Are multips "high risk"...

[Xiaohua]

just because of the number of babies they've had? And if so, where do you draw the line? I am due in July and considering another UC (already had two UC's). I am considering a UC because that is my only homebirth option; there is no midwife option this time.

Anyway, while I sort out my plans and feelings about the upcoming birth, I am doing prenatal care with an OB practice, at the hospital where I would definitely transfer if anything went wrong with a homebirth. I really don't plan to deliver with this OB practice, but need to keep my options open for later in case of emergencies.

So I picked the OB who has the reputation for being most "hand off". He does VBAC's against hospital policy. Was really excited to meet him. But once he started asking questions and figured out with my past history of homebirths (he doesn't even know the UC part) and my current wishes to decline some standard tests (like nuchal translucency) he starts talking about how "high risk" I am because of my "grand multipara" status. This is my 6th baby. I have never had hypertension, blood sugar issues, no sections or any other risk factors. Solely based on my number of pregnancies, he makes a big deal of my "very high risk" pregnancy". Huh? I even started to disagree with him, and told him that while there are risks during labor and delivery as a "grand multipara" I did not think that made the actual PREGNANCY high risk. He disagreed and said the pregnancy itself was definitely high risk. I was so blown away I didn't even think to ask him to explain and back that up with research.

Am I wrong? Does pregnancy risk escalate if you have had lots of babies already? Surely the risk of birth defects increases, but I'd say that is more to do with maternal age than parity. Right? And I am well aware of risks during labor/delivery. But what the heck makes my pregnancy high risk, at say, 16 weeks, more so than a mom who's only had one or two babies?

The other thing this guy said that really ticked me off is that due to my "grand multipara" status I would surely risk out of homebirth, regardless of what country I was living in. (Not in the US right now.) I beg to differ! Where on earth would you risk out of hb solely based on parity? And even if that were a factor, 5 babies is not some kind of record here. Sigh.

I think this guy is trying to bully me into his standard of care. But I don't have other options, so I am going to have to suck it up. I guess I'll feel better, though, if I hear from other mamas and midwives about higher parity births. Risk is all relative anyway. I prefer to think in terms of "higher" risk and "lower" risk. No pregnancy or birth is risk free, but it's not like there are only two catagories and everyone falls neatly into one of them.

What do you think?

Serena

[Kidzaplenty]

No, he is not trying to just bully you, OB's (and probably all MDs) truely think multips are "very high risk". (Beginning at baby number 6 for me).

My current OB never fails to inform me of that fact (top it off with my PIH and pre-E history, my OB considers me "Very, Very, Very high risk".

Her "training" has taught her (not sure how far spead this training is but she is VERY sure of this) that "Every time you are pg, your placenta attaches to the side of the interiour wall. Every time it detaches it leaves scar tissue behind in the place it was attached. After a few births, the likelihood of the newly attached placenta covering a 'scar' from another placenta is higher. And after a while (5 babies) there is no place you don't have any scars left. So you end up with probable complications like 'placenta acreeta' (and all those 'placental problems' that mean it grows to and through the uterine all and attaches to something it is not suposed to) and PPH."

She is absolutely positive that every birth I have (I am now on number 10) I am putting my life on the line and will likely have to have a historecomy because I am likely to have PPH due to these "placental issues". That is why I am considered "high risk" for just being a multip.

[MsBlack]

I think what kidzaplenty means....that is, I HOPE what she means ...is that your OB there is saying just the same things that OBs here would say; that what you are hearing is 'standard OB talk', not a special effort to bully you. Not exactly lying to make you toe his line.

I hasten to add, tho, that just because it is 'standard OB belief' does NOT make it true! At least, does not make it true for YOU.

As your own common sense already informs you, any pregnancy is really just itself...it is the sum total of an individual mom's general health, health history and pregnancy/birth history. Now, certain adverse events might demonstrate a tendency to repeat, and those have to be taken into account when assessing risk for this pregnancy--but of course, what also has to be taken into account are all the perfectly normal events! Such as successful, healthy, normal pregnancies and births. Not to mention that someone might have PIH/eclampsia or postpartum hemorrhage once or more, then later discover how to prevent such things with better habits of self-care and/or less invasive/interventive methods of birthing.

