Is there a point where size would influence your birth choice?

[Ninetales]

I'm due with my second in August.  At this point I am planning on, and my doctors see no reason why I can't, VBAC.  But, my first was 13 lbs, 8 oz.  We had no indication she was so large - I measured pretty much on track, no sugar problems, no problems whatsoever.  I gained maybe 70 lbs, which is a lot but certainly not unheard of.  I had no ultrasounds.  Big babies run in both families (9-11 lbs), so I expected a big one, but not that big.  I'm very scared it's going to happen again.

So far, if things stay on the track they are on now, I'm anticipating a 35 lb total gain.  So half the weight I gained the first time around.  I had an ultrasound at 20 weeks, and at the time they said the baby was measuring at about 1 lb, which I'm to understand is large but not scarily so.  I've measured ahead at my last two appointments - I was 27 cm at 24 weeks, and 29 cm at 28 weeks.  I'm getting weekly adjustments from my chiropractor, which I'm hoping will help me avoid the back labor and malpositioning that contributed to my c-section.

My hangup here is while I don't want a c-section, I'm also afraid to vaginally birth a child over 12 lbs.  I'm scared of the possible damage - cervical damage, incontinence, tailbone damage, broken shoulders, broken collarbone, or dystocia.  Which I know, I know can happen with babies of any size.  And I know that fundal measurements and late ultrasounds are not really very accurate, but there's no other way of estimating the size.  I know that I will be waiting to go into labor on my own no matter what I'm told to expect for size, but I'm both afraid of vaginally birthing another LGA baby and afraid that this fear is going to lead to me somehow sabotaging my VBAC.  And I know I'd be beyond pissed off if I gave in right away and was sectioned for a 10 lb baby.

So I guess what I want to know, is there a point where your caregiver tells you a size number that would make you just not want to do a vaginal birth?  Or would you just stick it out, hope for the best, and see how the labor progresses?  Do some people just grow freakishly large babies for no reason?  I don't want this hanging over me anymore but I don't know how to let it go.

[AmandaMamma]

It sounds like you have really supportive doctors. I think a lot of doctors would be pressuring a woman into a section after a 13 pound baby. Especially for a VBAC. I hear of so many pushing for induction or section for anything over 9 pounds. So that is good to hear.

Would you be up for another ultrasound down the line? Yes they aren't AS accurate but maybe it would help you with a decision?

[Ninetales]

I plan on getting another near 36 weeks, yes.

[Plummeting]

There actually IS another way to estimate the size of the baby. Multiple studies have shown that a skilled practitioner (midwives are generally better at this, according to the studies) is as or more accurate at guessing the weight of babies as ultrasound. So if you're concerned, then perhaps find someone to palpate and see what they think.

I do have to wonder how sure you can be that you had no blood sugar problems. Were you checking it at home? The 28 week test only tells you what's happening at 28 weeks, and you can develop GD after 28 weeks. It happened to me. So I'd be checking your blood sugar at home, if you aren't already. However, if I recall correctly, excessive weight gain or maternal obesity are just as strongly correlated with birth weight as GD (I think even more so, actually), so surely maintaining a more average weight gain will help some. I understand your concern about such a large baby. I don't know what my personal comfort zone is, but I definitely would not want to birth a 12 pound baby either! Good luck, and hopefully this baby is a little smaller and your VBAC goes well.
 

[Ninetales]

Thing is, I went through a freestanding birth center staffed by midwives with my first.  Four different ones and no one ever suspected a problem.  So I'm afraid my faith in palpating is pretty shaky, too.

I did the glucose test at 28 weeks with both pregnancies.  The first one was a postprandial, this one was with the glucola.  I asked about monitoring sugar later on, as I suspected the same as you - that some kind of issue developed later, possibly very close to the end.  I was told by two doctors at the practice I go to that if GD is going to present it will have by 28 weeks.  So I'm probably on my own if I'm going to keep tabs on it.  I wouldn't even know where to begin, either.  :(

It doesn't help that I am in fact obese.  I used to be so adamant that a body would only grow a baby it couldn't birth under extreme circumstances.

[holly6737]

With a history of a 13 lb 8 oz baby, yes, that would affect my choice to VBAC. Now, keep in mind I'm pretty pro-VBAC. I"ve had 2 myself. But history of a 13 and a half pound baby? Honestly, the risk of shoulder dystocia, postpartum hemorrhage, etc would just be too great for me. I would choose a repeat. Obviously this is something you should discuss with your physicians/CNMs, but that's the choice that I, personally, would make.

