c-section for large baby?

[chapulina]

Hello,

I am desperate for your thoughts and insights on my ob's recommendation for having a c-section d/t a large baby. u/s showed baby to be 8lb 9oz at 37 weeks.

my first baby was a vaginal delivery and weighed 9lb 6 oz. Apparently there was some "mild shoulder dystocia" with her delivery, something I didn't know until today when the ob said that my midwife had noted it on my chart. Anyway, he thinks that having a previous baby with shoulder dystocia is why I should have a c-section with this baby. and that by not having one, I am putting my baby at big, undeterminable risks.

I am so upset and emotional about this right now; not at all rational. I am thinking that I'd rather be induced than walk straight into a c-section without trying.
BTW, #1 was induced due to my water breaking and being GBS+, and ctx's not starting up. she was posterior, until some time right before delivery. this baby is posterior too, and I am once again GBS +.

[fire_in_july]

Okay.

1) Big baby does not guarantee shoulder dystocia. Many small babies have it as well, and many big babies don't.

2) Ultrasound measurements at this age of gestation can be off 1 to 2 pounds or occasionally more.

3) Though of course you have to come to your own conclusion on this, *I* would NOT consent to being induced OR having a Cesarean for this. The baby is showing no other medical complications or signs of distress right?

4) The hands-and-knees birth position is great for shoulder dystocia (IF your babe even has it). I believe (but am not as positive as on the dystocia) that it also can help with posterior babies. I personally would try this first.

You pushed out a 9lb 6oz babe! Even if this one is 10 pounds+ your body should be more than capable of doing it again!

Hope I helped a little!

[alegna]

I wouldn't have a section for size based on an u/s (which are notoriously inaccurate) Shoulder dystocia can happen with small babes too. Tends to be a position issue usually.

In your shoes I would not be induced or agree to a section. But I also wouldn't have had the u/s because I think they cause more worry and problems than they solve. I think hands-off homebirth is the best choice for most births.

-Angela

[Spark]

fireinjuly
:

What she said!

to you!

[chapulina]

hey, thanks for your thoughts!

ITA that having the u/s was a bad and wasted idea; in fact, seeing the ob at all was a bad idea. I should have know better.

my next appt. is with the midwife that delivered my #1, so I will get her thoughts on all this, and she is very cool and I have lots of confidence in her.

I am wondering if it is something about the shape of my pelvis that presents a problem - like is that why my babies like to lie posterior and that leads to some difficulty to getting the rest of their bodies out?

[Spark]

Thoughts on posterior babes -- sometimes I think moms need the baby to be posterior to go with her pelvis. A lot of times I think posterior is preventatable. Have you checked out www.spinningbabies.com ? It's a great read.

[alegna]

Ditto on the spinning babies site. Good stuff that.

-Angela

[Treasuremapper]

OK, I have two different perspectives on this issue, based on my experience and on the experience of an AP mama friend.

First, congratulations! Nine pounds, six ounces is not that big. I would not be concerned about shoulder dystocia based on size.

However, an AP friend of mine had her son naturally with a midwife in a hospital. Her babies were average size, I believe they were both seven or eight pounds. Her first baby had shoulder dystocia, but she decided that natural birth was very important for her for many reasons. Tragically, the second baby had shoulder dystocia as well, resulting in several severe and permanent disabilities. I get tears in my eyes as I type this, because she sent an email to me and several others saying, basically, that since the first baby had shoulder dystocia, there was a better chance that the second baby would have shoulder dystocia, and that she did not realize that before. Her email said that she had thought that having a natural birth was the most important thing, but she did not know about the history of shoulder dystocia being a risk factor. I have seen her and her baby, and he has the birth injury where one of the arms is paralyzed. They do not know whether he will have permanent brain damage as well.

So I think that the issue is not the size of the baby. I think that the history of shoulder dystocia may be significant, however, and you may want to investigage that further. I will try to find the link to the website message boards. They have a lot of information about how to predict shoulder dystocia.

[Treasuremapper]

Likelihood of SD in second baby is 14 times greater if first baby had SD

http://www.ubpn.org/

This organization has message boards. I think the TOS don't allow linking to other message boards, but I noticed that there are discussions about whether to have natural birth or cesarean birth after shoulder dystocia. The responses may surprise you, because some say to go ahead and go natural, depending on the circumstances and information, etc.

ETA: I noticed that at least one of the threads said that the likelihood of SD increases fourteen fold if other babies had SD. I don't know if this is accurate or not.

[chapulina]

Inezyv,

thanks for the website referral. very interesting.

[sarahwebb]

Talk to your midwife about her experience with shoulder dystocia and large babies. Then make your decision based on her comfort level and experience. You could also contact the midwives at The Farm for more information on shoulder dystocia.

That said, I wouldn't worry based purely on size or projected size. My guys were 10 pounds 2 ounces and 11 pounds 2 ounces respectively. I delivered them both at home with a midwife and had no tears or episiotomy. Their apgars were 9/10 and 9/9.