Remember that OBs see 'everyone': well-nourished moms as well as (a greater majority of) poorly nourished moms. Moms who are pretty much sober, and those who drink or drug to excess. Moms with normal health in general, and those with underlying problems. Moms with healthy, supportive marriages along with moms in abusive marriages and single moms with little social/emotional support. So, in their world, taking ALL moms into their stats, OBs surely DO see 'higher risk' for grand multips. And they don't separate you, your history and living habits from all the rest.

So, on one hand, no, I don't think your OB is making a special effort to bully you--he is just speaking from inside his world and practice (including not just the varying moms, but also including his own industry standards for 'managing' pregnancy and birth--much of which does cause problems for moms/babies that modern obstetrics simply does not acknowledge). On the other hand, what he is saying is just not true for *you*.

To make a short story long....I would not take his words to heart. You know yourself, your own health habits, birthing history, all that--and your common sense is quite sufficient to lean on, IMO

[Kidzaplenty]

Sorry if I did not make that clear. I do not believe that OBs are correct in the assumption. I just think that they are taught this nonsense, and that they truly believe it. I know my OBs have truly believed it.

Since I UC and just get OB care as a back up care, I usually just nod my head and go on.

I agree that everyone is the sum total of their own health. No matter how many children they have had. (The only reason I, personally, consider myself high risk - this time - is because of my issues I am having right now; and they have nothing to do with my multip status.)

[loveneverfails]

Here's where I come down, with this being my 5th birth:

Are there things to be aware of? Yes. Do I want anti-bleeding meds readily available? Yes. Am I fundamentally high risk? No. Because I've done this 4 times already, I know what I need to do, we know how my body works and what risks to be aware of and anticipate may become an issue.

There are some higher risks that come with higher maternal age and that tends to factor into the "OH NOES!!! GRAND MULTIP!" stuff because you have to be a certain age to have had 5 babies already, but that (in my opinion) just means that you watch some things more closely. Birth does have physical demands, like any high intensity and extended length activity. But I *personally* with my experiences and comfort levels would be betting on a 35-40 year old marathon runner who had done this 5 times already to know how to run that marathon again and who knew where she ran into problems last time over a very prepared 20 year old who had never run a complete marathon before. I mean, there are value judgments that factor in here, and risks need to be seen in the context in which they occur.

[MsBlack]

kidzaplenty--

I just reread your original post--which I apparently did not read too thoroughly to begin with, because I only now noticed the part about 'scar tissue anywhere you once had a placenta attach'...etc etc. What a load of nonsense! I'm almost speechless over that one (never truly speechless tho! )

I have helped several women at birth with their 7th, 8th, 10th....and know several others with 12-15 babies...and not a one ever had issues with placenta accreta. The only accreta/percreta I've seen or heard of has been with women who had SURGICAL uterine scars--either from csec, or other uterine surgeries including poorly done D&Cs. Oh yes, I guess one could have fairly extensive scarring from infection such as PID.

"there is NO PLACE YOU DON'T HAVE SCARS" after 5 babies????

I'm sorry, but that is just ridiculous. Pure and simply, absurd, untrue, silly! A great big load of horse hockey. Oh my goodness...what WILL they think of next to try to make us believe (as most of them do) that pregnancy and birth are just totally fraught with dangers for us? Oy freakin VEY.

[nikirj]

"higher" risk isn't the same thing as "high risk." Higher risk for malpresentation, prolapse, or bleeding than a primip, well, ok, but that doesn't mean we should slap "high risk" on the whole pregnancy/birth/postpartum. "Higher" risk doesn't mean the absolute in-numbers risk is so high that you need super-special care.

re: scar tissue - WTF? Yeah, and my menses scars up my uterus every time, too...damn we're walking time bombs...

