Grand Multiparity and PPH Risk

My midwives started talking about grand multips and hypotonia around about baby number 5. One GP I went to for an unrelated to pregnancy issue nearly died of shock when she found out I was having my 7th child at home! However, it is my personal experience that higher parity does not necessarily mean a hypotonic uterus and PPH risk if giving birth at home. My 7th birth yielded a massive bleed of….50mls.

Andrea Koedijk – koedyk.p@ihug.co.nz
(mum of 9)


I have a client just about to have her sixth baby in 9 years. I have now been with her for four births, all water at home. Last time she had a pph of 1,000 ml but was not clinically affected so did not need admission and made an excellent recovery.

When I come to think about it she had poor 2nd stage contractions and I think the baby was a bit asynclitic as well which I feel was the reason for the relaxed uterus after delivery. She has always requested a managed 3rd stage, which she had that time, but it didn’t prevent her pph.

Elaine, midwife


I have attended many, many grand , and great grand multips, and with the proper nutritional support I rarely see PPH in these women.

sherri, midwife


Does haemorrhage risk increase when you have had several previous births?

This seems to be generally accepted, but it’s hard to find any stats quantifying exactly how much the risk increases. Uterine atony, ie ‘flabby uterus’, means that the uterus doesn’t contract well after the birth – and it’s the contracting down that stops bleeding, as the ‘living ligatures’ of criss-cross muscle fibres in the uterus seal off the ends of blood vessels. Uterine atony is said to be more likely the more children you have. I hope the ‘real midwives’ on the list will be able to tell you more.

I wonder if some of the correlation could be connected to other factors, too – for example, in studies of women who have had a large number of children, the mothers may be in generally poor health. It probably is affected by the spacing of the children too. The fact that you have no history of high blood loss has to be in your favour.

Something else to think about – one very scary cause of major PPH is placenta accreta, where the placenta embeds very deeply into the uterus and cannot separate properly. This is rare, but more common amongst women who have had a past caesarean than among those who have not. The inclusion of women with past caesareans (and who by definition have already given birth at least once before) in studies of chances of PPH could skew the statistics slightly, in terms of making major PPH seem more likely in multigravidas. Probably not highly significant, but it’s an example of how studies which treat all women expecting their fourth baby as ‘higher risk’ could be inaccurate.


I’ve been looking for research on additional risks and benefits of grand multiparity, ie pregnancy 5 +, and on the way have found a few studies which discuss whether the risk of haemorrhage increases with parity or not.

Grand multiparity (definitions vary according to study but most are looking at 6th pregnancy +) was *not* associated with increased risk of postpartum haemorrhage in several studies [4:Israel, 5:Nigeria, 6:Zimbabwe], but did appear to be in others [2,3: Saudi Arabia, 1:USA].

Here are some abstracts from Medline:

[1]: Perinatal outcome in grand and great-grand multiparity: effects of parity on obstetric risk factors.

AUTHORS: Babinszki A; Kerenyi T; Torok O; Grazi V; Lapinski RH; Berkowitz RL
AUTHOR AFFILIATION: Division of Maternal-Fetal Medicine, Department of Obstetrics, Sinai School of Medicine, New York, NY, USA.
SOURCE: Am J Obstet Gynecol 1999 Sep;181(3):669-74
CITATION IDS: PMID: 10486482 UI: 99417457

ABSTRACT: OBJECTIVE: We sought to compare obstetric and neonatal complications among great-grand multiparous, grand multiparous, and multiparous women.

STUDY DESIGN: One hundred thirty-three great-grand multiparas, 314 grand multiparas, and 2195 multiparas who were delivered of their infants between 1988 and 1998 were selected for the study. To facilitate comparison, the patients were all >35 years old and had similar socioeconomic characteristics.

