What to Expect When You’re Expecting…After Age 35

If you're planning to have a baby after age 35, you're in good company. According to national data on US births in 2020, 19% of all babies were born to birthing people aged 35 and older. Additionally, 11% of first-time births happen in this over-35 age group. 

The average age to have kids, whether first, second, or beyond, has been steadily increasing in recent decades. Outdated (and downright cringey!) terms such as "geriatric pregnancy" have perpetuated an unfortunate belief that having a baby after 35 is somehow unhealthy or dangerous. 

In reality, it’s increasingly common for people over 35 to have healthy pregnancies and deliveries. The current medical term for pregnancy after 35 is “pregnancy of advanced maternal age”, but this doesn’t mean that 35+ is “too old” to have a baby! 

Origin’s clinicians are committed to helping their patients prepare for, progress through, and rehab after pregnancies at any age. Let’s dive in and discuss what to expect during an advanced age pregnancy and how you can prepare your body for the process.

What does prenatal care involve in pregnancies of advanced maternal age? 

In response to increasing numbers of people having babies after 35, the medical community has developed clear advanced maternal age pregnancy guidelines. These recommendations, established in collaboration between the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine, help ensure that both you and your baby are getting the assessments and care you need.

Pregnant at age 35-39: what to expect 

If you'll be between ages 35 and 39 at delivery, expect a detailed fetal anatomic ultrasound around 20 weeks of pregnancy. As the name implies, this scan assesses the anatomy of your developing fetus: it can help detect signs of congenital conditions that impact fetal health. 

The risk of certain congenital conditions is higher in pregnancies that occur after 35. Early identification of these conditions can help you and your provider manage your pregnancy appropriately.

Your healthcare provider may also discuss individualized fetal surveillance based on your specific risk factors. Fetal surveillance is specialized monitoring of your baby’s vitals and other metrics: it helps identify signs of fetal distress so your provider can intervene to prevent stillbirth.

Not all pregnancies in this age range require fetal surveillance: your provider will make individualized recommendations for you.

Pregnant at age 40 and up: what to expect

If you'll be 40 or older at delivery, your provider will recommend the same fetal anatomic ultrasound discussed above. You'll likely receive an additional third trimester ultrasound: this exam specifically assesses fetal growth, since pregnancy after 40 increases the risk of fetuses being either smaller or larger than typical.

Fetal surveillance is generally routine in pregnancies to mothers aged 40 and up, since the risk of stillbirth increases with maternal age.

The medical guidelines also recommend delivering the baby during week 39 of pregnancy, as the rates of neonatal complications and stillbirth increase if pregnancy continues past this point in those aged 40+. This may lead your provider to recommend inducing labor if it doesn’t happen on its own during this window.

Deciding how to deliver

Planning for how you’d like to deliver your baby is a deeply personal, sometimes confusing process. Some people wonder if planned cesarean delivery (aka C-section) is somehow better or safer for an advanced age pregnancy. 

Medical research hasn’t shown that C-sections are safer than vaginal birth for mothers in this age group or their babies. Current guidelines recommend that vaginal delivery can be safe and appropriate for many birthing people aged 40+, so age alone should not be the deciding factor. 

You and your care team should determine your delivery plan based on your overall health picture, your baby's needs, and your preferences, not just the number on your birth certificate.

How do pregnancy and age affect the pelvic floor?

Your pelvic floor is a complex network of muscles, connective tissues, nerves, and blood vessels that performs a ton of critical functions. From helping you poop to stabilizing your hips and spine, your pelvic floor rarely gets a rest. Both pregnancy and aging affect this critical system, and when the two factors interact, those effects may be more pronounced.

Even if you don’t currently experience pelvic floor problems, you might be wondering, “How old is too old to have a baby? Will I pay for this decision later?” Let’s consider what the research tells us about the pelvic floor, pregnancy, and age.

What happens to your pelvic floor during pregnancy?

