Obstetric complications in grand and great grand multiparous women

Objective.?To investigate pregnancy and labour outcomes in grand and great grand multiparous women.

Study design.?A retrospective population-based study was conducted between the years 1988 and 2007. Parturients were classified into three groups: multiparous; 2–5 deliveries, grand multiparous; 6–9 deliveries, and great grand multiparous; 10+?deliveries. Stratified analyses included multiple logistic regression models.

Results.?A significant linear association was found between parity and adverse maternal and perinatal outcomes such as malpresentation, labour dystocia, caesarean delivery, postpartum haemorrhage, maternal anaemia (HB<10), congenital malformations and perinatal mortality. Using multivariable logistic regression models, grand multiparity was found an independent risk factor for labour dystocia, first stage (OR?=?1.5, P?<?0.001), and perinatal mortality (OR?=?2.0, P?<?0.001). Great grand multiparity was found an independent risk factor for labour dystocia, first stage (OR?=?2.6, P?<?0.001), labour dystocia, second stage (OR?=?2.1, P?<?0.001), and perinatal mortality (OR?=?2.5, P?<?0.001).

Conclusion.?Women with high birth order are at increased risk for adverse obstetric outcomes. The risk is higher for great grand multiparous women compared to grand multiparous women. Grand and great grand multiparity are independent risk factors for labour dystocia and perinatal mortality.     

Parity and pregnancy outcomes

OBJECTIVE: The issue of parity and risk of pregnancy outcomes has been controversial for many decades. We conducted a study to evaluate the association between parity and pregnancy outcomes and to clarify the basis of the classification of risk based on parity. STUDY DESIGN: The study is a cross-sectional analysis on a large routinely collected data set of singleton births from 1992 to 1997 in New South Wales, Australia. Pregnancy outcomes were compared among parity groups. RESULTS: There was a significant association between different parity levels and pregnancy outcomes in terms of obstetric complications, neonatal morbidity, and perinatal mortality, after adjustment for potential confounders, including age, maternal smoking status, and socioeconomic status. In terms of obstetric complications, neonatal morbidity, and perinatal mortality, subjects can be classified into 3 groups according to parity: nulliparity, low multiparity (parity 1, 2, and 3), and grand multipara (parity 4 to 8). Compared with low multiparity, mothers and babies of nulliparity and grand multipara are at higher risk. CONCLUSIONS: This study supported the definition of grand multiparity that should start from parity 4 or the 5th baby. Attention should be paid to subjects of nulliparity and grand multiparity for their different problems.     

Does practice make perfect? An age-matched study on grand multiparity in Flanders, Belgium

AIM: To compare the perinatal outcome of grand multi-parous women (giving birth for the fifth to ninth time) and pauciparous (parity 2 to 4) women in the region of Flanders, Belgium. METHODS: Population-based, retrospective, age-matched study. RESULTS: 2832 grand multiparous women were compared with 2832 pauciparous women. In univariate analysis grand multiparous women showed more transverse lie, macrosomia, and fetal death and had less frequently epidural analgesia and episiotomy. Logistic regression demonstrated that grand multiparity was a significant factor contributing to fetal death and macrosomia. CONCLUSION: Grand multiparity is associated with fetal death and macrosomia in the region of Flanders, Belgium.     

Randomized Controlled Trial of Hands‐and‐Knees Positioning for Occipitoposterior Position in Labor