[cathicog]

what MsBlack and nikirj said. I have assisted at births of the 10th- 14th babies in some families, and if overall health is good, mom takes good care of herself, and has help(thereby reducing stress level) then the birth is generally no different than a 2nd or third birth. Baby may move around a little more(one time the baby's hand was on top of its little head, and the midwife felt her fingers drumming the top of her head- had to move that hand back and baby was born within a few minutes) but other than that, all was normal. I know a couple of ladies who had their 16th at home, no problems. I think that based on what the OB was probably taught, and sees in a hospital situation, then her fears might be a little justified. But at home we usually don't see problems like that, and the moms generally take very good care of themselves, and that avoids many problems...Remember Susannah Wesley(mother of Charles and John) had 20 children, including 2 sets of twins. I guess nothing was scarred up on her uterus... Enjoy your homebirth!

[mntnmom]

As for "risking out" of homebirth anywhere in the word, he is clearly misinformed. This is my 5th. We are planning a HB with a German (university trained BTW) midwife. I asked if multiparity was a risk factor. She looked at me like I'd sprouted another head! "2 babies, 10 babies... no difference. Mom's health is what matter's!" German's don't typically have large families, but she sees more than her share of "mom's of many". They seem to seek out HB here more often.

[Fruitful4Him]

Okay, so where are OBs getting the belief that scarring occurs at the placental site? Is there any research to back this up?

[Kidzaplenty]

I wish I knew where they were getting the info. All I know is that my OB (and every one in her practice) totally believe this (and were taught it somewhere).

I was just so flabergasted when I first heard it and had nothing in the way of "proof" against it that I said nothing. I don't even know where to begin to counter this thought. So, so far, I have just said nothing. Smile and nod. That is my usual response.

But, I don't for a minute believe it. I just wish I had something to counter it with that an educated, well trained doctor would listen to rather than just the words of someone who has had a bunch of children.

[MsBlack]

Yeah, I need to look into this....

And as for what nikirj says about 'higher risk'--just want to point out again, that the elevation of risk means that among ALL pregnant multips/grand multips, more of them have such issues as uterine prolapse, malpresentation, pph, than do women who've had no babies or only a few. But even so, these possible complications are NOT just caused by having had several babies--they occur for women who've had several babies who ALSO are somewhat depleted due to inadequate nutrition, or whose abs and pelvic floor have lost tone due to lack of exercise or inadequate time for recovery between babies. It is not the 'many babies' that causes this elevated risk for ALL multips--it is the lack of appropriate self care by individual women that elevates their personal risk for such problems.

So when I meet a grand multip, I'm going to consider the same things I consider for all women: nutrition and excercise, stress and support and all the factors that go into her health and her making/birthing of a baby. If a grand multip seems depleted nutritionally or energetically, if she has ab rectis diastasis or partial pelvic floor prolapse, or any other issue, then I'm going to give her info and encouragement on those issues. And I'm going to believe as I do with anyone else, that her efforts on her own behalf will most likely have the desired effect on her body to reduce risk and help make birth safe for her.

[mntnmom]

I found this:
Obstet Gynecol. 2002 Jun ;99 (6):971-5 12052583(P,S,G,E,B) Cited:45

Emergency peripartum hysterectomy: experience at a community teaching hospital.
Elana S Kastner, Reinaldo Figueroa, David Garry, Dev Maulik
OBJECTIVES: To estimate the incidence, indications, risk factors, and complications associated with emergency peripartum hysterectomy at a community-based academic medical center. METHODS: We analyzed retrospectively 47 of 48 cases of emergency peripartum hysterectomy performed at Winthrop-University Hospital from 1991 to 1997. Emergency peripartum hysterectomy was defined as one performed for hemorrhage unresponsive to other treatment less than 24 hours after delivery. Fisher exact test, Wilcoxon rank sum test, and Cochran-Armitage exact trend test were used for analysis. RESULTS: There were 48 emergency peripartum hysterectomies among 34,241 deliveries for a rate of 1.4 per 1000. Most frequent indications were placenta accreta (48.9%, 12 with previa, 11 without previa), uterine atony (29.8%), previa without accreta (8.5%), and uterine laceration (4.3%). Placenta accreta was the most common indication in multiparous women (58.8%, 20 of 34), uterine atony the most common in primiparas (69.2%, nine of 13). Twenty-two of 23 (95.6%) women with placenta accreta had a previous cesarean delivery or curettage. The number of cesarean deliveries or curettages increased the risk of placenta accreta proportionally. Thirty-eight (80.9%) of the hysterectomies were subtotal. Postoperative febrile morbidity was 34%; other morbidity was 26.3%. CONCLUSION: Placenta accreta has become the most common indication for emergency peripartum hysterectomy.


