An induction or c-section for a truly big baby?

[2sweetboysmom]

LONG BACKGROUND:-----
I am 37 weeks. I have excelently controled (diet) GD (one or 2 readings out of range per 4 weeks). Due to a history of loss I've seen a high risk perinatologist group for this pregnancy.
At 30 weeks I began to feel like my belly was getting big too fast.
At 31 weeks fundal measurement was 36cm, but fluid was normal at 12.5cm. Also at 31 weels labor was stopped, and shots given to develop lungs.
At 32 weeks an ultrasound by the perinatologist showed a baby measuring 6.5lbs with all measurements indicating a baby of 37 weeks, fluid still normal at 13cm and fundal height was 38.
At 36 weeks ultrasound by peri showed baby measuring 9lb9oz, 14inch head circumfreance,with all measurements indicating a baby of 41-42 weeks, fluid normal, fundus at 44cm. (between the two ultrasounds it would seem my boy is gaining 12 oz/week)
I have poured over the studies and statistics regarding various means of measuring babies in utero being "off" I am however confident (between my own sense of things, the fundal measurements, and the ultrasounds by a peri)that this guy is quite big.
I have 3 children already 2 were in the 7.5lb range at birth and one was 8.5lbs with a 15 inch head.
I have been having all day/night labor since 35weeks, but I simply don't make rapid progress or feel pain with my ctx until my water is broken, & I have always made wicked strong amniotic sacks. Also, his head will not stay engaged. He gets it down there LOA and I feel him start to drop and go for a walk and come home with that 'cannon ball in your crotch' feeling only to find him floating again the next morning.
I feel pretty confident in my ability to vaginally birth this "little" guy up to about 10.5+ lbs, but beyond that I think the risks to him and me for distocia are more than I can justify and my instincts say to not attempt it beyond that point. The peri I saw this week said he would rather I carry to 39 or 40 weeks and have a c-section than to induce/augment at 37/38 weeks (when I still feel able to potentially birth vaginally)


SHORT QUESTION: -----
For the sake of argument, assuming the weight estimates to be within 1 lb +/- if you had to choose between an induction at 37/38 weeks, or a c-section at 39/40 weeks, which would you choose and why?
Can you link me to any studys showing an earlier vaginal birth being superior to a later c-section for baby?

Thanks.

[kittywitty]

Neither. Both have huge risks and people give birth to "big" babies with no problems every single day. Fat squishes. They told me my son was "big" and u/s confirmed it. He was born at 7lbs. 2 oz. after a harsh induction and thanks to the u/s being wrong, he was also nearly premature at 36 weeks and has neurological and digestive issues still. His birth was far harder than my much bigger other children.

c-section triples maternal and fetal death rates and has much higher risk of respiratory distress. I would never choose that if the reason was "big baby". And isn't a prolapsed cord a big risk in induction/PROM when a baby is not engaged?

Some more threads: http://www.mothering.com/discussions...d.php?t=832449
http://www.mothering.com/discussions...d.php?t=834605
http://www.mothering.com/discussions....php?t=1130443

"The American College of Obstetrics and Gynecology does not support prophylactic cesarean delivery for suspected fetal macrosomia with estimated weights of less than 5,000 g, stating that “…it is safe to allow a trial of labor for estimated fetal weight of more than 4,000 g.”"
http://www.theunnecesarean.com/avoid-an-unnecesarean/

Evidence is lacking to support labor induction or elective cesarean delivery in women without diabetes who are at term when a fetus is suspected of having macrosomia.

Benacerraf BR, Gelman R, Frigoletto FD Jr. Sonographically estimated fetal weights: accuracy and limitation. Am J Obstet Gynecol 1998;159:1118-21.

From ACOG’s Guidelines on Fetal Macrosomia :

“In cases of term patients with suspected fetal macrosomia, current evidence does not support early induction of labor. Results from recent reports indicate that induction of labor at least doubles the risk of cesarean delivery without reducing the risk of shoulder dystocia or newborn morbidity”
http://www.ncbi.nlm.nih.gov/pubmed/11456432

[loveneverfails]

I would ask for a 3d ultrasound to confirm things, because those are going to give you a better weight estimate. Those are generally within 5%, and would probably give you greater clarity in your plans going forwards.

There are trade offs either direction. A later birth means more brain development in an uterine environment. However, c-section carries greater likelihood of breathing issues at birth and lack of exposure to vaginal bacterial flora. Also, keep in mind the risk of c-section to future pregnancies down the line.

I personally would go for the induction, but I also know that I've given birth to 11 lbs before. I don't know. It's just a hard situation!

[triscuitsmom]

Regardless of reason (assuming non emergent) I'd go for induction but push it as late as possible over cesarean with no labour.