Researchers have identified several specific changes that occur in the pelvis during pregnancy, particularly during someone’s first pregnancy:

• The bladder neck (where your bladder narrows to become the urethra) lowers and becomes more mobile.
• The urethra itself becomes more flexible, with decreased resting tone. (It’s sort of like swapping from a heavy-duty garden hose to a cheap version with thin walls.)
• Your pelvic organs (i.e., your uterus, bladder, etc.) descend lower in the pelvic bowl.
• The levator ani muscles, which make up the back half of your pelvic floor, get weaker.

These changes become more pronounced after the stress of vaginal delivery. All of these shifts can contribute to pelvic floor problems during and after pregnancy.

While cesarean delivery reduces some of these impacts, it doesn't completely prevent the pelvic floor changes that occur during pregnancy itself.

How does the pelvic floor change as we age?

You already know that the body transforms with age, and the pelvic floor muscles are no exception. The pelvic floor changes as we get older, even if we never give birth! 

Researchers have investigated these patterns using tissue samples from cadavers assigned female at birth. The data revealed some important patterns:

• The cross-sectional area of pelvic floor muscles decreases: they become thinner and smaller. Interestingly, this age-related size reduction is more pronounced in the pelvic floor than in other muscles throughout the body.
• The collagen content of pelvic floor muscles dramatically increases with age: this makes the muscles less elastic and more rigid. 
• Older pelvic floor muscles have less ability to generate force: basically, they become weaker and less powerful.

Note that this research compared pelvic floor muscles from donors who died in their early 40s to those who passed in their early 80s. Many of the younger, 40-something donors may have yet to complete the menopause transition, whereas all of the older, 80-something donors would have been postmenopausal for many years. We can’t say for sure how many of these changes were due to the menopause transition versus aging alone.

These cadaver studies also investigated how a history of vaginal birth affects the pelvic floor. The researchers found that several important pelvic floor muscles were lengthened and stretched out in those who’d given birth vaginally. Their pelvic floor muscles couldn’t generate as much force as those who’d never delivered vaginally.

As you might imagine, combining the effects of pregnancy and aging can really challenge the integrity of your pelvic floor! This is why it’s particularly important to stay on top of your pelvic health during an advanced age pregnancy.

How will pregnancy now affect my pelvic floor later in life? 

A large Swedish study followed over 14,000 women into middle age (ages 40 - 64) to understand the long-term interaction between childbirth and aging. The researchers were particularly interested in symptomatic pelvic organ prolapse, a pelvic condition that affects many people with vaginas.

In middle-aged women who had never delivered vaginally, the rate of symptomatic prolapse was the same regardless of their age: whether they were 40 or 60, fewer than 5% experienced prolapse symptoms. This applied to all the women in the group: those who’d never been pregnant, those who’d be pregnant but never delivered, and those who gave birth via C-section.

In contrast, the rate of symptomatic prolapse in those who had given birth vaginally increased four-fold from age 40 (3.8%) to age 64 (13.4%). These researchers concluded that the interaction between vaginal delivery and aging is the most important factor influencing whether you'll experience symptomatic prolapse later in life. 

Don’t panic: this doesn't mean prolapse is inevitable after vaginal delivery. It just highlights why proactive pelvic floor care and postpartum physical therapy are so important, especially if you're delivering at an older age.

How to prepare your body for pregnancy after 35

We get it: all these data about pelvic floor changes and organ descent after birth can feel intimidating. At Origin, we believe in addressing intimidation with information and evidence based-interventions that help.

Let’s consider what the research shows us about improving outcomes for people giving birth after 35.

What can I do now to prepare my pelvic floor for pregnancy?

Begin pelvic floor muscle training asap, even before pregnancy. Like any muscle group, your pelvic floor muscles respond to consistent, proper training. However, effective pelvic floor training involves more than kegels. 

You need to learn proper technique, including strengthening, relaxation, and more. That’s where pelvic floor therapy comes in: even just a visit or two with an Origin clinician may be all you need to get off on the right foot! 

Focus on coordination, not just strength. Your pelvic floor needs to be able to contract when appropriate, but also relax and lengthen. A well-rounded approach to pelvic floor training addresses both aspects. Check out the exercises in this article for some examples. 

Learn (and do!) perineal self-massage. Your pelvic health physical therapist can also teach you the proper way to perform perineal massage. This is a simple technique where you use 1-2 fingers (or a handy tool called a pelvic wand) to self-massage the tissues between the vaginal and anal openings to prepare them for delivery.