I found several references to multiparity as a risk factor of placenta accreta, but no reason was stated. This small survey seems to indicate they are really talking about complications from prior births/pregnancies causing the increase in risk. I wonder if this is somehow an indication of where the belief came from. I also wonder, completely unfounded, if "active management" of placenta removal could cause scarring?

[mwherbs]

Yes I would say review the lit, different things in birth different risks. I think as midwives we tend to evaluate a more complex set of information than high or low risk, so I do not think it would automatically rule you out of a home birth but you are at higher risk for certain things , probably the most surprising is regardless of your weight or family history grandmultips have an increased chance of becoming a diabetic, I don't mean gestational diabetic.
In any case things to consider, how far between pregnancies? longer than 18 months is recommended. Amount of nutrients available to you like do you have a garden or belong to a CSA some how get nutrient dense foods and not a diet that has a lot of filler carbs, and if you are skipping the carbs are you eating enough? Are you able to rest/wind down? how about not lifting anything over 10 lbs in the 3rd trimester? How do your babies lay in pregnancy? how is your abdominal and uterine muscle tone? perhaps a uterine tonic/mother's cordial and belly banding are in order...
I have found grandmultip moms to be highly organized household managers and when it gets down to birth they generally know what they want to do or have done.

[mwherbs]

Originally Posted by mntnmom

I found this:
Obstet Gynecol. 2002 Jun ;99 (6):971-5 12052583(P,S,G,E,B) Cited:45

Emergency peripartum hysterectomy: experience at a community teaching hospital.
Elana S Kastner, Reinaldo Figueroa, David Garry, Dev Maulik
OBJECTIVES: To estimate the incidence, indications, risk factors, and complications associated with emergency peripartum hysterectomy at a community-based academic medical center. METHODS: We analyzed retrospectively 47 of 48 cases of emergency peripartum hysterectomy performed at Winthrop-University Hospital from 1991 to 1997. Emergency peripartum hysterectomy was defined as one performed for hemorrhage unresponsive to other treatment less than 24 hours after delivery. Fisher exact test, Wilcoxon rank sum test, and Cochran-Armitage exact trend test were used for analysis. RESULTS: There were 48 emergency peripartum hysterectomies among 34,241 deliveries for a rate of 1.4 per 1000. Most frequent indications were placenta accreta (48.9%, 12 with previa, 11 without previa), uterine atony (29.8%), previa without accreta (8.5%), and uterine laceration (4.3%). Placenta accreta was the most common indication in multiparous women (58.8%, 20 of 34), uterine atony the most common in primiparas (69.2%, nine of 13). Twenty-two of 23 (95.6%) women with placenta accreta had a previous cesarean delivery or curettage. The number of cesarean deliveries or curettages increased the risk of placenta accreta proportionally. Thirty-eight (80.9%) of the hysterectomies were subtotal. Postoperative febrile morbidity was 34%; other morbidity was 26.3%. CONCLUSION: Placenta accreta has become the most common indication for emergency peripartum hysterectomy.


I found several references to multiparity as a risk factor of placenta accreta, but no reason was stated. This small survey seems to indicate they are really talking about complications from prior births/pregnancies causing the increase in risk. I wonder if this is somehow an indication of where the belief came from. I also wonder, completely unfounded, if "active management" of placenta removal could cause scarring?

I wanted to respond to this because it seems like a small sample but really it is a large sample out of 34,000 plus women giving birth this level of complication only happened 1.4/1000. as for placental attachment causing scar tissue formation it is possible and there is other info that puts interbirth interval into the mix increasing the liklihood of complication so maybe some are from not completely healed previous placental sites....