That being said I understand you feel the baby is big and I believe Mamas can be right on about these things. The ultrasound would do nothing for me though. I had the opposite problem. Was told my baby was 5lbs at 41 weeks after many ultrasounds showing him small (so that last one wasn't a shock).

He was born weighing 8lbs 12oz. That's more than 1.5 times bigger than they had him being on the ultrasound. They can be really really wrong.

On the flip side a Mama I know pregnant at the same time as I was kept having her due date moved back because her baby was so huge. They ended up inducing her at around 36 weeks because she wasn't going to be able to birth the baby safely vaginally (according to her OB) if she went any farther. They were wrong. Baby was 5.5lb.

Good luck deciding Mama

[2sweetboysmom]

I am Gestational diabetic ...I am 37 weeks. I have excelently controled (diet) GD...
and at aprox 12oz/week I am seriously looking at (5,000g)11lbs being a very real possibility by this time next week.

[kittywitty]

Even with GD and fetal macrosomia as a real possibility, the evidence stands in my post. It's *about* macrosomia regardless of GD. I have a friend who is type 2 who just had an 11 lb. girl yesterday vaginally. Such a cute little thing.

[cappuccinosmom]

What about giving labor a try and having c-section as a backup plan (it is anyway, afterall, in hospital births)?

[weliveintheforest]

Originally Posted by cappuccinosmom

What about giving labor a try and having c-section as a backup plan (it is anyway, afterall, in hospital births)?

Yes, I agree. I honestly would not induce or plan a c-section, especially since you are a multip.

[BetsyS]

Especially with the GD, I would opt to keep your baby inside as long as possible. GD babies are notorious for having slow maturing lungs, and I wouldn't want to chance any breathing issues at birth with an almost-term baby.

This coming for someone who has big babies (two of them over 11 lbs), and I've had 3 c-sections. My last baby was born at 40+3. The first two were 41 and 42 weeks. I'm happy that I waited for them to be more full cooked, even though it meant a bigger baby, which led to my c-sections. I don't have any regrets about forcing them to come out before their time, you know?

BUT...I also think this is something you have to be comfortable about yourself. Only you can know which way you'll have more regrets--having an induction with a baby that ends up in the NICU or waiting and ending up with a c-section.

[terra-pip]

I've always been told I look and feel like I carry small babies..but both were 9 pounds. I even had a u/s with my first indicating he was big...and my EDD was off by nearly a month. Nope... He was a week late! And I had them vaginally no problem.

I have heard so many stories of mom's getting csections for "big baby's" and they ended up being 6-8 pounds. I know of one mom who ended up having a baby life flighted because her "big baby" was way too small to breathe on his own. I even have a friend recently who was induced for a "big baby" just a few days before her due date...6 pounds. I would never consider a non vaginal birth if weight was the only concern. Especially since you said your diet was well controlled. And your measurements can be 2-4 cm on either side of your weeks, right?

Ultrasounds can be way off. I think people get a bit too concerned about the weight issue...what weight makes for a healthy baby. I would be more concerned with things being wrong and the baby being too small actually as well as the other problems that arise with induction/sections. And there are laboring positions you can try if you should be concerned about SD...hands and knees pushing, counter pressure, etc. I dealt with a mild case of that with my first. Everything went well.

I would keep researching, and keep asking questions, listen to your instincts. Hard choice to make. Hoping it all works out well for you.

[loveneverfails]

I am not thinking straight today and missed the GD mention. In that case, I would confirm size with a 3d ultrasound (just so that I really, really knew what we were looking at) and schedule a c-section.

Here is why I would choose a c-section:

I've had a shoulder dystocia, a pretty severe one, in a baby who was 10 lbs 2 oz. We are lucky that she is alive. While "fat squishes" is somewhat true, fat also impacts the ability that you have to maneuver a stuck baby. Unless you've seen or experienced a shoulder dystocia in a truly macrosomic infant, I don't think you can really see how bad this can be. You're not just up against extra padding. This isn't just a chubby baby. You can be giving birth to a baby who has the frame size of your average 3 month old, and go from a perfectly wonderful baby on the inside to a baby Apgaring at 0 in 3 minutes flat. This isn't something to write off.

Beyond that, the shoulder dystocia rate for moms with gestational diabetes is significantly higher than for moms without gestational diabetes even if the baby's birthweight is the same. It's been a long time since I looked at it, but my understanding was that the shape of babies born to mothers with GDM is different enough that a baby is more likely to get caught up.

I would want the ultrasound in 3d as a final confirmation that your son really is looking that big. But the previous poster is correct about lung maturation in babies born to diabetic mothers, so the scales *for me* would tip more towards c-section at this point.

