Int. J. GJsrzaecol. Ohstet.. 1986, 24: 435-438 [ntcrnational I‘ederation of Gynaecology & Obstetric5
OBSERVATIONS ON SOME PATIENTS HOSPITAL IN SAUDI ARABIA
435
OF HIGH PARITY
DELIVERING
IN A GENERAL
A.A. OPANEYI-: Department (Received (Accepted
o,f Obstetrics and Qwaecolog_v, King’s Hospital, Al-Kharj (Saudi Arabia) March 19th. 1986) July 3rd. 1986)
Abstract Opaneye AA (Department of Obstetrics and Gynaecology, King’s Hospital, Al-Kharj, Saudi Arabia). Observations on some patients of high parity delivering in a general hospital in Saudi Arabia. Int J Gynaecol Obstct 24: 435-438, 1986 In a prospective study 100 consecutive Saudi patients having their tenth or subsequen t deliveries in a general hospital were observed. Unlike in some other reports Il.81 fetal malpresentations, maternal anaemia or hypertension were few. However there was a high incidence of uterine inertia and primary cesarean sections. Early perinatal mortality rate was 50 per 1000. High parity is still a hazard to both mother and baby. Health education and family planning should be improved. Keywords: Hospital.
High parity; Saudi Arabia; General
Introduction A woman having her sixth or subsequent delivery [ I] is regarded as a grandmultipara. High parity is a frequent occurrence in Saudi Arabia [ 391. Al-Kharj is a town in the central zone of Saudi Arabia and it is located 80 km south of Riyadh, the capital of the country. Our maternity hospital serves the town and sur0020s7292/86/SO3.50 0 1986 International Federation Published and Printed in Ireland
rounding villages. Most of the population are Arabs and 75% of the deliveries are to Saudi patients, many of whom are of low socioeconomic background. Six per cent of the deliveries in our hospital are to patients having their 10th or subsequent children. This study was done to see how these grandmultipara and their infants survive labor and delivery. Patients and methods One-hundred consecutive Saudi women admitted in labor for their 10th or subsequent deliveries after 28 completed weeks of pregnancy were recruited to the study. During the period of study April 1-November 30, 1985, there were 161 1 women delivered in the department. On admission into the labor ward, all patients had their hemoglobin and blood group determined and also urine for analysis. The patients were given standard care in labor. Patients who needed stimulation of labor had amniotomy done and a few were given syntocinon infusion. The drip was regulated to give 4 milliunits of syntocinon per minute, under close supervision until regular uterine contractions were established. Pain relief was by demerol (pethidine) 100 mg and promazine 25 mg. Under normal conditions the patients were allowed 30 min in the second stage of labor before intervention. Methergine 0.5 mg was given intramuscularly and intravenously Int J Gynaecol Obstet 24
of Gynaecology
& Obstetrics
436
Opaneye
Table 1. Maternal
vaginal deliveries and 8% had cesarean sections. Five per cent had complications of the third stage of labor. A total of 53 female and 47 male infants were delivered, with a mean weight of 3.46 kg.
characteristics. No. of patients
(a) Age in years 30-34 35-39 40-44 >44
18 43 30 9
Comments
100 (b) Parity 10 11 12 13 14 15
50 29 15 3 1 2 100
after the delivery of the anterior shoulder, and the baby, respectively. The placenta was usually delivered by controlled cord traction. Results Results are shown in Tables I-III. The mean maternal age was 37 years (range 30.45 years); and the mean parity was 10.8 (range 10-15). Ninety-two per cent achieved
Table II.
Labor and delivery
Dilatation of cercix in cm on admission
o-3 4 5 6 7 8 9 10 Total
and discussion
Patients of high parity have always constituted an “at risk” group [4,6-81. Recently improved outcome in this group was reported [ 1 I. This uncontrolled study was done to investigate the situation for this group in the central region of Saudi Arabia. Antenatal clinic attendance was poor, as only 50% attended clinic on more than five occasions prior to admission in labor. High parity, ignorance and the burden of the housewife’s workload probably contribute to the low attendance at the antenatal clinic. Many authors [ 1,7,8,11] reported a high incidence of anemia in their patients of high parity. Hemoglobin of less than 10 g/d1 was reported in 4% of this group. The prevalence of anemia in the obstetric population in this region is about 1% [3]. Seven of the patients studied were diabetic. This is 70% of the diabetic mothers delivered during the period of study. One of them was admitted in labor
patterns.
No. of patients
No. that require syntocinon 4 munits/min
Mean duration of labor in h
Mode of delivery SVD
Breech
C/S
3 4
2 _
1 1
1 _
4 1 1 1 -
2
1 _ 8
Vent/ forceps
18 20 20 12 6 12 3 9
6 6 4 4 2 -
8.50 6.45 5.15 5.31 2.50 2.05 0.67 0.50
9 15 18 9 6 8 3 8
-
1
1 _ -
100
22
4.95
16
12
4
Overall mean = 4.95 h; 3/4 delivered Int J Gynaecol Obstet 24
in less than 8 h.
_
High parity delivering Table 111. Infant
morbidity
437
and mortality. --
Maternal age years
Parity
Infant
(11 (21 (3) (4) (5)
40 40 40 35 45
10 11 14 12 10
(6)
(71 (8) (91 (10) (11)
30 30 40 35 35 35
(12) (131
sex
W-t. kg
Delivery
Remarks
M r M M M
3.8 3.1 4.6 4.1 4.6
SVD Vent. Del. SVD SVD SVD
10 12 12 10 11 10
M M tI M I‘
4.1 3.6 4.1 1 .o 1.5 1.3
SVD SVD SVD Asst. Br. Del. Asst. Br. Del. SVD
35
13
M
2.5
SVD
35
10
M
4.1
Asst. Br. Del.