[Plummeting]

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Edited by Plummeting - 9/5/12 at 10:08pm

[nelson]

Originally Posted by Plummeting 

Perhaps your size made it more difficult to palpate the baby? (I always feel like I'm saying the wrong thing when I talk about weight, so please understand I'm just wondering on what may have happened, and not making any judgments or anything.) I don't know if that was considered in the studies I read, but I can see where it might make a difference, and having experienced that, I would also decide it didn't work for me. I've had the opposite experience (my midwives have been spot on at guessing the weight), so of course I lean more towards trusting it for myself.

I had midwives and nurses palpate the baby the day I went into labor, and they said, "Oh, I think this one will be quite small, probably only around 5.5-6 lbs."  DS actually ended up weighing 8lbs3oz.  Not that he was a huge baby, but they were off by a couple of lbs.  Any random person off the street probably could have guessed within a couple of lbs. just as easily.  Also I started off 5.5" and 120 lbs. and gained about 25lbs. with DS, so I wasn't very big. 

[folkgirl]

I am familiar with your story. I'm in your DDC this time and coincidentally I was last time, too. :) I think your situation is pretty unusual and definitely would give me pause. I have had GD with all of my pregnancies, but I've never had a particularly large baby. Mine have always measured larger than they actually turned out to be. In my last pregnancy they were estimating a 9-10 lb baby two weeks before she was born at 8lbs11oz. Even still, I know there is a possibility that I will have a "diabetes big" baby this time and I can't say that doesn't bother me sometimes.

The way I feel about it for me is that there's no way that I can know if the baby is going to come out unless i have a trial of labor. Sounds like that is the approach your providers are taking so far. If we know that fetal weight estimation is frequently wrong (very wrong) then what else can we do? Yes there are risks of shoulder distocia etc, but SD can occur even with smaller babies when no one is expecting it. Sometimes it has more to do with position than size. And even when we're talking big baby, proportions can matter a lot more than the overall size of the baby. And you're just as likely to have failure to descend or another non-emergent thing come up than SD (I think, don't have stats handy). And if you get to the pushing stage again and baby is just not going to come out, then that's what c-sections are for. I know it's intimidating to think of going through labor and still having a c-section. Most modern doctors are very skilled at doing c-sections in a variety of circumstances so I would think if you really needed one it would be ready.

And what if the baby IS the right size and come right out? That would be great.

Wishing you much luck.

[Ninetales]

Originally Posted by Plummeting 

Perhaps your size made it more difficult to palpate the baby? (I always feel like I'm saying the wrong thing when I talk about weight, so please understand I'm just wondering on what may have happened, and not making any judgments or anything.) I don't know if that was considered in the studies I read, but I can see where it might make a difference, and having experienced that, I would also decide it didn't work for me. I've had the opposite experience (my midwives have been spot on at guessing the weight), so of course I lean more towards trusting it for myself.

Your doctors were wrong to say that GD is always present by 28 weeks. It is almost always present by 28 weeks, and 28 weeks is the cut off at which it has been determined the benefits outweigh the costs of testing everyone, but you can absolutely, positively develop GD after 28 weeks. It's uncommon, but it definitely happens. If you want to test your own blood sugar at home, it's really very easy. You can get a cheap meter at WalMart for about $9. I know a lot of people don't shop there, and I generally don't either, but it was either buy the meter and strips there or pay over twice as much elsewhere, so...I just did it. Anyway, the brand is ReliOn. The one I use is called the Ultima, I think. It will come with a lancing device and ten lancets. I think maybe it comes with a few strips, but I can't remember. Just buy a pack of 25 strips for about $15 or so. Then you will need to order some testing solution from the company - there's an 800 number in the packaging and the solution is free. I live in Hawaii and I got it in under a week, so if you're on the mainland I imagine it wouldn't take long at all. Then just follow the directions for using the meter, making sure your fingers are ALWAYS clean before you do it. Don't milk the finger too much, as this can artificially lower your reading. Just prick, then wait a few seconds, then gently, gently milk (very gently) and you should get a good drop of blood. You want to test first thing when you get up in the morning, then an hour after your meals.

