This is a time of huge change, both physical and emotional. While your body starts to create the environment where your baby will grow, you may feel exhausted and emotionally overwhelmed.

Physical Changes

The most significant physical change in the early weeks of pregnancy is persistent tiredness, and although this feeling is by no means unique to women over 35 women who have had pregnancies in their 20s and again in their late 30s agree that the depth of fatigue is greater when older.

Many women also experience daily nausea or hunger pangs. The huge hormonal adjustments in response to pregnancy can also cause emotional turmoil. Being more tired than every one else, and more irritable, introduces new challenges in to your relationships and your career life. During these first months of pregnancy a gentle exercise program can help restore your emotional balance and increase your energy. Your food plan will need to include meals that cover your increased requirements for protein and help you deal with nausea. Now is also the time to find the doctor or midwife who will care for you during the next 9 months and help bring your baby in to the world. Understanding what to expect from your prenatal care will help you know what questions to ask your care provider so you get the answers you need. More screening tests are offered to women over 35 than to their younger counterparts. Becoming informed about tests, the pros and cons of genetic counseling, screening for down syndrome and one of the earliest screening tests for developmental abnormalities, CVS, will help ensure that your experience is a positive one.

Your Baby’s Development

Your baby creates a life sustaining connection with you, through the placenta. All of the major organs form during this time including your baby’s heart, spine and kidneys. Your baby’s heart will start to beat and the heartbeat can be seen on ultrasound by 6 weeks after your last period. Your baby’s arms and legs will form and your baby will start to move, although it is too early for you to feel it.

For women who want information about the risk of down syndrome but who wish to avoid moving directly to an invasive test such as chorionic villus sampling or amniocentesis, first trimester testing offers an early screening option, although it cannot give a definitive result.

First trimester screening is performed between 11 and 14 weeks of pregnancy and uses a combination of a blood test and an ultrasound to determine the risk of your baby being born with down syndrome or some other chromosomal abnormality. The ultrasound measures the thickness of the skin at the back of your baby’s neck, called the nuchal fold, which is thicker in babies with down syndrome. On the same day as the scan, you will have blood drawn and tested for levels of pregnancy associated plasma protein A (PAPP-A) and human chorionic gonadotropin (hCG). Using the combined results of blood tests, age, and nuchal translucency measurement, the doctor will be able to calculate your baby’s risk of down syndrome. You will receive the results a few days after the test. Your risk will be compared with what the risk of chromosomal abnormality would be for a woman of your age. Your new risk may be higher, lower, or the same as your risk based on your age alone. The test is called positive if your risk of having a baby with down syndrome is higher than a preset cutoff point, usually 1 in 250. A positive test does not mean that your baby has down syndrome, only that the risk is greater. First trimester screening will also detect most babies affected by trisomy18.

Test Accuracy

In women over the age of 35, first trimester screening will detect 85 to 95 percent of babies with down syndrome. However, it can also give a false negative result (suggesting the baby is at low risk down syndrome when in fact the baby is affected). First trimester screening will be negative in between 5 and 15 percent of pregnancies where the baby has down syndrome.

How Age Affects Results

The test is more likely to come back positive as you get older. In women over the age of 35, a quarter of tests will be positive. Although most of these mothers will still have a normal baby, their results may make CVS or amniocentesis a reasonable option. However, 75 percent of women will have a negative test and can feel more comfortable about avoiding CVS or amniocentesis.

Results

If your test is positive

Even with a positive result. the chance of your baby having down syndrome is still very small You will be told the actual statistical risk of your baby having down syndrome; you can compare this risk to the risk of miscarriage with CVS or amniocentesis. Only one of these tests can give you a definitive answer.

If your test is negative

If your first trimester screening test is negative, then your baby has a very, very low chance of having down syndrome. However, if you are still nervous after the screening test, you can have either CVS or amniocentesis. Both of these tests will give you a definitive result.

Nuchal Translucency Scan

• The test is usually performed at 11-14 weeks of pregnancy. The doctor or technician (sonographer) performing the scan will place the ultrasound probe on your belly and look for an area at the back of the baby’s neck called the nuchal translucency. The person doing the scan will mark two points and take a measurement of the thickness at this point. If the measurement is small, the risk of down syndrome is low (the exact measurement depends on the size of the baby). A larger thickness at this point generally indicates that there is a higher than normal risk of the baby having down syndrome.
• Normal nuchal scan shows the outline of the baby, two crosses marking the back of the neck. A narrow gap suggests a low risk of down syndrome. The nuchal translucency scan result must be combined with the results of your blood tests to accurately assess your baby’s risk of down syndrome.
• Abnormal scan shows a thickening at the back of the neck (marked with two crosses). The greater the thickness, the higher the (risk of down syndrome. This test is very dependent on the skill of the sonographer. A poor ultrasound can miss down syndrome or give a positive result with a normal baby.

