Friday, May 25, 2012

Big Babies and Homebirth

Do 9-plus pound babies need to be born via C-section? That's the thing that stood out for me after reading Samantha M. Shapiro's story in this week's New York Times Sunday Magazine. I read this reprise on the homebirth debate with interest (and some dismay, since I talk about a visit to Ina May Gaskin on the Farm in my book). There are several things I liked about the article (the tone for instance), and several I didn't (the title - ugh). But undoubtedly the strangest thing about the story was this:
"When I reached my due date, an ultrasound estimated that my baby weighed 9.4 pounds. I didn’t have gestational diabetes and had gained an average amount of weight, and fetal tests showed my baby was thriving. But the baby’s estimated size, combined with the fact that he hadn’t yet descended into my pelvis, worried my midwife.
She wanted the baby out by 41 weeks, and to my surprise, she suggested I consider going straight to surgery without labor. She sent me to be evaluated by a doctor she worked with. “One way or another, this baby will be a C-section,” he said."
Shapiro doesn't go for the prophylactic C-section, and that prophecy comes true:

"I was told I wasn’t progressing. The midwife pressed for a C-section, saying if I continued to labor I risked the chance of infection or shoulder dystocia. Bigger babies are at a greater risk for this complication, which in rare cases results in stillbirth or injury to the baby. ... The midwife told us, “You don’t want to wait until the baby shows signs of distress — at that point it’s too late.” I negotiated for two more hours, made no further progress and then, under pressure, agreed to surgery. It was the kind of coercion by dint of not offering any other options that Gaskin talks about."
Here I wanted to know one more thing: Was this midwife (and the doctor) making good recommendations backed by evidence? In this story it sounds like the medical consensus is that C-sections should be used to prevent shoulder dystocia. It makes intuitive sense that big babies will be harder to deliver, but everything I could remember on the subject said that because it was so hard to estimate the fetal weight it didn't make sense to do preemptive C-sections unless the baby was a real orca (I'm allowed to say that: 11 pound baby right here). Nine and a half pounds is still solidly in the bell curve--if C-sections are a forgone conclusion for all of then, whew, that's a lot of surgeries.

I asked Amy Romano, who has a new book out on precisely this sort of thing if the weight of evidence supported a prophylactic C-section for 9.5 a pounder. Basically, no, she answered:
"Some birth injuries would be averted if all women with suspected macrosomia [big babies] had c-sections, but the number needed to treat is in the thousands. (Thousands of women would need to have c-sections to prevent one permanent injury related to shoulder dystocia)."
The problem with this is that every C-section causes damage to the mother and increases her risk down the road, as well as the risk to any more babies she might have. These are small risks, but when you are talking about thousands, they add up. That's why the American College of Obstetricians and Gynecologists says this:
"A policy of planned cesarean delivery for suspected macrosomic fetuses in women who do not have diabetes is not recommended ... if all fetuses suspected of being macrosomic underwent cesarean delivery, the cesarean delivery rate would increase disproportionately when compared with the reduction in the rate of shoulder dystocia"
(ACOG notes that there is some evidence to support a C-section if it looks like the baby is over 11 pounds.) This is not some fringe group here--this is the main representative of the specialty reviewing the sum total of the science. Contrast that with the doctor saying “One way or another, this baby will be a C-section,” as if trying to give vaginal birth to a 9.5 lb baby was just crazy. In other words, this wasn't a case of clinicians being somewhat coercive, this was a case of clinicians being totally anti-scientific (at least it seems that way, maybe there's more to the story).

When I was reporting on childbirth I would see this kind of variation in care all the time. At one hospital they'd proudly assure me, (let's see, to keep it simple I'll use a made up example) say: "Oh, yeah, we paint every baby red within 5 minutes of birth. No exceptions." And then at the next hospital down the road. "Of course we paint every baby blue, because we've known for years that red doesn't work."

Case in point, a month ago my sister in law gave birth to a 10.5 pound chubster. No one pushed her to have a C-section. And a prophylactic C-section for all babies over 9.5 lbs? The midwifes and doctors on her team (at UCSD) probably would think that was crazy talk. What do you think accounts for this difference? East vs. West medical culture? The legal culture? Or was there maybe something going on that we don't know about with Shapiro?