ABSTRACT: Background: Hands‐and‐knees positioning during labor has been recommended on the theory that gravity and buoyancy may promote fetal head rotation to the anterior position and reduce persistent back pain. A Cochrane review found insufficient evidence to support the effectiveness of this intervention during labor. The purpose of this study was to evaluate the effect of maternal hands‐and‐knees positioning on fetal head rotation from occipitoposterior to occipitoanterior position, persistent back pain, and other perinatal outcomes. Methods: Thirteen labor units in university‐affiliated hospitals participated in this multicenter randomized, controlled trial. Study participants were 147 women laboring with a fetus at ≥37 weeks’ gestation and confirmed by ultrasound to be in occipitoposterior position. Seventy women were randomized to the intervention group (hands‐and‐knees positioning for at least 30 minutes over a 1‐hour period during labor) and 77 to the control group (no hands‐and‐knees positioning). The primary outcome was occipitoanterior position determined by ultrasound following the 1‐hour study period and the secondary outcome was persistent back pain. Other outcomes included operative delivery, fetal head position at delivery, perineal trauma, Apgar scores, length of labor, and women's views with respect to positioning. Results: Women randomized to the intervention group had significant reductions in persistent back pain. Eleven women (16%) allocated to use hands‐and‐knees positioning had fetal heads in occipitoanterior position following the 1‐hour study period compared with 5 (7%) in the control group (relative risk 2.4; 95% CI 0.88–6.62; number needed to treat 11). Trends toward benefit for the intervention group were seen for several other outcomes, including operative delivery, fetal head position at delivery, 1‐minute Apgar scores, and time to delivery. Conclusions: Maternal hands‐and‐knees positioning during labor with a fetus in occipitoposterior position reduces persistent back pain and is acceptable to laboring women. Given this evidence, hands‐and‐knees positioning should be offered to women laboring with a fetus in occipitoposterior position in the first stage of labor to reduce persistent back pain. Although this study demonstrates trends toward improved birth outcomes, further trials are needed to determine if hands‐and‐knees positioning promotes fetal head rotation to occipitoanterior and reduces operative delivery. (BIRTH 32:4 December 2005)     

Body Image,Maternal‐Fetal Attachment,and Choice of Infant Feeding Method: A Study in Taiwan

Abstract: Background : Many factors contribute to a pregnant woman's choice of infant feeding method, yet few studies have investigated which factors might be specific to pregnant women in Taiwan. The purpose of this study was to explore the relationships among factors of body image, maternal‐fetal attachment, and the choices made by pregnant Taiwanese women about infant feeding method. Methods : One hundred and ninety‐five pregnant women were recruited during their third trimester at five hospitals in Kaohsiung, Taiwan. Participants completed three questionnaires, including a demographic data form, an attitude to body image scale, and a modified maternal‐fetal attachment scale. Results : The results of stepwise logistic regression indicated that the best subset for predicting the criterion variable of breastfeeding intention included higher level of education, primiparity, and a higher level of maternal‐fetal attachment. Conclusions : Maternal‐fetal attachment, education, and parity are predictive of intended infant feeding method by pregnant women who choose breastfeeding, thereby adding to existing knowledge of the factors involved in feeding method choices of Taiwanese women. Further research should incorporate maternal‐fetal attachment into a supportive model of breastfeeding.     

Effect of grand multiparity on intrapartum and newborn complications in young women

OBJECTIVE: To examine the effect of high parity on complications in young women, aged 18-34 years. METHODS: Seven years of Utah birth certificate data were reviewed (1995-2001). Young nulliparas and primiparas were compared with young grand and great grand multi-paras by using logistic regression. Young grand multiparas were compared with older grand multiparas. RESULTS: Young grand multiparas were more likely to have a preterm delivery and less likely to experience fetal distress, instrumented delivery, cesarean delivery, and any intrapartum complication than young nulliparas or primiparas. Young grand multiparas were less likely to experience many complications than their older counterparts. CONCLUSION: Among young women, grand and great grand multiparity does not increase the risk for most intrapartum and newborn complications. Young grand and great grand multiparas are at significantly decreased risk for many complications when compared with young women of lower parity and older grand and great grand multiparas. LEVEL OF EVIDENCE: II-2.     

Trends in the Occurrence of Antenatal and Perinatal Complications with Increasing Parity

Purpose

In modern days, grand multiparity is confined to communities where contraception is not practiced because of social and religious beliefs. For this reason, it is quite prevalent in all GCC countries. Few studies have compared the outcomes between the three groups: low parity (2–4), grand multiparity (5–9), and great grand multiparity (10 and more) . This study intended to analyze the trends in the occurrence of various perinatal complications across these three groups.

Methods

This historical cohort study was conducted in Mafraq Hospital, Abu Dhabi between January 1, 2009 and December 31, 2011. There were 1,658 multipara, 1,198 grand multipara, and 160 great grand multipara.

