Issue #3: Risks Associated With Advanced Maternal Age And Caesarean Section.

Loving your podcast so far.

I’m 37 and have a 18 month old who arrived C-section due to being breech. Previous pregnancies were a missed miscarriage (was induced) and an ectopic and had surgery to remove tube. My dream is for next bub to be delivered VBAC and minimal intervention. I worry because I’ve been labelled high risk due to pregnancy history, age etc. I might be advised against this.

What are the actual risks and percentages associated with age, C-section etc?

From Jen x

Hello Jen,

Thank you! I am so happy you are loving the 🎙 podcast 😍

Ahh the f*#king labels. They are everywhere and our society for women and especially our maternity system lloovveess to stick a label on us 🙄 I’ve had the advanced for maternal age, plus size, and homebirther labels. You are not alone. I’m standing in line right beside you 👯‍♀️

A thought Jen, were you 35 or older or almost 35 when you had your first 👶 baby? If you are getting labelled high risk because of your age then did they have that label with your previous 🤰 pregnancy? Because the “risk” they say is if you are 35 years and older and are having your first 👶 baby. And the “risks” they are talking about are - Possible maternal complications of 🤰 pregnancy at age 35 or older include increased risk of spontaneous miscarriage, preterm labour, gestational diabetes mellitus, pre-eclampsia, stillbirth, chromosomal abnormalities, and caesarean delivery (ncbi).

When you are over the age of 35 and having your second + baby, your risk of stillbirth actually reduces. That is the card often played to encourage induction or a repeat caesarean. Your age in regards to your next 🤰 pregnancy, shouldn’t really play a factor, especially in regards to how you birth.

I’ll leave you with two quotes.  

The good news is that the majority of people 35 and older who make it to term will have a healthy baby. Intervention rates for this group may be further lowered by using a midwifery-led model of care, as a large English study showed excellent outcomes and fewer interventions for people who were 35 and older and planned a birth with the midwifery-led model of care.’

Evidenced Based Birth


Australian hospital policy for advanced maternal age

For more info and detailed risk factor stats, you can suss below to find 🎙 podcasts discussing advanced maternal age along with research from Evidence Based Birth and an article from The International Journal of Women’s Health.

Now VBAC. 

A lot of my private midwife work is working with women who have had previous cesareans (sometimes 1 previous, sometimes 2+ more previous cesarean) and they want their next birth to be a VBAC (vaginal birth after cesarean) or HBAC (🏡 homebirth after cesarean). The majority of clients I do support get told by either their GP’s or Private & Public Obstetricians that they are “high risk” and they should book in for a repeat cesarean (they say this because of the risk of uterine rupture). My next question to this information is, “Did they provide you the risks of having a repeat cesarean?”. So far not ONE of them who told women they were “high risk” shared the risks of having a repeat cesarean. NOT ONE! What I find 🤔 interesting is that no matter how you birth your uterus is involved and no matter where or how you birth risk is involved, and a uterine rupture can happen with any type of birth (extremely rare but still a fact). By having a repeat cesarean, it does not wipe you of having any risks. In fact it increases your risk.

Research shows (sourced from Childbirth Connection);

If you do not have a clear and compelling need for a cesarean in your present pregnancy, having a VBAC rather than a repeat C-section is likely to be:

  • Safer for you in this pregnancy

  • Much safer for you and your babies in any future pregnancies

The below information is often not discussed with women having a repeat cesarean.

Research shows: (sourced from Childbirth Connection) that repeat caesarean is worse than a planned VBAC, for;

Physical problems for mothers. Compared with vaginal birth, caesarean increases a woman's risk for a number of physical problems, ranging from less common but potentially life-threatening problems like hemorrhage (severe bleeding), blood clots and bowel obstruction (due to scarring and adhesions from the surgery). More common problems like longer-lasting and more severe pain and infection. Scarring and adhesion tissue can make it more likely that women will have ongoing pelvic pain and twisted bowel.

Longer hospital stays. If a woman has a caesarean, she is more likely to stay in the hospital longer and to be re-hospitalised.

As the number of caesareans (and related scarring and adhesions) grow, risks for women and babies grow. A systematic review found that risk of the following complications associated with caesarean increases with each additional caesarean:

  • Measures of serious maternal health problems (severe morbidity)

  • Emergency surgery to remove the uterus (hysterectomy)

  • Serious condition of the placenta covering the opening of the cervix (placenta previa)

  • Serious condition of the placenta growing into the wall of the uterus (placenta accreta)

  • Excessive blood loss (hemorrhage)

  • Blood given through IV line (blood transfusion)

  • Scars that cause organs to bind together and may lead to pain and other problems (adhesions)

  • Surgical injury

I could go into all the VBAC research, stats & percentages but it is not my forte. I understand that is what you have asked me, but there are two amazing researchers; Hazel Keedle and Rachel Reed and they do an awesome job on discussing all the stats, and percentages. Hazel has recently released her 📗 book Birth After Caesarean: Your Journey to a Better Birth and it discusses her own Phd. research in conjunction with international research and it delves into VBAC with a higher BMI, Induction, Gestational Diabetes, Breech, Twins, more than 1 caesarean, special scars and 🏡 homebirth. It’s very easy to read and you can get it for $10 on kindle. I HIGHLY recommend! I have added links to Hazel’s book and Rachel’s blog below for you to 🤓 read, along with some great 🎧 podcasts to soak in.

