Friday, May 24, 2019

Increasing maternal age – particularly with levator ani dysfunction

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The shorthand system of describing gravidity and parity has evolved based on local obstetric traditions; it may vary slightly between different communities and this can cause confusion.

Gravidityis defined as the number of times that a woman has been pregnant.

Parityis defined as the number of times that she has given birth to a fetus with a gestational age of 24 weeks or more, regardless of whether the child was born alive or was stillborn.

For example, a woman who is described as gravida 2, para 2 (sometimes abbreviated to G2 P2) has had two pregnancies and two deliveries after 24 weeks, and a woman who is described as gravida 2, para 0 (G2 P0) has had two pregnancies, neither of which survived to a gestational age of 24 weeks.

If they are both currently pregnant again, these women would have the obstetric history of G3 P2 and G3 P0 respectively. Sometimes a suffix is added to indicate the number of miscarriages or terminations a woman has had. So if the second woman had had two miscarriages, it could be annotated G3 P0+2.

has not given birth previously (regardless of outcome).

has given birth once. The term primip is often used interchangeably with primagravida, although technically incorrect, as a woman does not become primiparous until she has delivered her baby.

is a woman who has already delivered five or more infants who have achieved a gestational age of 24 weeks or more, and such women are traditionally considered to be at higher risk than the average in subsequent pregnancies.

has been pregnant five times or more.

has delivered seven or more infants beyond 24 weeks of gestation.

Multiple pregnancies present a problem: a multiple gestation counts as a single event and a multiple birth should be interpreted as a single parous event, although this remains contentious. In a survey, only 20% of British midwives and obstetricians recognised a twin delivery as a single parous event – G1 P1 rather than G1 P2, revealing the potential lack of standardisation in our documentation[1].

A more elaborate coding system used elsewhere, including America, is GTPAL (G = gravidity, T = term deliveries,杭州桑拿 P = preterm deliveries, A = abortions or miscarriages, L = live births).

The current total fertility rate (the average number of children a woman would have if she experienced the fertility rate of a particular year for her entire childbearing years) stands at 1.91 (2012 figures)[2].

Women are commencing their childbearing later and having fewer children in total. Women born in 1982 have had slightly fewer children (average 1.02) by their 30th birthday than women born in 1967 who had an average of 1.16 children by the same age.

More women remain childless (19% of women born in 1967 compared to 11% of those born in 1940). One in ten women born in 1967 had four or more children, compared with nearly one in five women born in 1940. The number of higher order grand multips has fallen significantly.

Obstetric histories should always record parity, gravidity and outcomes of all previous pregnancies because:

Outcomes of previous pregnancies give some indication of the likely outcome and degree of risk with the current pregnancy.

The number of previous pregnancies and deliveries will also influence the risks associated with the current pregnancy.

What is considered normal labour varies according to parity:

Normal labour in a primagravida is significantly different to normal labour in multiparous women, as physiologically the uterus is a less efficient organ, contractions may be poorly coordinated or hypotonic. The average first stage in a primagravida is significantly slower than in a multiparous woman (primarily due to the rate of cervical dilation). Therefore, progress is expected to be slower but delay longer than expected should prompt augmentation in managed labour.

Interestingly, grand multips have a longer latent phase of labour than either nulliparous or lower-parity multiparous women but then begin to dilate more rapidly. After 6 cm dilation, partogram curves for lower parity multips and grand multips are indistinguishable. Progress of labour does not appear to continue to improve with additional childbearing.

Risks associated with nulliparity/primagravidae

Higher risk of developing pre-eclampsia (relative risk 2.1 with confidence interval 1.9-2.4)

Delayed first stage of labour, although this could be considered normal in a primagravida.