Results

Different complications revealed different trends with increasing parity. Many antenatal and intrapartum complications like diabetes (overt and gestational), anemia, preterm delivery, malpresentation at term, postpartum hemorrhage, and macrosomia showed a linear increase with increasing parity, while some, like the need for labor augmentation and soft tissue injuries showed a declining trend with increasing parity. Interestingly, some complications like placenta praevia, need for induction of labor, cesarean delivery, and post-term delivery followed an inverted V curve, showing an increase in their occurrence up to parity nine but a decline thereafter with further increasing parity of ten or beyond.

Conclusion

Women in different parity groups were at risk of different complications. There are some complications which decrease with increasing parity, and perinatal mortality remains very low suggesting that in modern settings, with favorable socioeconomic conditions and access to high-quality healthcare, a satisfactory perinatal outcome can be expected with low morbidity and mortality.     

Great grand multiparity: is it a risk?

We wished to compare antenatal and intrapartum complications among women delivering for the 10th or subsequent time and to compare them with women of lower parity (para 2-5). The records of 154 women of great grand parity (para >/= 10) were reviewed and compared with 308 women (para 2-5) delivered during the same period. Antepartum as well as intrapartum complications were compared. All the women delivered between 16 April 1994 and 15 January 1995. Great grand multiparous women were, not surprisingly, older. The incidence of diabetes millitus, chronic hypertension, preterm labour are similar to those with low parity while they have higher incidence of pre-eclampsia (7.1% vs. 2.6%) and intrauterine fetal death (5.2 vs. 1.3%) P < 0.04. There were no differences in the incidence of placental abruption, placenta previa, malpresentation and postpartum haemorrhage between the two groups. Great grand multipara had a higher incidence of macrosomia (7% vs. 2%) and operative delivery (20.6% vs. 11.4%) P < 0.02. Great grand multiparous woman are at some increased risk of having severe pre-eclampsia, intrauterine fetal death macrosomia and subsequently operative delivery with its associated risk of maternal mortality and morbidity.     

A comparison of induction with vaginal prostaglandin E<Subscript>2</Subscript> versus spontaneous of labor in grand multiparous women

Objective: To compare the outcome of labor in grand multiparous women (para 6 or more) who had induction of labor with vaginal prostaglandin E₂with grand multiparous women in spontaneous labor. Methods: A retrospective case-control study was performed, 202 grand multiparous women were induced labor with vaginal prostaglandin E₂ and compared with outcomes with grand multiparous women who entered in spontaneous labor and delivered during the same study period and served as control group. Results: There were no statistically significant differences in the duration of labor, fetal birth weight, use of oxytocin augmentation, and Apgar scores in the two groups. Fourteen women (6.9%) in the induction group delivered by cesarean section compared to six woman (3.0%) in the control group. This was a statistically significant difference (P=0.01). In the induction group, the mean duration of the hospital stay was longer (P=0.003) and there was one neonatal fetal death and one uterus rupture. Conclusion: Induction of labor with vaginal prostaglandin E₂ in grand multiparous women is still relatively safe.     

The grand multipara — still an obstetrical challenge?

Summary To study whether grand multiparity (parity of 6 or more) still carries risk, we studied two birth cohorts in northern Finland: the first comprised 12231 births to 12068 mothers in 1966 and the second comprised 9478 births to 9362 mothers in 1985/86. The percentage of grand multipara decreased from 7.7 to 4.0. The grand multipara made fewer antenatal visits than the others. The proportion of grand multipara referred to maternity outpatient clinics of hospitals was smaller, but the mean number of visits was higher than of lower parity women. The mean number of admissions to hospital was similar in both groups but grand multipara stayed longer in hospital, smoked less (4.3% vs. 22.7%) and had a higher incidence of essential hypertension than women of lower parity. The grand multipara had fewer caesarean sections (7.5% vs. 14.1%) and vacuum extractions (0.5% vs. 5.1%) but more inductions of labour (33.1% vs. 23.%) than mothers of lower parity. The number of low birth weight (LBW) infants (<2500 grams), stillbirths and neonatal deaths (before 28 days) was significantly lower in 1985/86 than in 1966 in women of lower parity but there was no such change in grand multipara. However, the percentage of LBW infants was smaller among grand multipara than among women of lower parity in both cohorts (2.7% vs. 4.1%, NS). The stillbirth plus neonatal death rate in grand multipara was higher than in women of lower parity (1.9% vs. 0.9%,P<0.05) partly because of a higher incidence of major congenital anomalies.     