[Storm Bride]

I'd sit around crying for week...then, I'd probably go with the c-section, to give the baby the extra time to mature. However, I think I'd do everything I could to at least go into labour first, instead of scheduling. Of my three scheduled c-sections, the one I hated the most, and the one where my baby had the most trouble, was the one where I didn't have any labour beforehand. My other two were as good as a scheduled section can get, imo - labour started spontaneously just before the surgery (the night before in one case and about an hour before I left for the hospital in the other).

I don't really know a lot about GD, but I'm very edgy about early inductions...

Honestly, the more I think about it, the more I don't know what I'd do...I have a real thing about choosing a section, but I'd also hate to choose induction.

I'm am curious about one thing. If one does attempt induction, can you just leave if it doesn't "take"? I hear so many stories about emergency c-sections for failure to progress when labour's being induced, and I'm just wondering if there's a reason why they can't just stop the induction and either wait for spontaneous labour or schedule a c-section later (barring an induction for pre-e or something like that). Is there a reason or is just a "once we've started, we'll finish" thing?

[34me]

This is only coming from my experience, so definitely take what you can use and throw the rest away. I was having issues with phlebitis in my pregnancy with my dd so my gp decided to induce her at 38 wks so that I would stop retaining fluid in my legs. I went in the night before and started induction and the pit was started at about 9am. I went home about 9pm because you know what - it doesn't always work . No one told this formerly mainstream mamma this little fact 16 years ago. She was born 2 weeks later on her due date at 8lbs even. Her brother was born at 41+4 by emergency (general anesthesia and everything) c section and was 9lbs 3 oz after he went into distress with induction.

So really it is whatever you are comfortable with as your mileage may vary...

[kittywitty]

As for weight and shoulder dystocia (From the unnecessarean):

One half of all cases of shoulder dystocia occur at birth weights of less than 4,000 g (8 lbs., 13 oz.).

Acker DB, Sachs BP, Friedman EA. Risk factors for shoulder dystocia in the average-weight infant. Obstet Gynecol 1986;67:614-8.

In a 1993 study to test the hypothesis that elective induction of labor, compared to spontaneous labor, reduces the cesarean rate in women with a sonographic diagnosis of fetal macrosomia, researchers concluded that because elective induction of labor increased the cesarean rate and did not prevent shoulder dystocia, mothers with macrosomic fetuses can safely labor spontaneously. [Combs CA, Singh NB, Khoury JC. Elective induction versus spontaneous labor after sonographic diagnosis of fetal macrosomia. Obstet Gynecol. 1993 Apr;81(4):492-6.]

Also, shoulder dystocia only occurs in about 0.5% of births.
http://www.shoulderdystociainfo.com/anticipated.htm

http://www.library.nhs.uk/Diabetes/V...x?resID=236711

http://www.gentlebirth.org/archives/gdhgoer.html

http://journals.lww.com/greenjournal..._Fetal.10.aspx

[loveneverfails]

The flip side to the 50% of shoulder dystocias being in babies who are under 4000 grams is that the other 50% of shoulder dystocias are happening in only the top 10% by weight of babies. 50% of a given complication happening in only 10% of the birthing population is enough to give one pause. Weight is a relevant factor if you are concerned about shoulder dystocia, and the OP *is* concerned about that complication.

[kittywitty]

And the research shows an increase risk of sd in inductions. But still in a very small percentage of births compared to the tripling of death rates and respiratory distress with c-sections. I'm just providing information as she requested on the subject.

[2sweetboysmom]

StormBride- I am throwing at least one full on temper tantrum over this daily. I feel like I am in a position of deciding between 3 things which all have genuine risk and weighing in the balance my lil guy and his health and my own ongoing health too as the mom of 4 busy boys. My ability to be an active part of their lives going forward has value too, YK.
I am having some pretty intense prodromal stuff for weeks now and alternate encourageing it and ignoring it. It really seems to me that he is just not finding a good position. In addition to having followed spinning babies stuff the whole pregnancy (last baby was a late breach) I am continuing to do all of the positioning stuff and my regular chiro.

Kittywitty- Thank you. I appreciate your links and such. I have been researching this for a few weeks now and want to make as informed a decision as possible. I honestly never thought I'd be here. My last birth was to an IUGR babe!

Originally Posted by kittywitty

As for weight and shoulder dystocia (From the unnecessarean):
One half of all cases of shoulder dystocia occur at birth weights of less than 4,000 g (8 lbs., 13 oz.).
Acker DB, Sachs BP, Friedman EA. Risk factors for shoulder dystocia in the average-weight infant. Obstet Gynecol 1986;67:614-8.