Don’t forget about full-body exercise! Your pelvic floor is just one part of your larger body system, all parts of which must prepare for the challenges of pregnancy. A consistent exercise routine that targets your whole body is a crucial component for pregnancy readiness at any age.

Get an individualized assessment. Every body is different, and every pelvic floor has unique strengths and challenges. Working with a pelvic health physical therapist will help you address any existing dysfunction and optimize your baseline pelvic health, no matter your age.

Wondering if pelvic floor preparation during pregnancy really matters? Consider this research: A 2019 study of 400 pregnant women over age 35 compared two groups: an intervention group that learned perineal massage and pelvic floor muscle exercises, and received education about preventing pelvic floor dysfunction. The control group received only the educational component. The results were striking. Compared to the control group, women in the intervention group:

1) Experienced significantly fewer perineal tears. Tears that did occur were mostly first and second degree (minor tears) rather than more severe injuries.

2) Required significantly fewer episiotomies (to surgically cut the pelvic floor muscles).

3) Reported lower levels of postpartum pain. They required less pain medication after birth, and their hospital stays were shorter.

Pelvic floor problems to watch out for

Pregnancy after 35 requires additional monitoring and comes with unique considerations, but increasingly, it's both safe and common. Understanding how age and pregnancy affect your pelvic floor and your overall health puts you in the driver's seat. 

Rather than worrying about what might happen or accepting postpartum problems as unavoidable, you can take specific, evidence-based steps now to prepare and care for your body. The following are just some of the many concerns an Origin provider can help you address:

• Urinary issues of all types (leaking with coughing, sneezing, exercise; sudden urges you can’t control; needing to pee frequently)
• Bowel problems, including constipation or difficulty controlling gas or stool
• Sensations of pelvic heaviness or pressure, or feeling “like there’s something inside” the vagina
• Bulging at your vaginal opening that you can see or touch
• Pain or other problems with sexual activity 
• Any other concerns about pelvic or overall physical function: there are no stupid questions, and there’s no such thing as TMI!

You don't have to accept pelvic floor dysfunction, pain, or other physical issues as the price of choosing pregnancy after 35. With the right support and preparation, you can have a healthy pregnancy and a strong recovery at any age.

Ready to get started on your over-35 pregnancy and postpartum journey? Schedule your first visit with an Origin clinician today! 

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Sources 

Alperin, Marianna et al. “Impact of vaginal parity and aging on the architectural design of pelvic floor muscles.” American journal of obstetrics and gynecology vol. 215,3 (2016): 312.e1-9. doi:10.1016/j.ajog.2016.02.033

Åkervall, Sigvard et al. “Symptomatic pelvic organ prolapse in middle-aged women: a national matched cohort study on the influence of childbirth.” American journal of obstetrics and gynecology vol. 222,4 (2020): 356.e1-356.e14. doi:10.1016/j.ajog.2019.10.007

American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics et al. “Screening for Fetal Chromosomal Abnormalities: ACOG Practice Bulletin, Number 226.” Obstetrics and gynecology vol. 136,4 (2020): e48-e69. doi:10.1097/AOG.0000000000004084

Dieb, Amira S et al. “Perineal massage and training reduce perineal trauma in pregnant women older than 35 years: a randomized controlled trial.” International urogynecology journal vol. 31,3 (2020): 613-619. doi:10.1007/s00192-019-03937-6

Osterman, Michelle J.K. et al. "Births: Final Data for 2020" vol. 70, no. 17, 2022

“Pregnancy at Age 35 Years or Older: ACOG Obstetric Care Consensus No. 11.” Obstetrics and gynecology vol. 140,2 (2022): 348-366. doi:10.1097/AOG.0000000000004873

Umana, Otto D., et al. “Antenatal Fetal Surveillance.” StatPearls, StatPearls Publishing, 11 August 2024.

Van Geelen, Hans et al. “A review of the impact of pregnancy and childbirth on pelvic floor function as assessed by objective measurement techniques.” International urogynecology journal vol. 29,3 (2018): 327-338. doi:10.1007/s00192-017-3540-z