Fetal macrosomia--maternal risks and fetal outcome

Two hundred eighty-four macrosomic babies of 4000 g or over at birth were compared with an equal number of appropriate weight term infants, to identify maternal risk factors and fetal outcome. Maternal obesity, grand multiparity, diabetes mellitus and postmaturity were the major maternal risks. Prolonged labor, shoulder dystocia and injury to infant following instrumental delivery for mid-cavity arrest were the major fetal risks. A protocol for management of fetal macrosomia is proposed.     

The Relationship of Maternal Personality Characteristics to Birth Outcomes and Infant Development

Background: Previous studies reported an association between maternal psychological factors and adverse pregnancy outcomes. The objective of this study was to evaluate the relationships between maternal personality characteristics, as determined by the Minnesota Multiphasic Personality Inventory (MMPI), and infant birth outcomes and development. Method: The inventory was administered during pregnancy to 638 pregnant women enrolled in a staff model health maintenance organization. MMPI validity as well as clinical and research scales were evaluated in relationship to infant birth outcomes (low birthweight, preterm birth) and 15‐month‐old infant development as assessed by the Bayley Scales of Infant Development. Results: Mothers of low birthweight infants scored significantly lower on the hypochondriasis scale, a relationship which was no longer significant after controlling for ethnicity. No other relationships were observed between infant birth outcomes and maternal MMPI scale scores. A higher infant Mental Developmental Index (MDI) was related to higher maternal masculinity‐femininity and ego‐strength scale scores and lower lie and hypochondriasis scale scores. Only the relationship between infant MDI and maternal masculinity‐femininity scale score remained significant after controlling for ethnicity and socioeconomic index (β= 0.104, p =0.036). Conclusions: Maternal personality characteristics, as determined by the MMPI, did not appear to be significantly related to the occurrence of preterm birth or low birthweight in this healthy, general population. Maternal personality characteristics reflected in the MMPI masculinity‐femininity scale appeared to be related to infant mental development, above and beyond the effects of socioeconomic status and ethnicity.     

Pregnancy outcomes according to increasing maternal age

ObjectivesTo investigate the risks of increasing maternal age on the perinatal and obstetric outcomes.Materials and MethodsInformation about 29,760 singleton pregnancies delivered between 2005 and 2008 was extracted from our database. Patients were categorized into four groups according to age: 20–29 years, 30–34 years, 35–39 years, and ≥40 years. Multivariable logistic regression analysis was used to evaluate the adjusted odd ratios (AORs) of adverse pregnancy outcomes according to maternal age after adjusting for parity, body mass index, medical history and use of in vitro fertilization.ResultsThe majority of adverse perinatal outcomes were associated with a maternal age ≥35 years as follows: low birth weight (AOR 1.2 and 1.6 for women aged 35–39 years and ≥40 years, respectively); Apgar score < 7 at 1 minute (AOR: 1.7 and 1.8); and chromosomal anomaly (AOR: 2.7 and 12.3). However, women aged ≥30 years also had greater risks for adverse maternal outcomes such as: gestational diabetes (AOR: 2.0, 3.6 and 5.1 for women aged 30–34 years, 35–39 years and ≥40 years, respectively); placenta previa (AOR: 1.6, 2.1 and 3.6); and cesarean delivery (AOR: 1.5, 2.3, and 4.1), as well as adverse fetal outcomes such as: preterm delivery (AOR: 1.2, 1.4 and 1.8) and neonatal intensive care unit transfer (AOR: 1.1, 1.2, and 1.6).ConclusionIncreasing maternal age is an independent and substantial risk factor for adverse perinatal and obstetric outcomes. These adverse outcomes become more common as increasing maternal age without a clear cutoff age.     

Outcomes of multiple gestations with advanced maternal age

Objective.?To investigate outcomes of twin gestations with advanced maternal age (AMA).

Study design.?Historical cohort of twin gestations cared for by a maternal–fetal medicine faculty practice. Outcomes of patients with AMA (70) and non-AMA (75) were compared. AMA was defined as age ≥35. Analysis including mode of delivery, gestational age at delivery and overall complications was performed. Significance was determined using the chi-square test or the Student's t-test.