[Xiaohua]

Originally Posted by mntnmom

I found several references to multiparity as a risk factor of placenta accreta, but no reason was stated. This small survey seems to indicate they are really talking about complications from prior births/pregnancies causing the increase in risk. I wonder if this is somehow an indication of where the belief came from. I also wonder, completely unfounded, if "active management" of placenta removal could cause scarring?

Hmmm... that is very interesting. Thanks for sharing. I was under the impression that the biggest risk for placenta accreta (these days, anyway) was repeat c-section or previous uterine surgery. And I do wonder, like you, if 3rd stage active management has anything to do with raising the risk. That is one of my biggest pet peeves, is the way 3rd stage is handled in the hospitals. Even my midwife attended births were awfully agressive when it comes to getting the placenta out. That was one of my greatest pleasures with UC, was the totally hands off 3rd stage.

Many thanks to those who responded with your various thoughts and opinions. I really don't feel this pregnancy is high risk, nor do I feel it is significantly higher risk than my previous one. I pay very close attention to my health during pregnancy, diet and nutrition (well, once I get past the morning sickness) and I trust in my body's ability to give birth. And honestly, weighing the risks, I BELIEVE that home birth is safer FOR ME than the hospital options available here in China. With my third baby I bought into the OB's bs about risk, and consented to the IV (in case of emergencies) and the 3rd stage active management etc. Everyone who sees me wants to remind me that I am rh- and there is no rh- blood banked in China. No transfusions for you, so we have to do all we can to prevent that. Well, wouldn't you know that I DID end up with a serious PPH after that birth, DESPITE all of their precautions, including pitocin in the IV line after the placenta was out. (Actually, on a side note, I believe they CAUSED that heavy bleed with all of their "helpful" interventions.)

With my next two UC births, I was aware of the risks. I believe that the 4th and 5th were slightly higher risk than the 3rd was, solely based on parity. However, I wanted responsiblity for managing that risk. I did not want to TRUST them and have them fail again. For me, the risk is what it is. It depends on whether you trust the "system" to manage the risk, or whether you want to accept the responsibilities for managing that risk (whatever it is) yourself. It's a big responsiblity, to be sure, and I don't know yet it I am up to taking that on this time or not. I will spend the next weeks and months evaluating my feelings and my health and make that decision as I near the actual birth. But it makes me mad when they make a blanket statement like "You are very high risk" without even considering MY pregnancy individually, and then to ASSUME I will trust them to handle these risks whatever way they feel best. GGRRRR. That just makes me mad!

[MsBlack]

Originally Posted by Xiaohua

Hmmm... that is very interesting. Thanks for sharing. I was under the impression that the biggest risk for placenta accreta (these days, anyway) was repeat c-section or previous uterine surgery. And I do wonder, like you, if 3rd stage active management has anything to do with raising the risk. That is one of my biggest pet peeves, is the way 3rd stage is handled in the hospitals. Even my midwife attended births were awfully agressive when it comes to getting the placenta out. That was one of my greatest pleasures with UC, was the totally hands off 3rd stage.

Many thanks to those who responded with your various thoughts and opinions. I really don't feel this pregnancy is high risk, nor do I feel it is significantly higher risk than my previous one. I pay very close attention to my health during pregnancy, diet and nutrition (well, once I get past the morning sickness) and I trust in my body's ability to give birth. And honestly, weighing the risks, I BELIEVE that home birth is safer FOR ME than the hospital options available here in China. With my third baby I bought into the OB's bs about risk, and consented to the IV (in case of emergencies) and the 3rd stage active management etc. Everyone who sees me wants to remind me that I am rh- and there is no rh- blood banked in China. No transfusions for you, so we have to do all we can to prevent that. Well, wouldn't you know that I DID end up with a serious PPH after that birth, DESPITE all of their precautions, including pitocin in the IV line after the placenta was out. (Actually, on a side note, I believe they CAUSED that heavy bleed with all of their "helpful" interventions.)