Maternal Hypertension. Asphyxia Nconatorum. Asphyxia Neonatorum. Maternal Diabetes. Asphyxia Nconaturum. Congenital bilateral talipes. SFOIIImcconium. Maternal Diabctcs. Shoulder dystocia. 1:racturc (L) 11umerus. Shoulder dystocia. Erb’s palsy. Shoulder dystocia. Erh’s palsy. Maternal Diabctcs. Shoulder dystocia. Erb’s palsy. Maternal Diabctcs. Preterm. Asphyxiated. Neonatal dcarh. Prctcrm. Asphyxiated. Neonatal death. Aprupto placenta. Preterm. Multiple Congenital Malformation. Stillbirth. Intra-uterine fetal death. Maccratcd stillbirth uncontrolled maternal diabetes. Maternal Diabctcs. Maccratcd stillbirth.
with an intra-uterine fetal death. She had no antenatal care. In our obstetric population, increasing age, high parity, genetic predisposition and diet (high consumption of dates) are contributory factors. Although the mean maternal age was 37 years, only 2% were hypertensive. A low incidence of hypertension has also been mentioned in other regions of this country [ 2,101. This is unlike the situation in Western Europe and North America where hypertensive diseases of pregnancy play a major role in antenatal ward admissions. Malpresentation was not a noticeable feature, as only one patient had shoulder presentation and placenta previa. On admission, the presenting part was usually at the brim and on several occasions, engagement did not occur until in the second stage. Inertia was noted in 22% of the patients, being primary in 15%. They all had syntocinon infusions, under close supervision. Despite previous vaginal deliveries, obstructed labor can still occur. Failure to recognise disproportion may lead to uterine rupture [ 5 1. Fortunately no patient suffered this catastrophe.
Eight per cent of the patients had cesarean sections - 4 for lack of progress: 2 for cephalopelvic disproportion and 2 for antepartum hemorrhage. This cesarean section rate is double the overall rate of 334% for the department. Patients of high parity arc prone to post partum hemorrhage [ 1,4,6,81. In this series 5% of the patients had complications of the third stage as against 3% for all mothers during the period of study. Retained placenta necessitating removal under general anesthesia occurred in 2%, and post partum hemorrhage occurred in 3% of the studied patients. There was no significant injury to the genital tract. Neonates National figures for perinatal mortality rate is not known. Several factors prevent accurate data. In this series, early perinatal mortality (EPNMR) is 50/1000 but it is about 22 per 1000 for the whole period of study. There were three stillbirths, two macerated and one fresh due to placental abruption. giving a stillbirth rate of 30 per 1000. This is against the
438
Opaneve
overall stillbirth rate of 12.5 per 1000 for the period of study. The two neonatal deaths followed preterm births at 30 and 32 weeks, weighing 1.3 kg and 1.5 kg, respectively. Both mothers were admitted in advanced labor. The mean weight of the infants in this series is 3.46 kg but 20% of all the babies weighed 4.0 kg or more. Asphyxia neonatorum occurred in 10% and 4% of the babies had shoulder dystocia with subsequent bony or nerve injuries. The mean weight of the infants with shoulder dystocia was 4.25 kg. Conclusion It is without doubt that high parity still constitutes a risk to both mother and baby. Although the percentage of patients of parity 10 and above is small, they make a major contribution to the maternal and infant morbidity and mortality figures in our hospital. Definitely there is room for improvement. Such an improvement could come from health education and family planning since many of these pregnancies were unplanned. Since this study nearly 30% of these patients have come to the family planning clinics for contraceptive advice.
ities at the King library in Riyadh.
Specialist
Hospital
References 1 Chang A et al.: The obstetric performance of the grand multipara. Med J Aust 1977 1: 330, 1977. 2 Chatterjee TK, Al-Awdah A et al.: A review of high risk factors in 586 patients delivered at the Al-Khobar Teaching Hospital. Abstracts: The Seventh Saudi Medical Meeting, Dammam, 3-6 May 1982, p 95. 3 Chattopadhyay SK, Sengupta GS et al.: Maternal mortality in Riyadh, Saudi Arabia. Br J Obstet Gynaecol 90: 809,1983. problem of the grand 4 Colizzi E, piorilli A: The obstetrical multipara with special reference to some cases of postpartum haemorrhage. Min Ginecol28: 351, 1976. stimulation 5 Dawood MY, Ng R, Ratnam SS: Oxytocin and uterine rupture in the grand multipara. Singapore Med J 15: 40,1974. and labor in the 6 Eastman NJ: The hazards of pregnancy “grande multipara”. NY State Med 4: 1708, 1940. problem of I Lo Dice G, Gigliotti B et al.: The obstetrical the grand multipara. Min Ginecol31: 609, 1979. 8 LOBS DE, Soumplis AC: The grand multipara. Influence of parity on labor. Int Surg 53: 245, 1969. 9 Ohlsson A: Better perinatal care in Saudi Arabia. Ann Saudi Med5: 169,198s. 10 Pugh CK, Ledward RA: Trop Doct April: 74,198l. 11 Aramatsu T: The grand multipara and other complications of pregnancy and labor. Clln Anesth 3: 179, 1965.
Acknowledgments
Address for reprints:
I am greatly indebted to my medical colleagues and the midwifery staff in the department. I am also grateful to Dr. Remi Sogunro for his assistance; and for the use of the facil-
A.A. Dpaneye, M.D. 83 Highfield Road South Shields Tyne and Wear NE 34 9HY UK
Int J Gynaecol Obstet 24
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