.27 healthier eating impacts the development of GDM Though there have been no studies done specifi- in healthy weight people, how these interventions cally on the use of fetal movement counts among impact obese clients is less clear. Studies focusing clients of advanced age, one could surmise that on overweight people show little or no difference be- such an early warning system may usefully be em- tween intervention and control groups.32,33 ployed at 37 or 38 weeks–before the point at which CONCLUSION research suggests that advanced age clients are at The research shows, conclusively, that people of ad- higher risk for stillbirth as younger clients. vanced age are at increased risk of complications GESTATIONAL DIABETES DETECTION, in pregnancy, labor, and birth. This risk increases PREVENTION, AND MANAGEMENT incrementally with a person’s age and, for most Universal diabetes screening at 24-28 weeks is the complications, also with the prevalence of chronic standard in the US, since up to 90% of pregnant health problems like hypertension, diabetes, un- people have at least one risk factor for glucose im- controlled blood sugars, and obesity. AMA is, in pairment during pregnancy.28 Lifestyle changes to particular, linked to significantly elevated risks of exercise and diet are the first-line management op- hypertensive disorders, gestational diabetes, intra- tion for most people with GDM, including those in uterine growth restriction, and stillbirth. While the out-of-hospital (OOH) midwifery care. A 2017 me- increased risks for these complications are statisti- ta-analysis finds that lifestyle changes reduce the cally significant, the absolute rates of these compli- number of large-for-gestational-age (>4000g) in- cations in the healthy AMA population are low. fants and reduce neonatal fat mass associated with Because AMA is an independent risk factor for childhood obesity.29 stillbirth, many healthcare providers recommend A systematic review finds that 30-40 minutes of that AMA clients have early inductions or planned exercise 3-4 times a week leads to significantly low- cesareans. It is, however, still unclear why the risk er incidences of gestational diabetes (2.9% versus of stillbirth rises with age and whether any particu- 5.6%), as well as lower incidences of hypertensive lar induction or cesarean may prevent a stillbirth. disorders and cesarean delivery.30 Another study Also, even if intervention prevents all cases of still- finds that 30 minutes of exercise 3 times aweek birth, more than one hundred interventions based from early in pregnancy on is associated with re- on AMA alone would prevent less than one stillbirth, duced development of gestational diabetes, less ges- since the rate of stillbirth in AMA clients is less than tational weight gain by 25 weeks and at the end of 1%. Given the associated risks of induction and cae- pregnancy, and reduced insulin resistance levels at sarean, an elevated risk of stillbirth does not jus- 25 weeks.31 Importantly, neither of the latter studies tify a blanket recommendation of early induction or finds an association between exercise and preterm planned caesarean for all AMA clients. labor, which is an oft-cited concern with exercise In the medical model, healthcare providers rarely during pregnancy. give clients detailed information about their mater- Despite these positive findings, defining specific nity care choices. Instead, hospital protocol often dietary and exercise advice for AMA clients is dif- drives doctors to make the decisions on behalf of ficult. Wang et al propose that pregnant people be- clients. Few clients, then, understand the risks of gin an exercise regime early in the first trimester early induction and cesarean, compared to the risks to optimize outcomes.31 ACOG points to the con- of spontaneous vaginal birth at AMA. The - tribution of lean muscle mass to the body’s ability ry model offers an alternative. In our care, an AMA to better manage insulin, which can contribute to client should be able to access detailed information better glucose management in people with GDM. It about the increased risks of complication and the recommends 30 minutes of exercise 5 days a week. available monitoring options. At any point, the cli- ACOG also recommends that pregnant people con- ent should be able to access intervention by trans- sume a diet of 33-40% carbohydrates, 20% protein, ferring care to a doctor, but midwives should not and 40%-47% fats. It recommends complex carbo- immediately recommend intervention for all AMA clients or, even, for all postdate AMA clients. Because some pregnancy complications dis- qualify clients from out-of-hospital care, midwives Given the associated risks of have an important role to play in prenatal risk as- sessment. By taking an excellent health history of induction and caesarean, clients, midwives can identify the chronic health an elevated risk of stillbirth problems and socioeconomic factors that intersect with AMA pregnancies and increase risk. Midwives does not justify a blanket can work to prevent complications in AMA clients recommendation of early by targeting for ongoing risk assess- induction or planned ment and, if possible, offering lifestyle counselling in preconception or early pregnancy. By modifying caesarean for all AMA some clinical practices to encourage ongoing risk clients. assessment and preventive behavior for clients in the >35 age group or (depending on your commu- nity norms and the expectations of the client’s other healthcare providers) the >40 age group. See the