I was GBS+ both times and despite having long labors, my water didn't break until close to delivery. Neither of my guys were affected by the GBS.

Both of my guys were malpositioned. Ds #1 was turned halfway between posterior and anterior. My midwife manually turned him after I had been pushing a while.

Ds #2 was posterior. He turned anterior and I went into labor, then he turned again and my labor stalled. My midwife did a diaphramatic release based on the following article, and he turned while we watched. He was born 8 hours later.
"How to Do a Diaphragmatic Release"
(http://www.naturalchildbirth.org/nat...or/labor29.htm)

Best of luck,
Sarah

[flapjack]

Braxton Hicks contractions and the early stages of labour may well turn baby closer to the time- you can use the positioning tools from spinning babies to help as well.
As far as the initial question goes, I wouldn't worry about the estimated birth weight at all. I would ask to see your records from your first delivery, just to confirm that such an entry actually exists (not that I'm at all sceptical, but I've heard of doctors lying to their clients before) and discuss the shoulder dystocia with your midwife at length. Remember that this OB probably sees very few natural deliveries and very many problem/ surgical deliveries, so his perspective may be somewhat unrealistic.

[cappuccinosmom]

What they said.

My midwifes back-up OB was a total jerk and tried to encourage me to induce early or he was certain I'd need a section. :

As it happened, the u/s was on target, and I delivered a 9 lb 15 oz boy. In 4 hours, with 15 min pushing. No epidural, no episiotomy, and only intermittent monitoring. He had mild SD, but it didn't hinder the birth enough for me to even notice.

Now, while the u/s was right this time, it was wrong, wrong, wrong with my first baby. They were scaring me with stories of a gigantic baby and urging induction, and he came out under 7 lb, and it was harder than pushing out the ten-pounder.

[Sagesgirl]

Shoulder dystocia is not a laughing matter by any means. True shoulder dystocia, that is. However, with your report saying "mild shoulder dystocia" and your later comment that the baby was posterior, it sounds much more likely to me that it was a positioning issue rather than an actual size issue. As others have said, consult your midwife, as I am assuming it is she who will be present at the birth. One hopes that since she didn't mention it to you (and not to excuse her, because she should have) it did not present a problem at all and another wouldn't either. But it is definitely a subject you need to discuss with her.

[mwherbs]

I read some time back the studies that show that C-section did not necessarily prevent problems like shoulder dystocia because there are more factors than just weight involved.

here is one study but I know that there are more and will keep looking

Obstet Gynecol. 1996 Oct;88(4 Pt 1):526-9.

Is macrosomia predictable, and are shoulder dystocia and birth trauma
preventable?

Gonen R, Spiegel D, Abend M.

Department of Obstetrics and Gynecology, Bnai Zion Medical Center, Faculty of
Medicine, Technion, Haifa, Israel.

OBJECTIVE: To assess our ability to detect macrosomic fetuses, and to examine
the relationship between prenatal diagnosis of macrosomia and the incidence of
shoulder dystocia and birth trauma. METHODS: We instituted a protocol for
routine detection of macrosomic fetuses, defined as weight estimated to be at
least 4500 g. Fetal weight was estimated by ultrasonography when there was
clinical suspicion of macrosomia. We collected data on these pregnancies as well
as on deliveries of macrosomic infants, shoulder dystocia, and birth trauma.
RESULTS: During the 14-month study period, there were 4480 deliveries. There
were 23 macrosomic newborns (0.5%), of whom 17 were born vaginally. Six of these
17 (35%) vaginal deliveries were complicated by shoulder dystocia, and one
infant sustained brachial plexus injury. The overall frequency of shoulder
dystocia was 2%, the majority (93%) occurring in infants weighing less than 4500
g. Eleven newborns sustained brachial plexus injury (0.2%), and 39 had isolated
clavicular fracture. Six of nine cephalic deliveries that resulted in brachial
plexus injury were associated with shoulder dystocia. The sensitivity and
predictive value of the study protocol were 17% (four of 23) and 36% (four of
11), respectively. Surprisingly, clinical estimation alone had a sensitivity of
43% (ten of 23) and a positive predictive value of 53% (ten of 19). CONCLUSION:
The ability to predict macrosomia is limited. The predictive value of clinical
estimation of fetal weight alone may be slightly higher than when it is combined
with ultrasonography. Because most cases of shoulder dystocia and birth trauma
occur in nonmacrosomic infants, these conditions are practically impossible to
prevent.

[mwherbs]

here is another one this is quite a high cost if you ask me for prevention---- and it really doesn't look like the quality of life scores are much different

Int Urogynecol J Pelvic Floor Dysfunct. 2005 Jan-Feb;16(1):19-28; discussion
28. Epub 2004 Jul 29.

Elective cesarean section to prevent anal incontinence and brachial plexus
injuries associated with macrosomia--a decision analysis.