Which seems reassuring to the mother of a LGA baby, but the other side of that equation is...One half of all shoulder dystocias occur at birth weights greater than 4,000g (8lb13oz)
Incidently 4,000g is the 90th% line for birth weight. So the 10% of births (which happen to be over 4,000g) get 50% of all occuring shoulder dystocias.
Babes born with weight in excess of 4500g experienced dystocias 22.6% of the time. Acker (1985)

"The overall incidence of shoulder dystocia varies based on fetal weight, occurring in 0.6 to 1.4 percent of all infants with a birth weight of 2,500 g (5 lb, 8 oz) to 4,000 g (8 lb, 13 oz), increasing to a rate of 5 to 9 percent among fetuses weighing 4,000 to 4,500 g (9 lb, 14 oz) born to mothers without diabetes.2–4 Shoulder dystocia occurs with equal frequency in primigravid and multigravid women, although it is more common in infants born to women with diabetes."
Shoulder Dystocia
ELIZABETH G. BAXLEY, M.D., University of South Carolina School of Medicine, Columbia, South Carolina
ROBERT W. GOBBO, M.D., University of California at Davis Family Practice Network, Merced, California
Am Fam Physician. 2004 Apr 1;69(7):1707-1714

[loveneverfails]

2sweetboysmom, scroll down further on the shoulderdystocia info page. They've got the chart for diabetic moms on there. I know you've been controlling your diet really really carefully, and the "diabetic mom" group here includes the entire population from you to the mom who drinks 56 oz slushies 8 times a day.

According to the diabetic chart, you've got the following likelihood of encountering shoulder dystocia:

Weight Non-Diabetic Diabetic
< 4000 g 1.1% 3.7%
4000-4499 g 10.0% 30.6%
> 4500 g 22.6% 50%

Now, even if you encounter shoulder dystocia, that doesn't mean you get a permanent injury. It runs the gamut from simple repositioning to the last ditch trying to put the head back in the uterus and perform an emergency c-section. There are some temporary things you can run into after a shoulder dystocia that more or less resolve on their own. But shoulder dystocia can cause permanent nerve damage, bone fracture (arm or clavicle), and hypoxic brain injury. It can be fatal.

And another factor to consider is that if you induce, your baby may be somewhat oxygen deprived from the pitocin already going into a shoulder dystocia scenario. That is worrisome to think about.

[April422]

Another factor everyone is leaving out (or I've missed it entirely) is how our birthing practices contribute to shoulder dystocias. Supine positions, epidurals, etc. Further control for those factors and the risk can be reduced.

I'd never have an elective cesarean for a suspected or even "confirmed" LGA baby.

There's also some room for debate about a "diabetic" who is diet controlled only, vs a true diabetic who requires insulin, etc. If your "diabetes" is controlled you don't have the same risk factors that diabetics who can't get control even with insulin do.

Twice in over a decade have I seen ultrasound correctly predict a LGA baby. Twice.

[seren]

I have thought about this a lot in the last two years. There are times I look at my 25 month old as he conducts music (his favorite activity) and it literally brings me to tears. I thank God every day for the miracle that He blessed us with. I am overweight. I did not have gd for most of my pregnancy, I tested frequently. I stopped towards the end and we think I developed it then. Or maybe I had it all along, I was just very careful and when I quit testing I wasn't so careful. I also had a football sized fibroid on top of ds in my uterus, so it was hard for my midwife to accurately gauge how big ds was. Even I didn't realize. When I was pregnant with my third, I knew she was bigger than my other two and she was 1.5-2 lbs bigger than they were. When ds's head came out he got stuck. Nothing I did helped, no way I moved, no position I got it. I was pushing with everything I had. I could tell it wasn't doing anything. THe midwife used what she called "the corkscrew method" to get him out. He was 10 lbs 6 oz. He had gone into distress. He did not breathe on his own for four minutes. His 1 minute apgar was either 0 or 1. I can't remember right off the top of my head right now. By 5 minutes he was up to 8. It took a bit for us to realize ds wasn't moving his arm. The midwife had bruised his nerves. He had perfect finger print bruises on his arm and shoulder. He had a brachial plexus injury. We took him to the dr at 4 days old (he was born Thursday) and they did x-rays. They sent us to a physical therapist. I cried when we met with her. She told us that ds might never clap his hands, he might never crawl, he might never be able to use his left hand to feed himself. Let's not even talk about the mommy guilt. Ds was in therapy for 13 months. He healed so quickly he astounded all the therapists at the place we went. He only went for so long because he got so used to not putting weight on his arm he wouldn't crawl properly, so we worked on that until he could walk. My son literally is a miracle baby. His story could have had many different endings. I never realized just how dangerous dystocia can be. We're lucky he only had a brachial plexus injury. Where he had therapy, they have 4-6 year olds who are not doing as well as ds was at 6 months. I thank God every day, I truly believe he work a miracle to heal ds.

Now, after all that. Would I have had a c-section instead? Absolutely! I would have saved him from all that if I had known it was even a possibility. The birth was traumatic. Physical therapy was hard, he hated it. As much as I fear a c-section, I would have done it for him.