I’ve been on hiatus in the Northwest Territories for a couple of weeks (and getting ready to leave before that). But on the last day before my vacation, I ended up doing an induction for a Mennonite woman having her eleventh baby. She was 41 weeks, and had reduced amniotic fluid on ultrasound.
The resident talking to my student told her that she should give her rectal misoprostol prophylactically in an attempt to prevent the inevitable massive postpartum haemorrhage (PPH) that this woman would have because of the number of babies she’d given birth to already. She had not had a PPH previously in her obstetrical career, although she apparently did bleed quite a bit with a miscarriage since her previous birth.
Ah, the terror of the grand and great grand multipara. For those less familiar with the terminology: grand multiparity means that a woman is having her fifth (or greater) baby and great grand mulitparity means that she is having her tenth or greater baby. Years ago, before I was a midwife, I did labour support for a woman having her sixth baby. One of the physicians involved with her in labour kindly explained to her that she was like an old tire without any tread — or at least her uterus was. It wasn’t going to work properly. She was going to have a dysfunctional labour and haemorrhage, among other things.
The fact is that, apart from those who watch the Duggars on reality TV, most of us don’t know people who have large families. These days, it’s seen as something fairly backward to do and related to religious orthodoxy of some sort or another. And, in truth, most of the physicians I know don’t have much experience with grand multiparas, and tend to fall back on the old myths (which are not well-supported by the sparce amount of literature there is on the topic), and fears.
Don’t get me wrong. Women who have a great number of babies are at higher risk for some things. Placenta previa (placenta covering the cervix) is generally agreed to be more common, as is fetal malpresentation and unstable fetal lie (although we’ve had lots of grand multips who do just fine in that regard). But so many of the reputed risks of grand multiparity are drawn from data from low resource countries that it’s difficult to know if complications are related to the multiparity or the generally poor living conditions.
Interestingly, “dysfunctional labour” is often cited as a complication. We think that their labours aren’t dysfunctional, just different (and there is at least one study that supports our observation). We often joke that sometimes we spend more time with the grand multips than we do with the women having a first baby. We have to think about their labours differently. For sure, we don’t tell them to wait until it gets hard to call us, because we would be sure to miss the birth. Typically, they will have a sporadic labour pattern, then have a few really good contractions and then a baby. Sometimes startlingly fast.
One woman having her sixth baby was taking castor oil because she was overdue. My partner (who was her primary midwife) sat with her patiently, but nothing much seemed to be happening. The woman decided to go to bed, and my partner wisely decided to stick around, and also have a nap. About an hour or so later, the woman woke up, got out of bed and her membranes ruptured. Very shortly thereafter, the baby was born. I joked to the parents that by the time I got there, the kid was ready to go out and start doing chores, he was so old!
Another time, we had a woman having her tenth baby who had called us early, because the previous baby had been born not only without us present, but without her husband around (he was off to the neighbour’s, calling us to come). Although she did just fine, she prefered to have her midwives present to help. She was having sporadic contractions (every 10 to 15 minutes) which were strong when they came. As the “second” or helper midwife, I decided to go sleep in the car for awhile. My partner decided that, finally, the head was low enough to rupture the membranes to help labour pick up a bit. It surely did. She was 5 centimetres and 50% effaced when her membranes were ruptured, and she gave birth after the next two contractions!
In over 20 years of helping with grand/great grand multiparas (both in my practice and in my training, where I attended many Old Order Mennonites), what I’ve noticed that they don’t do is bleed after the birth — at least certainly not as much as women who have had fewer babies and especiallyt those first time mothers who have long labours and long pushes and then a big bleed. Their uteri are not like worn tires; they are experienced and efficient. They give birth without much effort and after the placenta is out, they promptly contract down — sometimes to the great misery of the mother. Although some grand multips are not too bothered by postnatal afterbirth pains, there are some who find this period of time after the birth to be far worse than labour!
We do not, as a practice, have a risk “cut-off” for how many babies is too many to have a home birth — rather we assess the risk as we would for any other woman, and it’s served us and them well to do so.
As for the Mennonite woman? She bled a bit more than usual and we did give her some oxytocics. But there was no massive haemorrhage, and one might argue that her oxytocin induction might have been as much a risk for PPH as her parity. And, just incidentally, the baby had a nuchal cord times four, which likely explained the low fluid as much as her “post-datism”.