Culligan PJ, Myers JA, Goldberg RP, Blackwell L, Gohmann SF, Abell TD.

Department of Obstetrics, Gynecology and Women's Health, Division of
Urogynecology and Reconstructive Pelvic Surgery, University of Louisville Health
Sciences Center, 315 East Broadway M-18, Louisville, KY 40202, USA.
[e-mail]

Our aim was to determine the cost-effectiveness of a policy of elective
C-section for macrosomic infants to prevent maternal anal incontinence, urinary
incontinence, and newborn brachial plexus injuries. We used a decision analytic
model to compare the standard of care with a policy whereby all primigravid
patients in the United States would undergo an ultrasound at 39 weeks gestation,
followed by an elective C-section for any fetus estimated at > or =4500 g. The
following clinical consequences were considered crucial to the analysis:
brachial plexus injury to the newborn; maternal anal and urinary incontinence;
emergency hysterectomy; hemorrhage requiring blood transfusion; and maternal
mortality. Our outcome measures included (1) number of brachial plexus injuries
or cases of incontinence averted, (2) incremental monetary cost per 100,000
deliveries, (3) expected quality of life of the mother and her child, and (4)
"quality-adjusted life years" (QALY) associated with the two policies. For every
100,000 deliveries, the policy of elective C-section resulted in 16.6 fewer
permanent brachial plexus injuries, 185.7 fewer cases of anal incontinence, and
cost savings of $3,211,000. Therefore, this policy would prevent one case of
anal incontinence for every 539 elective C-sections performed. The expected
quality of life associated with the elective C-section policy was also greater
(quality of life score 0.923 vs 0.917 on a scale from 0.0 to 1.0 and 53.6 QALY
vs 53.2). A policy whereby primigravid patients in the United States have a 39
week ultrasound-estimated fetal weight followed by C-section for any fetuses >
or =4500 g appears cost effective. However, the monetary costs in our analysis
were sensitive to the probability estimates of urinary incontinence following
C-section and vaginal delivery and the cost estimates for urinary incontinence,
vaginal delivery, and C-section.

[MamaChel]

I had a u/s with # 1 that had him to be huge according to the ob, I mean we're talking too big to push out huge. He was 7 pounds 6 ounces. They were predicting over 10 pounds of baby based on the u/s. So I really wouldn't consider a c-section over that.

[mwherbs]

There is another fairly recent review of the litature but no abstract I think that the title says quite a bit.

Also i read the Erbs palsy sight that was mentioned and linked by someone else, there are some things that they have like position for birth - McRoberts (flat on your back with your knees almost to your ears) which is one way to move the tail bone and the baby's shoulder under the arch and another way which they didn't have is the Gaskin manuver- hands and knees which not only shifts the mother's tail bone but also the baby changes position a bit because of gravity- so that little bit of shift may be enough to allow a baby to spin--- a full squat is also good if you can hold that position -- using a vacume, forcepts or fundal pressure all increase the likelyhood of a shoulder dystocia .


Clin Obstet Gynecol. 2004 Jun;47(2):352-64.

Cesarean delivery for suspected macrosomia: inefficient at best.

Ecker JL.

Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical
School, and Vincent Memorial Obstetric Service, Massachusetts General Hospital,
Boston, Massachusetts 02114, USA. [e-mail]

Publication Types:
Review
Review, Tutorial

[Full Heart]

Originally Posted by mwherbs

CONCLUSION: The ability to predict macrosomia is limited. The predictive value of clinical estimation of fetal weight alone may be slightly higher than when it is combined with ultrasonography. Because most cases of shoulder dystocia and birth trauma occur in nonmacrosomic infants, these conditions are practically impossible to prevent.

This is great to read. I always suspected as much but never had any proof, just peoples stories.

Also....There was a study done some years ago, probably about 10 years now, on Nuns and urinary incontinence. None had ever been pg or given birth and yet they had the same rate for UI as the rest of the population. So I don't think birth, however its done, has much weight on UI. Perhaps if there is a direct injury.

Michelle

[Yummymummy74]

Originally Posted by chapulina

hey, thanks for your thoughts!

ITA that having the u/s was a bad and wasted idea; in fact, seeing the ob at all was a bad idea. I should have know better.

my next appt. is with the midwife that delivered my #1, so I will get her thoughts on all this, and she is very cool and I have lots of confidence in her.

I am wondering if it is something about the shape of my pelvis that presents a problem - like is that why my babies like to lie posterior and that leads to some difficulty to getting the rest of their bodies out?

I should offer to you .. that if your prone to posterior.. that might mean that that presentation is EASIEST for your baby to come out!! my pelvis is like this.. and I do not make ANY effort to rotate an OP...

Some people are just built different and you may be one of them.. were they trying to turn your baby at your last birth? maybe he/she got stuck in an anterior spot and thats what got the babe hung up?