Results.?The Cesarean rate for AMA was significantly greater compared to non-AMA (80.0% vs. 54.7%; p = 0.001). The main reason for the increased rate was uterine dysfunction. The mean gestational age at delivery for AMA was significantly greater than for non-AMA (36.7 weeks vs. 35.4 weeks; p = 0.02). There were no differences in rates of other adverse outcomes including gestational hypertension, pre-eclampsia, gestational diabetes, suspected fetal growth restriction, preterm birth, low birth weight or low birth weight percentiles. This remained true when we compared the 32 women ages ≥40 years to 118 women ages <40 years.

Conclusion.?Among twin pregnancies, AMA women are not at an increased risk of adverse pregnancy outcomes, aside from an increased rate of cesarean delivery.     

Parity-related prevalence of rhesus antigens among Mozambican parturients.

The potential risk of rhesus alloimmunization and the ensuing risk of fetal death with increasing parity were investigated in two groups of parturients; primiparous and grand multiparous (para > or = 5) women with liveborns. It was hypothesized that significantly fewer women of the latter than of the former group would be rhesus negative, since grand multiparity would be expected to be associated with an increased risk of late fetal death in rhesus-negative parturients. Primiparous (n = 390) and grand multiparous (n = 755) parturients with liveborns were studied in order to identify D- and Du-negative individuals. Sixteen out of 390 primiparas (4.10%) and 28/755 (3.71%) grand multiparas were D and Du negative. The difference did not reach statistical significance. It appears that being a D- and Du-negative grand multiparous parturient, in the absence of anti-D prophylaxis, is not a significant reproductive disadvantage to being primipara in terms of an increased risk of having stillborn babies.     

Reduced fetal movement: factors affecting maternal perception

Objective: Evaluate physiologic factors associated with reduced maternal perception of fetal movements (RFM).

Methods: A historical cohort study of all women (years 2011–2013, n?=?399) that visited the maternal emergency room (ER) (gestational age 24?+?0–42?+?0) due to RFM (group A), that was compared to a control group consisted from women with normal perception of fetal movements (group B). Groups were compared for maternal characteristics (age, gravity, parity, BMI), gestational age, placental location, gestational age at birth and fetal outcomes (birth-weight and Apgar scores).

Results: In a multivariate regression analysis, including maternal age, height, weight, BMI, gestational age on admission to ER, gravity, parity and placental location, only two variables remained significantly associated with RFM – nulliparity (OR?=?2.28, p?=?0.001) and anterior placenta (OR?=?1.44, p?=?0.034). Group A was not associated with lower Apgar scores (1 and 5-min, p?=?0.40 and 0.57, respectively) or low birth-weight (p?=?0.76), nor was it associated with prematurity (p?=?0.41), low (<7) 5-min Apgar score, fetal death or neonatal death.

Conclusions: Reduced fetal movements are associated with anterior placenta and nulliparity.     

The association between maternal height and pregnancy outcomes in twin gestations

Objective: We sought to assess the association between maternal height and the risk of preterm birth, fetal growth restriction and mode of delivery in twin gestations.

Study design: Cohort study of patients with twin pregnancies delivered from 2005 to 2014. We compared pregnancy outcomes between patients of short stature?≤159?cm to those of normal stature?≥160?cm. Patients with monoamniotic twins and major fetal anomalies were excluded. Pearson’s correlation, Chi-square and Student’s t-test were used as appropriate.

Results: Six hundred and sixty-six patients were included, 159 (23.9%) of whom had short stature (mean height 155.8?±?2.5?cm) and 507 (76.1%) of whom had normal stature (mean height 167.2?±?5.5?cm). There were no differences in outcomes between the groups in regards to preterm birth, gestational age (GA) at delivery, birth weight of either twin, preeclampsia, gestational diabetes or cesarean section rate. Results were similar when the groups were stratified by parity. As a continuous variable, maternal height did not correlate with GA at delivery (p=?0.388), cesarean delivery (p?=?0.522) nor the birth weight of the larger (p?=?0.206) or smaller (p?=?0.307) twin.