The signals that cause labor to start are not well understood, but signs from your baby that indicate to your uterus that he or she is ready to be born are probably involved. Once your uterus is is ready to go in to labor, many other signals can stimulate contractions. However, if your body is not ready, things you try to start labor may only cause an increase in mild contractions.

Home Strategies

Probably the most enjoyable way to bring on labor is to make love with your partner. Human sperm contains natural prostaglandin’s that are a great stimulant to the uterus. Having sex is not harmful to your baby unless your doctor has specifically told you to refrain from intercourse for a medical reason. Stimulating your nipples either

during sex or by it self can also cause the release of the oxytocin, a hormone that causes the uterus to contract and the cervix to ripen. This works best if the nipples are rolled between the thumb and forefinger for about 20 minutes. It’s safe to do this several times a day. Other less effective methods of bringing on labor include walking and other exercise that may cause a mild increase in uterine contractions, but are safe to try.

Herbal Remedies

These remedies, are best avoided some are potentially harmful, and the level of active ingredients with in herbal. preparations varies widely, so it is difficult to know how much medication you and your baby are getting. Many powerful drugs that we currently use were originally purified from plants, and so called natural preparations can still contain potent medications with side effects that can be every bit as serious as drugs you buy from a pharmacy. In the end, you must balance your beliefs against the scientific unknowns that surround herbal medicine. Castor oil and enemas are not particularly effective for bringing on labor and can dehydrate you.

Medical Induction

It is not surprising that many women beg to be induced once they approach their due date or even before. After discussing your reasons with your care provider, choosing labor induction is an option, but there are risks. It is not recommended if you have previously had a cesarean.

Risks of induced Labor

Induced labor is less effective than spontaneous labor, and you are 1.5-2 times more likely to need a cesarean delivery if this is your first baby. Induced labors are also longer than spontaneous labor, and you are likely to spend an extra day or two in the hospital while your cervix is made ready for labor and contractions are induced with drugs.

Methods Of Induction

There are several medical methods for inducing labor.

Stripping The Membranes

This is the least invasive way for your care provider to stimulate labor. To strip or sweep the membranes your provider will do a cervical exam as usual and then run a finger between your cervix and the bag of water. This action stretches the cervix and releases natural substances that may help ripen your cervix and increase contractions. It is common to have vaginal spotting on your underwear afterward, but you do not need to call your care provider unless the bleeding is heavy, you think your water has broken, your baby is not moving frequently, or you go in to labor. The procedure will not increase your chance of a cesarean delivery.

Cervical Ripening

Various medications or devices may be used to soften, thin and dilate the cervix. Once the cervix is dilated, oxytocin is usually given to start contractions. Ripening is usually done with prostaglandins (administered as a suppository or gel) or with a foley catheter. A Foley catheter is a narrow tube with a balloon on its end, which is placed through the cervix while deflated, then inflated at the top of the cervix. Neither of these procedures are more uncomfortable than a regular vaginal exam, but both can result in mild contractions.

Misoprostol

This is a prostaglandin treatment that causes cervical ripening and contractions at the same time. It is usually only given in hospital and won’t be used if you’ve had a cesarean in the past because there is a greater risk of uterine rupture. Misoprostol can be given vaginally or by mouth.

Oxytocin

This is a substance that is naturally released during labor. In cases of induction, synthetic oxytocin is given to make uterine contractions stronger. It can also be used to strengthen contractions once you are in labor. Some people believe oxytocin makes contractions unnaturally strong, but because some of the early painful contractions are strengthened, it may help move you more quickly in to active labor. Most hospitals will want you to have continuous fetal and uterine monitoring to check your baby for signs of stress if you are receiving oxytocin.

Rupture Of Membranes

If you have had a vaginal delivery in the past and your cervical exam is favorable, releasing the amniotic fluid from around your baby may be enough to send you in to labor. Sometimes, membrane rupture is used in combination with oxytocin.

Medical Reasons For Induction

Sometimes the medical balance is in favor of being artificially induced. In these cases, the risk of continued pregnancy to you and your baby outweigh the increased risk of cesarean delivery. Some medical indications for induction include.

• Low levels of amniotic fluid
• Preeclampsia
• Your baby is not growing well (intrauterine growth restriction)
• Prolonged pregnancy past 41-42 weeks (1 to 2 weeks past your due date).

Labor for most women is painful and exhausting. Sometimes it’s easy to forget that this is what your pregnancy has been leading up to and that you are going to meet your baby for the first time.

Labor is different for older women. Some of these differences are positive and wonderful. After the age of 35 you arc more likely to be better educated about what will happen during labor and more likely to have an extensive support network. Knowledge and support are power not only helping you participate more fully in health care decisions during labor, but ensuring that you have support for the decisions that your make. On the other hand, you may be more likely to enter labor with a medical complication where interventions such as electronic fetal monitoring are more likely, and you are at increased risk of having a cesarean delivery.