8 / midwifery matters Since the incidence of MONITOR FOR ECTOPIC PREGNANCY Though a midwife will not care for an older client chromosomal abnormalities with an ectopic pregnancy differently than a young- increases dramatically with er client, it is worth monitoring older clients more age, it is especially important to closely. Since the likelihood of ectopic pregnancy is much higher in advanced age clients, midwives give excellent informed choice should always be ready to respond appropriately. regarding prenatal genetic testing This may entail, for example, quicker referral for and one’s options, should an bleeding or abdominal pain. OFFER INFORMED CHOICE AROUND EARLY anomaly be discovered. ULTRASOUND Practice Guidelines for Clients of Advanced Age, be- Because early ultrasounds help healthcare provid- ers predict gestational age with more accuracy, they low, for recommendations. 24 There is no clear age when an AMA client is too may reduce induction rates by 40%. More accurate old to receive out of hospital care. Because so much gestational dating also alleviates unnecessary fears depends on the client’s overall health, midwives of complications, especially stillbirth, in clients who must evaluate and monitor each client with ongoing go postdate because of imprecise due dates. It also helps healthcare providers give clients a better un- risk assessments and proactive prenatal care. All derstanding of their risk factors and identify condi- the evidence, including the Carolan review, shows tions like fetal growth restriction, which can reduce that the vast majority of AMA clients “will achieve a the likelihood of a misdiagnosis. Midwives should successful pregnancy outcome.”6 By offering high- give clients the information they need to make an quality care options to clients who are broadly con- informed decision about early ultrasound. For accu- sidered high risk, midwives can help change the rate gestational dating, healthcare providers should narrative around AMA. Given our model of care and perform an ultrasound before 14 weeks. education, we are well positioned to help AMA cli- ents make informed choices based on their complete START FETAL MOVEMENT COUNTS FROM 37 risk profiles. We are also positioned to offer them a WEEKS range of evidence-based care options that consider Systematic fetal movement counts from 37 weeks their bodies and their pregnancies, rather than the onwards can help identify clients who are experienc- risk profile of their age group alone. ing decreased fetal movement and need further fetal assessment, which can reduce fetal mortality. By Practice Guidelines for Clients starting fetal movement counts at 37 weeks, clients have the opportunity to establish a normal baseline of Advanced Age in an Out-of- of movement before they enter the risk window of Hospital Midwifery Care Setting increased stillbirth. OFFER LIFESTYLE COUNSELING PRECONCEPTION While there are a range of methods for perceiv- OR IN EARLY PREGNANCY ing fetal movement, only one seems to have been A number of the complications for which AMA evaluated for efficacy in reducing poor outcomes. clients are at increased risk of developing can be The “count to 10” method asks the client to time linked to diet and exercise. While this type of coun- how long it takes to count ten movements when selling is typically standard care in the midwifery they are at rest on their side and focused on fe- model, spending extra time on this with clients of tal movements. If it takes longer than 2 hours to advanced age may help mitigate the development count 10 movements, the client should contact their of these complications. It may be appropriate, dur- maternity-care provider with a report of decreased ing postpartum appointments, to speak with clients fetal movement. Fretts recommends the “count to who are approaching 35 about diet and exercise if 10” method in the current UpToDate paper on de- they are planning to have more children. creased fetal movement.20 PRESENT ALL THE CARE OPTIONS GDM PREVENTION AND EARLY SCREENING Though there are no professional standards dic- A discussion of a nutrition and exercise during tating exactly how care be given for advanced age pregnancy is a major contributor to the prevention clients, it is common to hear of AMA clients being and management of gestational diabetes. It is worth monitored weekly for growth and doing biophysi- starting this conversation early in pregnancy with cal profiles or non-stress tests from as early as 32 AMA clients, who often have accumulated more risk weeks. It is a standard practice, too, for doctors to factors than younger clients. People of advanced induce AMA clients at 40 weeks. age, whether pregnant or not, are, for example, more As with all areas of care in which midwives may likely to have preexisting overt diabetes mellitus. vary from the community or national standard of If there is some suspicion that the client has un- care, it is important for midwives to give excellent diagnosed preexisting diabetes or if the client is informed choice regarding what kind of care one overweight (BMI >25 or >23 for Asians) and has might get in another setting. When midwives open- one or more other risk factors for GDM (see the ly discuss the risks of AMA, explain their positions full list of risk factors below), then, during the first and standards on subjects like postdate induction, prenatal visit, ACOG recommends an A1C draw or screen followed by a diagnostic test if indicated.15 and allow informed choice, clients have a good un- t derstanding of the options available to them. Since the incidence of chromosomal abnormali- Rachel Cypryk will soon graduate from Birthwise ties increases dramatically with age, it is especial- Midwifery School. She lives in Washington DC with her ly important to give excellent informed choice re- young family and plans to open a new OOH practice in the garding prenatal genetic testing and one’s options, DC-MD area. She can be reached at [email protected]. should an anomaly be discovered.

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