RESULTS: The incidence of malpresentation at the time of delivery, maternal obesity, anemia, preterm delivery, and meconium-stained amniotic fluid increased with higher parity, whereas the rate of excessive weight gain and cesarean delivery decreased. Compared with grand multiparas, great-grand multiparas had significantly elevated risks for abnormal amounts of amniotic fluid, abruptio placentae, neonatal tachypnea, and malformations but lower rates of placenta previa (P < .05). The incidence of postpartum hemorrhage, preeclampsia, placenta previa, macrosomia, postdate pregnancy, and low Apgar scores was significantly higher in grand multiparas than in multiparas, whereas the proportion of induction, forceps delivery, and total labor complications was significantly lower than in the multiparous group (P < .05). Similar frequency of maternal diabetes, infection, uterine wall scar rupture, variations in fetal heart rate, fetal death, and neonatal mortality was found in the 3 groups.

CONCLUSION: Both high-parity groups have their own risk factors, but the rate of some complications decreases with higher parity. In addition, perinatal mortality remains low in these patients, and therefore, under satisfactory socioeconomic and health care conditions, high parity should not be considered dangerous.

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[2]: The grand multipara in modern obstetrics.

AUTHORS: Evaldson GR
AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, Huddinge University Hospital, Karolinska Institutet, Stockholm, Sweden.
SOURCE: Gynecol Obstet Invest 1990;30(4):217-23
CITATION IDS: PMID: 2289702 UI: 91146952

ABSTRACT: From April 1985 to March 1986, 1,252 women were admitted for delivery at the Al Hada Armed Forces Hospital, Taif, Saudi Arabia. Of these, 224 (17.9%) were grand multiparas (GM) defined as mothers of parity greater than or equal to 6. History, labor and delivery as well as postpartum and neonatal courses were recorded using computerized records for later statistical calculations. The obstetric and perinatal outcome was calculated comparing the GMs to para-1 mothers and para-2-5 patients (P2-5), respectively. The latter group being empirically considered as the ‘ideal’ patient group. On comparing the GM group to that of P2-5, significantly higher frequencies of intercurrent diseases, especially diabetes mellitus and gestational diabetes, were found. Among GMs, transverse lie, primary uterine inertia, fetal heart rate abnormalities, failure to progress and postpartum hemorrhage were encountered significantly more often than in the other groups. The incidence of placenta previa was likewise significantly increased among the GMs as was the number of cesarean sections, particularly those of the primary emergency type. There was no maternal mortality. The perinatal morbidity was significantly higher in the GM group. However, no significant difference in perinatal mortality was found between the groups. It is concluded that with few exceptions the GM can be safely delivered by means of modern obstetric management.

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[3]: The problem of grandmultiparity in current obstetric practice.

AUTHORS: Mwambingu FT; Al Meshari AA; Akiel A
AUTHOR AFFILIATION: Department of Obstetrics and Gynaecology, King Abdul Aziz University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
SOURCE: Int J Gynaecol Obstet 1988 Jun;26(3):355-9
CITATION IDS: PMID: 2900162 UI: 88297001

ABSTRACT: A retrospective analysis of 646 Arab grandmultiparas who booked for hospital confinement between 1983 and 1985 was carried out. The results were compared with that of non-grandmultiparas during the same period. In the grandmultiparas, the incidences of gestational diabetes, hypertension rheumatic heart disease, antepartum, postpartum hemorrhage and macrosomic infants were increased. However, contrary to some previous reports the incidences of anemia, cesarean sections, induced labor, dysmaturity and perinatal deaths were decreased. This is thought to be due to the provision of modern specialist perinatal care and improved socioeconomic standards.

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[4]: The grandmultipara: is she still a risk?

