Sarah S Osmundson1, Jeffrey B Gould2, Alexander J Butwick3, Amanda Yeaton-Massey4, Yasser Y El-Sayed4. 1. Department of Obstetrics and Gynecology, Stanford University, Stanford, CA. Electronic address: sarah.osmundson@vanderbilt.edu. 2. Department of Pediatrics, Stanford University, Stanford, CA. 3. Department of Anesthesiology, Stanford University, Stanford, CA. 4. Department of Obstetrics and Gynecology, Stanford University, Stanford, CA.
Abstract
BACKGROUND: Women of advanced maternal age (AMA) are at increased risk for cesarean delivery compared to non-AMA women. However, it is unclear whether this association is altered by parity and the presence or absence of a trial of labor. OBJECTIVE: We sought to examine modes of delivery and maternal outcomes among AMA women stratified by parity and the presence or absence of a trial of labor. STUDY DESIGN: This is a retrospective cohort study of all women delivering singletons births at ≥20 weeks' gestation in the state of California from 2007 through 2011. Data were extracted from maternal discharge data linked to infant birth certificate records. We compared non-AMA women (age 20-34 years, reference group) to AMA women who were classified as follows: age 35-39, 40-44, 45-49, and ≥50 years). The primary outcome was route of delivery (cesarean vs vaginal) stratified by parity and whether a trial of labor occurred (prelabor vs intrapartum cesarean delivery). The association between a trial of labor and perinatal morbidity was also studied. RESULTS: There were 1,346,889 women who met inclusion criteria, which included 181 (0.01%) women who were age ≥50 years at the time of delivery. Overall, 34.7% underwent a cesarean delivery and this risk differed significantly by age group (30.5%, 20-34 years; 40.5%, 35-39 years; 47.3%, 40-44 years; 55.6%, 45-49 years; 62.4%, >50 years). Nulliparous women age ≥50 years were significantly less likely to undergo a trial of labor compared to the reference group (relative risk [RR], 0.44; 95% confidence interval [CI], 0.32-0.62). Furthermore, nulliparous women age ≥50 years were significantly more likely to experience an intrapartum cesarean delivery (RR, 2.61; 95% CI, 1.31-5.20), however the majority (74%) who underwent a trial of labor experienced a vaginal delivery. Compared to the reference group, women age ≥50 years were 5 times more likely to experience severe maternal morbidity (1.7% vs 0.3%; RR, 5.08; 95% CI, 1.65-15.61) and their infants 3 times more likely to require neonatal intensive care unit admission (14.9% vs 5.2%; RR, 3.1; 95% CI, 2.2-4.4), however these outcomes were not associated significantly with having undergone a trial of labor, a cesarean delivery following labor, or a prelabor cesarean delivery. Similar trends were observed among multiparous women. CONCLUSION: Compared to non-AMA women, women age ≥50 years with a singleton pregnancy experience significantly higher rates of cesarean delivery. However the majority of those who undergo a trial of labor will have a vaginal delivery. Neither a trial of labor nor a prelabor cesarean delivery is significantly associated with maternal or neonatal morbidity. These data support either approach in women of extremely AMA.
BACKGROUND:Women of advanced maternal age (AMA) are at increased risk for cesarean delivery compared to non-AMA women. However, it is unclear whether this association is altered by parity and the presence or absence of a trial of labor. OBJECTIVE: We sought to examine modes of delivery and maternal outcomes among AMA women stratified by parity and the presence or absence of a trial of labor. STUDY DESIGN: This is a retrospective cohort study of all women delivering singletons births at ≥20 weeks' gestation in the state of California from 2007 through 2011. Data were extracted from maternal discharge data linked to infant birth certificate records. We compared non-AMA women (age 20-34 years, reference group) to AMA women who were classified as follows: age 35-39, 40-44, 45-49, and ≥50 years). The primary outcome was route of delivery (cesarean vs vaginal) stratified by parity and whether a trial of labor occurred (prelabor vs intrapartum cesarean delivery). The association between a trial of labor and perinatal morbidity was also studied. RESULTS: There were 1,346,889 women who met inclusion criteria, which included 181 (0.01%) women who were age ≥50 years at the time of delivery. Overall, 34.7% underwent a cesarean delivery and this risk differed significantly by age group (30.5%, 20-34 years; 40.5%, 35-39 years; 47.3%, 40-44 years; 55.6%, 45-49 years; 62.4%, >50 years). Nulliparous women age ≥50 years were significantly less likely to undergo a trial of labor compared to the reference group (relative risk [RR], 0.44; 95% confidence interval [CI], 0.32-0.62). Furthermore, nulliparous women age ≥50 years were significantly more likely to experience an intrapartum cesarean delivery (RR, 2.61; 95% CI, 1.31-5.20), however the majority (74%) who underwent a trial of labor experienced a vaginal delivery. Compared to the reference group, women age ≥50 years were 5 times more likely to experience severe maternal morbidity (1.7% vs 0.3%; RR, 5.08; 95% CI, 1.65-15.61) and their infants 3 times more likely to require neonatal intensive care unit admission (14.9% vs 5.2%; RR, 3.1; 95% CI, 2.2-4.4), however these outcomes were not associated significantly with having undergone a trial of labor, a cesarean delivery following labor, or a prelabor cesarean delivery. Similar trends were observed among multiparous women. CONCLUSION: Compared to non-AMA women, women age ≥50 years with a singleton pregnancy experience significantly higher rates of cesarean delivery. However the majority of those who undergo a trial of labor will have a vaginal delivery. Neither a trial of labor nor a prelabor cesarean delivery is significantly associated with maternal or neonatal morbidity. These data support either approach in women of extremely AMA.
Authors: Anura W G Ratnasiri; Steven S Parry; Vivi N Arief; Ian H DeLacy; Satyan Lakshminrusimha; Laura A Halliday; Ralph J DiLibero; Kaye E Basford Journal: Matern Health Neonatol Perinatol Date: 2018-12-12
Authors: Ana Casteleiro; María Paz-Zulueta; Paula Parás-Bravo; Laura Ruiz-Azcona; Miguel Santibañez Journal: PLoS One Date: 2019-11-26 Impact factor: 3.240