With my next two UC births, I was aware of the risks. I believe that the 4th and 5th were slightly higher risk than the 3rd was, solely based on parity. However, I wanted responsiblity for managing that risk. I did not want to TRUST them and have them fail again. For me, the risk is what it is. It depends on whether you trust the "system" to manage the risk, or whether you want to accept the responsibilities for managing that risk (whatever it is) yourself. It's a big responsiblity, to be sure, and I don't know yet it I am up to taking that on this time or not. I will spend the next weeks and months evaluating my feelings and my health and make that decision as I near the actual birth. But it makes me mad when they make a blanket statement like "You are very high risk" without even considering MY pregnancy individually, and then to ASSUME I will trust them to handle these risks whatever way they feel best. GGRRRR. That just makes me mad!

I, too, can believe that the group at highest risk for placenta accreta/percreta is the group of csec moms. Which makes sense because so many women are having csecs these days, and repeat csec as well--and also, fewer women are having more than 2-4babies by any birth route. Not that I know the numbers on this issue--just saying I can see where you're coming from with that thought.

I also have to question the involvement of aggressive 3rd stage mgmt in later risk for placental-site scarring. And, I question active 3rd st mgmt's involvement with current risk of pph--and my suspicion in this is only supported by your story of your one active 3rd stage mgmt birth/pph, something I hear about all too often. In my opinion, for healthy moms and babies there is just no 'mgmt' that can improve upon respect for, and simple support of mom, baby, and the natural process (keep mom fed, hydrated and warm enough, privacy, etc). However it is not my experience that OBs (in general) understand normal birth....

You say you want the responsibility and I say "YES!" IMO, as a UC mom and mw both, this is best, healthiest/safest attitude. Whether you UC or have a mw or OB attended birth, for parents to take on full responsibility for maternal/baby health throughout pregnancy, and for all choices made during birth, is the closest thing we get to a 'guarantee' of outcome. Only a woman can grow and birth a baby, and the processes involved have been wondrously designed for women to do so quite well. All of our medicalization and interference with birth for healthy women has NOT improved things for moms or babies....has only brought a host of new problems for all--from physical problems following procedures and drugs, to bonding/breastfeeding issues, to a growing body of women who feel traumatized, to lawsuits against docs and climbing medical costs....and so on and on and on!

[Lizbiz]

I'm in China - rh negative blood can be reserved for you - i just did it (it wasn't easy, but it can be done). pm me for more details. just had a great uc here with good prenatal care at a taiwanese-run hospital.

[fruitfulmomma]

probably the most surprising is regardless of your weight or family history grandmultips have an increased chance of becoming a diabetic, I don't mean gestational diabetic.

Interesting... A new study just came out suggesting that breastfeeding reduces the risk of diabetes, especially for moms with gd, and the longer one breastfeeds the lower the risk. I wonder if the studies you refer to differentiated between moms who did and did not bf.

http://www.webmd.com/heart/metabolic...-diabetes-risk


Back to the OP, my 5th baby was born at home. I was actually seen for a NST at the hospital a few days prior to her birth and the nurses and doctors there didn't seem a bit phased by the idea of me having her at home and weren't interested in getting me to transfer care.

I know/know of many many large families and most of them have their babies at home with little or no complications, or at least no complications above and beyond women with few children. I think you really need to look at women individually to determine risk. And I believe our bodies were designed to give birth so I don't buy into the idea that it is inherently risky to give birth to a certain number of children.

[Collinsky]

This is my sixth pregnancy (I had a m/c last summer, so this will be my fifth baby) - either way I'm a grand multipara now. The main risk that I've heard of is hemorrhage, the thinking being that each time the uterus is stretched out for pregnancy, it has a harder time clamping down after the birth.

About scarring of the uterus where the placenta attaches -- I agree with what others suggested, that the tendency to aggressive third stage "management" may have created this situation. It seems to me that IF this scarring is a reality, it's most likely iatrogenic and NOT a flaw of the design.

And it's funny - some women hear that the placenta has to attach to the same place each time, causing problems after many births... and some hear that the placenta has to attach to a NEW spot each pregnancy, causing a woman to "run out" of places for it to attach if she has too many babies.

The way I see it, personally, is that this time I'm more high risk in some ways than a first time mom. And in other ways, I'm much lower risk than a first time mom. It is different, but it's not more inherently dangerous for either one to homebirth than the other.