My forte is more looking at it from another angle and 🧭 navigating the system and choices available.

Firstly, if your care provider 🙅‍♀️ refuses to support you or says that they don’t recommend a VBAC, then find another care provider, or get a second opinion.

Find a Private Midwife (🙋me, but not just me. We are growing 🇦🇺 Australia wide and don’t forget I have my Find me a Midwife page and I’ll help you find one).

If your care provider is all for supporting you, just don’t take it on that alone. Unfortunately I have seen it too many times that at the beginning of 🤰 pregnancy full support is given, but by the end of 🤰 pregnancy that support falters and rules start coming into play with a lot of limitations. To get a feel if this is going to play out then start stating your requirements and state them early and keep stating.

Some requirements you can research deeper on and potentially have on your list are;

💥 No induction (will discuss once I am at so many weeks),

💥 no booked caesarean date “just in case”,

💥 fetal monitoring,

💥 vaginal examinations,

💥 admission to hospital,

💥 time limits on labour and birthing, and

💥 artificial rupture of membranes (ARM).

💥 If you would like to book in a caesarean date as late as possible, ask what happens if I go into labour before?

💥 If they are supportive of VBAC then the answer should be, you birth.

💥 Ask what reasons would they suggest a caesarean section during labour and birth? Then discuss those answers with your Private Midwife or your second opinion. And research the reasons they give you. Research everything! 

💥 Discuss with your midwife.

💥 Join VBAC groups, ask and discuss in them.

💥 If at the end of 🤰 pregnancy they start mentioning that a caesarean may be the best option, then find another care provider. I have had clients change at 36+ weeks. It’s worth it 100%. You need someone supporting YOUR wishes.

💥 Plus don’t forget you could always 🏡 homebirth. Research shows women are more successful in having a VBAC at 🏡 home and even just planning a homebirth than women are more successful in having a VBAC.

Another topic that often isn’t discussed when discussing VBAC or repeat caesarean, is that labour is of great 👍🏻 benefit to mum and 👶 baby. If you decided to book in for a caesarean section, labour happening before is of huge 🙌 benefit and your care provider should be supportive of this. Contractions actually send signals to your 👶 baby that birth is happening and that their body system needs to start preparing because soon they will be doing it on their own and won’t have a placenta to help them. Your 👶 baby's physiology starts to change and this helps them in initiating their 🫁 breathing, 🫀 heart beating and 🩸 blood pumping all on their own when born. When a 👶 baby is born with no contractions prior (what is often called a cold caesarean or an elective caesarean) research shows that it is more common for those babies to require 🫁 breathing support after birth. They also have more fluid/mucous on their chest as they haven’t been squeezed by the contractions to expel that fluid. They can also take longer to initiate 🤱 breastfeeding. No contractions can also impact on their microbiome, that's all our good bacteria and you give it to your 👶 baby via contractions and vaginal births which aids in immunity and improves 👶 baby’s long term health outcomes.

Before I head off, I want to pull one more thread 🪡 out from your question. ‘My dream is for the next bub to be delivered VBAC and minimal intervention.’ The thread 🧵 I want to pull out and ask you to tap into a little deeper and ask yourself, what does minimal intervention mean to you? And why not ‘My dream is for the next bub to be delivered VBAC with no intervention’? My final question for you to explore if you desire, is - where is my best place to birth to achieve my dream? Who are the best people to have in your 🤰 pregnancy journey and birth space to achieve your dream? Ok one more, envision your dream birth, every fine little detail. The smell, the sounds, the surroundings, the people, the feelings in your body, how you move your body, how you labour, how you birth, everything that comes to 🧠 mind and vision. Write ✍️ it down, every detail. Then work backwards. What steps do I need to take to have that vision? Keep that vision in 🧠 mind, visit it often, feel it, 🫁 breathe it, and keep taking the action steps needed to live it.

I agree with Rachel Reed; VBAC is; making a mountain out of a molehill. What is all the fuss? 🤷 And age…..ahh we don’t just start going downhill at the tick of 35. Our bodies and babies don’t do numbers. My best advice is to 🤓 read and 🎧 listen to the links 🔗 below and discover that the label of “high risk” being placed on you is actually not so high and it’s more created high by the beliefs of a certain part of society and not by the research. Then find yourself a care provider who believes the high is not warranted and that you, birth and babies are not flawed or broken. Women and babies are made and wired to birth, even with a scar and even when your 37!

Love Kate 💚