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Advanced Maternal Age

There is the perception that nurse-midwives are ill-prepared to care for high risk women, and this is a huge misconception in my opinion. In all aspects of women's health, I believe, a woman's experience can be greatly enhanced by the care of a #midwife. This isn't to say that the nurse-midwife may manage her care exclusively or that there isn't an important role for the #obstetrician or the maternal/fetal medicine specialist, but having a high risk status should not exclude women from midwifery care.


Midwifery and obstetrics are complementary professions. Both are improved with the support of the other. It is not that the obstetrician encompasses all of our knowledge and skill set and ultimately exceeds all that a midwife can offer; rather, our focus is different. We have expertise in different aspects of women's health and when the two work respectfully together, not only is the care of women improved, but the experience and satisfaction of each clinician is greatly enhanced. One is not complete without the other.



Often when I meet with women who are thirty-five-years or older, they ask if my caring for them is within my scope of practice. Certainly there are important considerations for women at the latter aspect of their childbearing age, but because these women can sometimes be overly generalized and because they may require a bit more patience, midwifery care be especially ideal for encouraging their success. The reality is certainly there however, that women at what is often called "advanced maternal age," experience more miscarriage and chromosomal abnormalities in their fetus, and can suffer more often congenital malformations, preterm birth, and stillbirth.


Ovarian Maturity


When a female child is developing within her mother's womb, she has the infinite number eggs which will mature with her throughout her life. If she becomes pregnant at forty, her eggs are therefore forty years old. It is this age progression that currently leads the theories in why older women have a higher incidence of chromosomal abnormalities and miscarriage. Uterine and placenta dysfunction are additional potential causes, as well as environmental and behavioral exposures and comorbidities which are more common in themselves as we age.


Comorbidities


The simple reality that the older one becomes increases their risk for other diseases such as hypertension and diabetes makes pregnancies later in our childbearing years at a greater risk. However, without these additional conditions and beyond the #chromosomal issues, other pregnancy risks are fairly similar to pregnancies in younger ages. The key then is to diligently assess for potential conditions that may place the pregnancy at risk, all of which are with the expertise of a nurse-midwife and even within their wheelhouse to work to prevent. For example, nurse-midwives prioritize education, counseling, and building a trusting relationship with the client which encourages behavioral change. This can make the difference in the food choices a client makes, her movement and sleep routine, and even her relationships, each of which can impact the potential for comorbidities.


Older studies have also demonstrated that a woman having her first child later in her childbearing years may have a longer second stage, which again is well within the expertise of a nurse-midwife, who is often especially trained in how to optimize success in physiologic birth, as opposed to what the primary focus of an obstetrician - a surgeon. Midwifery care therefore, can be essential to improving outcomes in high risk pregnancies, like women of advanced maternal change. Consulting with specialists offers a #multidisciplinary team of experts.


Frederiksen, L. E., Ernst, A., Brix, N., Lauridsen, L. L. B., Roos, L., Ramlau-Hansen, C. H., & Ekelund, C. K. (2018). Risk of adverse pregnancy outcomes at advanced maternal age. Obstetrics & Gynecology, 131(3), 457-463.

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