Dystocia (or difficult labour) was diagnosed in 37% of primagravidae in one Danish study

. Maternal age is an independent risk factor for dystocia, regardless of parity

Risks associated with grand multiparity

Precipitate and preterm delivery although higher age is more significant

Stress incontinenceandurinary urgency symptoms

Risk equates to factors that increase likelihood of harm to mother or baby. There is no universally accepted definition of a high-risk pregnancy and antenatal risk screening cannot identify every pregnancy/labour that will run into complications. Usually risk factors are combined and weighted to try to match an appropriate level of medical care and intervention to a more risky pregnancy to attempt to reduce the chances of a poor outcome.

Increased parity is often associated with:

Increasing maternal age – particularly with levator ani dysfunction

Lower socio-economic and educational status.

Poorer prenatal care (more likely to be late bookers and poor attenders).

Higher rates ofgestational diabetes.

It is not always possible to disassociate the various risk factors attributable to each factor.

Good antenatal care with particular vigilance to early warning signs of pre-eclamptic toxaemia (PET). The National Institute for Health and Care Excellence (NICE) recommends nullips with uncomplicated pregnancies should have 10 routine antenatal appointments (versus 7 in parous women)

Good antenatal and parenting education, support during labour and pain control (if desired) are especially important in a first pregnancy, as anxiety levels are likely to be high.

Where there is delay in the first stage of labour in a primagravida, active management is with artificial rupture of membranes and/or oxytocin to augment labour.

The second stage of labour can be allowed to continue for longer than the traditional time associated with multips, as long as fetal monitoring is satisfactory and there is ongoing fetal descent.

It is usually appropriate to book for delivery in a specialised unit. Consider:

A plan for the care of existing children during admission.

Vigilance for abnormal fetal presentations from 36 weeks onwards.

Planning for possible rapid labour and delivery.

Monitoring strength of contractions and fetal presentation during delivery.

Planning for the possibility of postpartum haemorrhage.

Good physiotherapy and postnatal follow-up for urogynaecological problems.

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Opara EI, Zaidi J; The interpretation and clinical application of the word parity: a survey. BJOG. 2007 Oct114(10):1295-7.

Total fertility rate; Office for National Statistics

Bartsch E, Medcalf KE, Park AL, et al; Clinical risk factors for pre-eclampsia determined in early pregnancy: systematic review and meta-analysis of large cohort studies. BMJ. 2016 Apr 19353:i1753. doi: 10.1136/bmj.i1753.

Kjaergaard H, Olsen J, Ottesen B, et al; Incidence and outcomes of dystocia in the active phase of labor in term nulliparous women with spontaneous labor onset. Acta Obstet Gynecol Scand. 200988(4):402-7.

Waldenstrom U, Ekeus C; Risk of labor dystocia increases with maternal age irrespective of parity: a population-based register study. Acta Obstet Gynecol Scand. 2017 Sep96(9):1063-1069. doi: 10.1111/aogs.13167. Epub 2017 Jun 20.

Hu CY, Li FL, Jiang W, et al; Pre-Pregnancy Health Status and Risk of Preterm Birth: A Large, Chinese, Rural, Population-Based Study. Med Sci Monit. 2018 Jul 824:4718-4727. doi: 10.12659/MSM.908548.

Waldenstrom U, Cnattingius S, Vixner L, et al; Advanced maternal age increases the risk of very preterm birth, irrespective of parity: a population-based register study. BJOG. 2017 Jul124(8):1235-1244. doi: 10.1111/1471-0528.14368. Epub 2016 Oct 21.

Handa VL, Harvey L, Fox HE, et al; Parity and route of delivery: does cesarean delivery reduce bladder symptoms later in life? Am J Obstet Gynecol. 2004 Aug

Roman H, Robillard PY, Verspyck E, et al; Obstetric and neonatal outcomes in grand multiparity. Obstet Gynecol. 2004 Jun103(6):1294-9.

Waldenstrom U, Ekeus C; Risk of obstetric anal sphincter injury increases with maternal age irrespective of parity: a population-based register study. BMC Pregnancy Childbirth. 2017 Sep 1517(1):306. doi: 10.1186/s1-7.

Antenatal care for uncomplicated pregnancies; NICE Clinical Guideline (March 2008, updated 2018)

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