A pregnant woman who has had four or more previous viable births is termed a grand multipara. The incidence of such grand multiparity has been progressively declining over the last two decades as a result of the more widespread acceptance of the small family norm. However, even in the present times, about 10% of women delivering in public hospitals all over the country fall into this category.
These women often belong to the lower socioeconomic strata of society. Lack of education, poverty, rampant malnutrition, poor housing, sanitation and hygiene, and a lifestyle bound down by traditions and misconceptions affects their health and wellbeing.
These women who often had their pregnancies in quick succession, with poor spacing between births have not had adequate time to recover from the effects of their previous pregnancy before embarking on to next pregnancy. Efforts of looking after the domestic chores of a large family often leaves them very little time to devote to their own needs. The result is a tired, harrassed, malnourished, anaemic patient, who does not avail of adequate prenatal care, and is the victim of neglect, which contributes to an adverse pregnancy outcome.
High risk factors during pregnancy and labour
A higher incidence of abortion—spontaneous or induced.
A pendulous abdomen predisposing to foetal malpresentations.
The pronounced lordosis of the spine leads to an increased pelvic inclination and non-engagement of the foetal head at term.
Contracted pelvis due to calcium deficiency leading to osteomalacic changes in the pelvis contributing to problems of mechanical dystocia.
Multiparae are more vulnerable to enhancement of their medical problems like anaemia, hypertension, gestational diabetes, cardiac problems, haemorrhoids, varicose veins, hiatus hernia, and preterm birth.
An increased incidence of malpresentations, cord prolapse, and premature rupture of the membranes.
Cephalopelvic disproportion causing mechanical dystocia—prolonged labour, obstructed labour, even rupture uterus.
After delivery there is a higher risk of postpartum haemorrhage.
The need for obstetric interventions with its accompanying risks increases.
After delivery, there is a greater risk of secondary postpartum bleeding, uterine subinvolution, and insufficient lactation.
During the antenatal period, the haemoglobin status is corrected and anaemia prevented, nutritional advice complied with, all medical problems brought under optimal control, foetal growth monitored, check for malpresentations and foetopelvic disproportion. Institutional delivery is recommended.
During labour watch out for malpresentations, mechanical dystocia, avoid prolonged draining, prolonged labours, use oxytocics with great care, and avoid difficult vaginal interventions. Practise prophylactic use of oxytoeics to avoid third stage bleeding. Ensure mental and physical rest after delivery.