Normal blood sugar for a pregnant woman is lower than for a non-pregnant woman, due to the extra blood volume of pregnancy. This is what you're looking for:

Fasting (first thing in the morning, before eating): 80 or less

One hour after meals: 122 or less

Two hours after meals: 110 or less

One hour after a meal means one hour after the FIRST BITE, not one hour after you finish. Two hours means two hours after the first bite, of course. Here's a link discussing those numbers and where they came from: http://diabetesupdate.blogspot.com/2011/10/normal-blood-sugars-in-pregnancy.html

In all likelihood, you don't have GD, just because it is rare to develop it after 28 weeks, but it's still possible, so personally I'd want to find out for sure, given your enormous first baby.  I'm a totally normal size and I still got GD after 28 weeks. I was only checking because I had declined the test (and I probably would've passed it anyway) and wanted to be sure nothing crazy happened. Good thing I didn't stop at 28 weeks. :) You may not even be interested in checking your own blood sugar, and I totally understand that, but I did want to provide the information for you, just in case you did want to check it. It really isn't that difficult, once you know what to do and what you're looking for.

You are a lifesaver!  That is just the information I was looking for.  I don't mind buying from Walmart, and I am relieved to know there is a relatively inexpensive option for testing on my own.  I was afraid I'd have to go to a medical supply store and spend hundreds of dollars or something.  And no offense taken re: palpating and size.  I've started coming to terms with the fact that some things I've taken for granted just don't apply to me.  I think it will be worth checking myself as I go on just to be sure I don't develop something.  I'm more afraid of vaginal birth with an unnaturally large baby vs. one my body grew on its own.

[Ninetales]

Originally Posted by folkgirl 

I am familiar with your story. I'm in your DDC this time and coincidentally I was last time, too. :) I think your situation is pretty unusual and definitely would give me pause. I have had GD with all of my pregnancies, but I've never had a particularly large baby. Mine have always measured larger than they actually turned out to be. In my last pregnancy they were estimating a 9-10 lb baby two weeks before she was born at 8lbs11oz. Even still, I know there is a possibility that I will have a "diabetes big" baby this time and I can't say that doesn't bother me sometimes.

The way I feel about it for me is that there's no way that I can know if the baby is going to come out unless i have a trial of labor. Sounds like that is the approach your providers are taking so far. If we know that fetal weight estimation is frequently wrong (very wrong) then what else can we do? Yes there are risks of shoulder distocia etc, but SD can occur even with smaller babies when no one is expecting it. Sometimes it has more to do with position than size. And even when we're talking big baby, proportions can matter a lot more than the overall size of the baby. And you're just as likely to have failure to descend or another non-emergent thing come up than SD (I think, don't have stats handy). And if you get to the pushing stage again and baby is just not going to come out, then that's what c-sections are for. I know it's intimidating to think of going through labor and still having a c-section. Most modern doctors are very skilled at doing c-sections in a variety of circumstances so I would think if you really needed one it would be ready.

And what if the baby IS the right size and come right out? That would be great.

Wishing you much luck.

Haha, I told my sister that I was planning on staying home as long as possible before going into the hospital, and she was all "ohh, be careful, you don't want to have the baby in the car!"  And I said, "um, sure I do!  My problem is more likely that it won't come out at all, so the car is just fine!"  Especially because that would be an awful lot cheaper.  ;)

I have been hoping that if it's too big it will just not come out again, like the first time. 

I feel loads better about it, either way I decide to go.  Thanks to everyone for their thoughts!

[hildare]

size influenced my decision to have a RCS rather than a VBAC. 

dd was 10 pound plus at birth, no signs of GD (and the c wasn't for size, it was for water being broken 24 + hours with no dilation/effacement).  we read everything, all the recommendations and lit reviews and research.  none of it was particularly conclusive, though there is some info out there that there is an increase of rupture with a baby over 8.8 pounds. 

i was in much the same situation as you are- we knew that second baby wasn't going to end up smaller than the first, and at the end, we knew ds would be over 8.8, but i also had other issues not associated with size that made an RCS seem like the safest route for us.  i also have problems dilating in general, and it wasn't happening at 39 weeks, not at all.

if your only concern is size, there was a thread somewhere in VBAC forum where lots of people contributed that they had successfully VBAC'ed large babies. 

also, if your midwives/doctors are encouraging you to VBAC, you probably have a good chance at it working.  :) 

i wouldn't let size be the one thing that kept you from trying, though. 

some people do just have large babies, i am one of them :)  but you sound like you're really on track with monitoring. 

good luck!!!!