AUTHORS: Eidelman AI; Kamar R; Schimmel MS; Bar-On E
AUTHOR AFFILIATION: Department of Pediatrics, Albert Einstein College of Medicine, Yeshiva University, Bronx, New York.
SOURCE: Am J Obstet Gynecol 1988 Feb;158(2):389-92
CITATION IDS: PMID: 3341414 UI: 88131188

ABSTRACT: Grandmultiparity is reported to increase both maternal and perinatal mortality and morbidity. Unique religious and demographic factors in Jerusalem allowed us to analyze a population wherein parity could be dissociated from socioeconomic status. A total of 7785 mothers was studied, 889 (11.5%) of whom were grandmultiparas. Comparison of grandmultiparous mothers with all others revealed no increase in the incidence of hypertension, diabetes, uterine atonia, antenatal or postnatal hemorrhage, cesarean sections, stillbirth rate, or congenital malformations. The grandmultipara had significantly lower neonatal mortality and low birth weight rates and a significantly higher incidence of multiple births and trisomy 21 (p less than 0.01). These results strongly suggest that grandmultiparity in and of itself in a healthy, economically stable population afforded modern medical care is not a major risk factor and that previous reports primarily reflected social class factors and not parity per se.

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[5]: Risk factors for primary postpartum haemorrhage. A case control study.

AUTHORS: Selo-Ojeme DO; Okonofua FE AUTHOR AFFILIATION: Department of Obstetrics and Gynaecology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria. SOURCE: Arch Gynecol Obstet 1997;259(4):179-87 CITATION IDS: PMID: 9271837 UI: 97417779

ABSTRACT: The objective of the study was to determine which background factors predispose women to primary postpartum haemorrhage (PPH) at the Obafemi Awolowo University Hospital. The study consisted of 101 women who developed PPH after a normal vaginal delivery and 107 women with normal unassisted vaginal delivery without PPH Both cases and controls were investigated for sociodemographic risk factors, medical and obstetric histories, antenatal events and labour and delivery outcomes. Data were abstracted from the medical and delivery records and risks were estimated by multivariate logistic regression.

The results of the univariate analysis revealed a number of potential risk factors for PPH but after adjustment by logistic regression three factors remained significant. These were prolonged second and third stages of labour and non-use of oxytocics after vaginal delivery. Previously hypothesised risk factors for PPH such as grand multiparity, primigravidity and previous episodes of PPH were not significantly associated with PPH.

We conclude that primary PPH in this population is mostly associated with prolonged second and third stages of labour and non use of oxytocics. Efforts to reduce the incidence of PPH should not only be directed at proper management of labour but also training and retraining of primary health care workers and alternative health care providers in the early referral of patients with prolonged labour.

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[6]: Postpartum haemorrhage in Zimbabwe: a risk factor analysis

AUTHORS: Tsu VD
SOURCE: Br J Obstet Gynaecol 1993 Apr;100(4):327-33
CITATION IDS: PMID: 8494833 UI: 93264355
COMMENT: Comment in: Br J Obstet Gynaecol 1993 Dec;100(12):1152

ABSTRACT: OBJECTIVES: To identify risk factors associated with postpartum haemorrhage (PPH) in order to improve the effectiveness of antenatal screening.

DESIGN: A population-based case control study. SETTING: Harare, Zimbabwe

SUBJECTS: Two groups of women, one group consisting of those with postpartum haemorrhage after a normal vaginal delivery and the other of women with normal unassisted vaginal delivery without PPH. METHOD: Data abstracted from the medical records; relative risks were estimated by multivariate logistic regression.

RESULTS: Low parity, advanced maternal age, and antenatal hospitalisation were among the strongest risk factors, with more modest associations for history of poor maternal or perinatal outcomes and borderline anaemia at the time of booking. No association with grand multiparity was found.

CONCLUSIONS: These findings confirm the importance of previously recognised factors such as low parity, poor obstetric history, anaemia, and prolonged labour, but call into question the significance of grand multiparity. Previously undocumented factors such as maternal age greater than 35 years and occiput posterior head position emerged as predictors worthy of further investigation.



See also: Grand Multiparas and Home Birth, on www.homebirth.org.uk

 

AH updated 19 January 2001

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