Coping With Labor

As a woman over 35 you may be well informed about the various options for coping with the pain of labor. For first time moms, it’s hard to imagine what labor will be like, and there’s a chance that you are more likely to get exhausted than when you were younger. Being informed of all the options for coping with the pain before you go in to labor from simple breathing techniques to epidural’s is really important. Information gathering is an important part of your preparations for labor, and you can incorporate your wishes in to a carefully considered birth plan.

Medical Intervention

First time mothers over the age of 35 are significantly more likely to have medical interventions during labor. These may range from electronic fetal monitoring to medications for speeding up of labor to cesarean delivery. The reasons for a higher cesarean rate in over 35s may be in part because more women are likely to have complications, such as previous surgery for fibroids or placenta previa (where the placenta blocks the cervical opening) that result in the need to avoid labor.

Being informed about possible interventions before labor and thinking about decisions you may have to make ahead of time will make you feel more in control.

The early stage of labor is followed by three distinct stages. Some evidence indicates that in older women who haven’t had a baby before, the first stage of active labor can take longer than that of a younger first time mother. But on the whole, the principles of labor remain the same irrespective of age.

Early Labor

During early labor, which can be short or last for several days, your body readies it self for the main event. You may notice an increase in braxton hicks, or practice, contractions. The muscle cells in your uterus are getting ready to act together to create strong, organized contractions. At the same time, your cervix is remodeling it self from a firm, inflexible protective gate to become softer and more stretchy. You may notice the loss of your mucous plug as the cervix thins out and opens slightly.

When To Go To The Hospital

If your pregnancy is low risk, you are almost certain to be more comfortable at home in early labor. However, yon should call your care provider and go to the hospital immediately if.

• you have regular contractions every, 2-4 minutes that are so strong you cannot talk during them.
• you have vaginal bleeding that is more than just a little pink on the toilet paper.
• you have a gush of fluid from your vagina.
• your baby is not moving.

If your pregnancy is high risk, your baby is not head down, you have had a prior cesarean delivery, or if your baby is growth restricted, you should go to the hospital if you have regular contractions, even if they are not painful.

Getting To The Hospital

Do not drive your self to the hospital if you can possibly avoid it. When you get to the hospital, you will get checked in and the nursing staff will either put you directly in to a labor room if you look like you are in active labor, or in to an assessment bed if they are not sure. A labor nurse will take your vital signs and check your cervix, often a blood specimen will be drawn for routine tests.

If your provider decides that you are staying, you will usually have an intravenous (IV) line inserted. If you are still in early labor, you may be sent home. This does not mean that you were silly to come to the hospital it is important for your care providers to know where you are in the labor process and to make sure your baby is doing well.

Active Labor

Every woman is different and enters active labor at a different point. Traditionally, care providers call labor active when a woman’s cervix is around 4cm dilated. Most women are in considerable pain by the time they enter active labor and are having regular strong contractions every 2-3 minutes. During active labor, your cervix should open at a minimum of 1 cm per hour. If your cervix does not change as much as expected, there are two possible explanations.

• Your contractions are not strong enough.
• Your baby is not coming down the labor canal to place pressure on your cervix and affect change.

Later in active labor, you may feel the urge to push or bear down as the baby’s head starts to descend.

Pushing And Delivery

Your care provider will ask you not to push until your cervix is fully dilated (1ocm) and out of the way. Pushing against a cervix that is not yet fully open can cause tears and bleeding. When your cervix is fully dilated, you can begin to push. Usually your midwife, doula, and your labor nurse will teach you how to do this. In many cases you can feel an urge even with epidural analgesia, if your dose is lightened. There are many different ways to push, including on your back, squatting, on your side, and on your hands and knees. Pushing is hard work, and with a first baby it can take up to 2 hours with out and up to 3 hours with epidural analgesia. Lots of emotional support and cheerleading are key.

Delivering The Placenta

The last stage of labor involves delivering your placenta. The placenta is soft and squishy and easy to deliver compared to a baby. In most cases, the placenta will start to separate from your uterus and be delivered with in 30 minutes of your baby being born. Finally, your care provider will need to repair any tears that happened during the delivery. He or she will also make sure that any bleeding has stopped.

Stages Of Labor

The active stage of labor can be divided in to three distinct stages.

First stage

This is the time when the neck of the uterus or cervix, opens up to let the baby through. It is the longest part of labour particularly in a first pregnancy.

Second stage

The cervix is now fully opened and the baby is moving down the birth canal toward the vagina and the outside world beyond. During the second stage you are pushing your baby out. On average, your second stage is longer during a first delivery than in subsequent ones.

Third stage

The baby is now born, but you still need to deliver the placenta. Your care provider will help by massaging your uterus and placing gentle traction on the umbilical cord. Usually the placenta takes 5-10 minutes to deliver, but the process can take up to 30 minutes.