[AmandaMamma]

Originally Posted by Ninetales 

And no offense taken re: palpating and size.  I've started coming to terms with the fact that some things I've taken for granted just don't apply to me.  I think it will be worth checking myself as I go on just to be sure I don't develop something.  I'm more afraid of vaginal birth with an unnaturally large baby vs. one my body grew on its own.

Hi there. I'm obese as well and it is harder for my midwife to get a detailed palp. Also the external monitors don't work as well for me.

I was kind of close to the cutoff numbers for GD so decided to test myself. It has been extremely reassuring to see the numbers. And very educational to have the accountability and how certain food affect things. Good luck!

[homebirthing]

I go by 90 or less for fasting, 140 1 hr pp and 120 2 hr pp

[Youngfrankenstein]

Originally Posted by Ninetales 

It doesn't help that I am in fact obese.  I used to be so adamant that a body would only grow a baby it couldn't birth under extreme circumstances.

I think many of us fell prey to this myth.  It was "shouted" over and over that a mom wouldn't grow a baby she couldn't birth vaginally.  That obviously isn't true.  I was 200# during my last pregnancy and while I didn't have sugar issues (did at home blood testing) and I lose weight while I'm pregnant (I puke a lot), I still feel my high carb intake made a larger baby for me.

I am a hypocrite to give this advice because I was never successful at it, but try to keep your diet in check.  I think if I could do that I'd wait for some ultrasounds towards the end and make a decision closer to that time.

I have never faced choosing a c/s where it was a difficult choice.  I wish you luck and keep your chin up.  Whatever you decide that keeps mom and baby healthy is a right choice.

HUGS!

[Plummeting]

Originally Posted by homebirthing 

I go by 90 or less for fasting, 140 1 hr pp and 120 2 hr pp

Those are not normal numbers. Those are targets for women who have GD. If you are hitting those numbers, you have GD. The OP wasn't asking for targets for women with GD. She was saying she had wondered if perhaps there were some blood sugar problems during her pregnancy, so I shared with her what normal numbers would be.

[AmandaMamma]

Originally Posted by Plummeting 


Those are not normal numbers. Those are targets for women who have GD. If you are hitting those numbers, you have GD. The OP wasn't asking for targets for women with GD. She was saying she had wondered if perhaps there were some blood sugar problems during her pregnancy, so I shared with her what normal numbers would be.

Could you point me to a resource for this? I've been shown conflicting information and have been curious about it. Thanks!

Edited to add that I just saw the link in your first post!

[1stTimeMama4-4-10]

Originally Posted by Plummeting 

Those are not normal numbers. Those are targets for women who have GD. If you are hitting those numbers, you have GD. The OP wasn't asking for targets for women with GD. She was saying she had wondered if perhaps there were some blood sugar problems during her pregnancy, so I shared with her what normal numbers would be.

Are you sure about that?  I spoke to my midwife today about the cutoffs for the glucose screen and I don't remember the exact numbers, but the cutoff was pretty high.  I know the glucose test involves an insane amount of sugar in a short period, but I'm not so sure that the numbers cited by the PP are wrong.

[Youngfrankenstein]

Originally Posted by 1stTimeMama4-4-10 

Are you sure about that?  I spoke to my midwife today about the cutoffs for the glucose screen and I don't remember the exact numbers, but the cutoff was pretty high.  I know the glucose test involves an insane amount of sugar in a short period, but I'm not so sure that the numbers cited by the PP are wrong.

Yes, I curious too.  Those were the numbers I was given when I was doing self blood testing over a 3 day period at the end of my pregnancy.

[AmandaMamma]

I followed the link which talks about a study done last year supporting the lower numbers. There are some doctors now who have commented that the numbers should be lowered. So it seems that this info is fairly new and only has one study. But there is also a debate about how going too low on carbs causes ketosis and the affects on the baby. More info needs to be conducted before the majority of doctors and midwives change the official recommendations.

When I look up glucose levels in healthy adults it looks like the diagnostic numbers were even higher than the 120 2 hour number most of us have been taught.