Conclusion: In twin pregnancies, maternal short stature is not associated with preterm birth, fetal growth restriction or cesarean section rate. This suggests that although anthropometric measurements have long been used to counsel patients in regards to outcomes, patients of short stature should be reassured that their height does not appear to lead to adverse twin pregnancy outcomes.     

Obstetric outcome in grand multipara in the United Arab Emirates

Objective: To compare the obstetric outcome in grand multiparous and low parous United Arab Emirates women. Method: The records of 418 grand multiparous women (study group), defined as having had given birth at least 5 times after completed 22 weeks gesta- tional age, and 418 women of parity 2–4 (control group) were reviewed. Results: Mean parity in the study group was 7.9±2.4. The number of subjects who attended for antenatal care and the number of visits were equal in both groups. Diabetes mellitus (both overt and gestational) was significantly more common in the study group (p<0.0001) but there was no significant increase in the incidence of other obstetric complications nor in perinatal mortality rate. Babies of grand multiparous mothers required significantly more admissions to special care unit because of maternal diabetes mellitus (p<0.0002). Conclusion: Diabetes mellitus was more common in grand multiparous United Arab Emirates women but the incidence of other obstetric complications was similar to lower parity women. Received: 20 January 2000 / Accepted: 26 June 2000     

Factors Related to Genital Tract Trauma in Normal Spontaneous Vaginal Births

Abstract: Objective: Episiotomy rates are declining in the United States. In settings with very low rates, evidence remains sparse on how best to facilitate birth without lacerations. The purpose of this investigation was to identify maternal and clinical factors related to genital tract trauma in normal, spontaneous vaginal births. Methods: Data from a randomized clinical trial of perineal management techniques were used to address the study objective. Healthy women had spontaneous births with certified nurse‐midwives in a medical center setting. Proportions of maternal characteristics and intrapartum variables were compared in women who did and did not sustain sufficient trauma to warrant suturing, according to parity (first vaginal births versus others). Logistic regression using a backward elimination strategy was used to identify predictors of obstetric trauma. Results : In women who had a first vaginal birth, risk factors for trauma were maternal education of high school or beyond, Valsalva pushing, and infant birthweight. Risk factors in women having a second or higher vaginal birth were prior sutured trauma and infant birthweight. For all mothers, delivery of the infant's head between contractions was associated with reduced trauma to the genital tract. Conclusions: Delivery technique that is unrushed and controlled may help reduce obstetric trauma in normal, spontaneous vaginal births. (BIRTH 33:2 June 2006)     

Maternal perception of fetal movement type: the effect of gestational age and maternal factors

Objective: To assess maternal perception of fetal movement types and its association with maternal factors in normal pregnancies with good pregnancy outcome.

Methods: This study was conducted on 729 normotensive singleton pregnant women with good pregnancy outcome who had referred for prenatal visit. After completing a questionnaire, the participants were asked to count fetal movements for 1?h/3 times/day. They were also asked to identify the type of fetal movement: general body movement (GBM) (rolling and stretching/strong), isolated limb movement (ILM; simple flutter or kicks/weak), trunk movement (TM) (strong jab, startle/strong), or hiccup movement (HM) (high frequency and rapid/weak). All the participants were followed till delivery to exclude pregnant women with preterm birth and/or small for gestational age from the study.

Results: 90.8% of participants perceived GBM, which was independently associated with maternal unemployment (OR?=?2.28, 95% CI?=?1.18–4.4). 74.2% of participants perceived TM, which was associated with multiparity (OR?=?1.69, 95% CI?=?1.18–2.4). 86.3% perceived ILM, which was independently associated with maternal unemployment (OR?=?2.67, 95% CI?=?1.53–4.68), lower gestational age (OR?=?2.17, 95% CI?=?1.28–3.67), perception of fetal movements at night (OR?=?2.05, 95% CI?=?1.27–3.32), and multiparity (OR?=?1.68, 95% CI?=?1.04–2.72). 36.6% perceived HM, which was independently associated with higher gestational age (OR?=?1.71, 95% CI?=?1.2–2.44).

Conclusions: Most pregnant women could discriminate changes in fetal movement type that follow a general pattern through the third gestational trimester, however this can be affected by maternal employment, parity and time of perception.