  1. A few months ago, I was a doula at two births a week apart. One mom had been told the whole 3rd trimester that her baby was going to be huge and had weekly ultrasounds. The other mom was told (by midwife's guesses) she'd have an 8 pound baby. Mom #1 had a 2 day labor that ended in a cesarean. Mom #2 had a 6 hour labor and pushed for 10 minutes. Both babies were ounces shy of 10 pounds. I think attitude was everything.

    1. I mean, clearly attitude isn't literally *everything* (if the Mom has a ricketts-deformed pelvis attitude isn't going to change that) - but I think you're just saying that attitude is important. There's certainly a lot of evidence for that. Everyone would agree that oxytocin is important, and that's a hormone that depends on feelings and attitude for release.

  2. Also, in the Times piece did she confirm that after the c-section the baby was in fact large? She doesn't say which makes me wonder if they were off with the weight. We know that weight estimates can be off a pound in either direction so the baby could have been 8.5 lbs, which is well within the range of normal.

  3. Attitude certainly is a factor (but I agree it's just one of multiple factors). There are a few studies that show that a baby large baby is more likely to be born by c-section if the provider suspected it was large (ultrasound or clinical estimate 8lb 14oz or more) than if it actually weighs that much, but the provider didn't suspect it. I think the attitude that "you're going to have a c-section one way or another" almost certainly biased the providers, but of course it's impossible to know what the outcome would have been with a more trusting provider. I, too, was left curious what the actual birth weight was.

  4. As a mom that vaginally delivered a 9lb 4oz baby, at home, I am very glad that I did not have a clue about her size. I knew that she had a growth spurt at 37 wx, but all 3 of my previous babies were in the 7lb range so I assumed that she would be no bigger than 8 lbs. So, when laboring to bring her into this world, my only concerns were positioning myself into an excellent position, and focusing on remaining mentally strong and confidant. I KNEW that I could get her out, because we ALL knew that I could get her out.
    It was never a question.
    My labor was 2 hours and 2 minutes from start to finish.
    With this in mind, I say "guessing" a baby's weight is not necessary and in fact detrimental to the NATURAL birthing process.

    Just my 2 cents anyway.

  5. At 42 weeks it was "realized" that my "late" baby was actually later than we realized, as my midwife had been using a due date from the date of last period, and the ultrasound showed an earlier due date. The baby was not in distress, and she was large. The consulting ob-gyn asked me what size shoe I wore...I told her a nine, she said oh you'll be fine. The baby was estimated at about eight or so pounds, I am 5'4" and small boned. This being my second pregnancy and being "older", having a little one at home, parents who had been staying six weeks already at my house waiting for the birth of this child, and well being a normal human being, I wanted to be done being pregnant! When we realized the baby was even later than we thought I got scared. As husbands often do it was up to me if I wanted to induce. Even though I had been thoroughly educated on the risks of inducing I was frightened enough ( that end of pregnancy fear of something happening at the last minute) to choose an induction. The midwife agreed ( although I don't know why!) and I was admitted in the evening and given the cervidal cap. The next morning labor began ( they never even gave me the Pitocin) the contractions were horrible, I could barely handle them, and I had gone through ten hours of natural labor with my first. Because I had elected to induce I had to be in the hospital instead of the birthing center, so I had to be hooked up to all the monitors, and I couldn't labor freely. My daughter was being forced out of my body by chemicals that I had elected to take, and she wasn't ready. The cord wrapped around her neck and her heart rate dropped, and my midwife told me in no uncertain terms that I had to get this baby out now. I understood her very clearly and set to doing just that. With such a force that her shoulder became stuck ( apparently it cannot be termed a shoulder dystocia if the situation is resolved) My midwife had me stop pushing and told me she had to get the baby's shoulder unstuck ( at the time I didn't know what the alternative was) I told her to do whatever she had to do. She cut me open reached inside, lifted my daughter's shoulder out of the way, and I pushed her out the rest of the way. She was blue, she was not breathing. I knew she would be o.k. though, and she was resuscitated quickly and place in my arms and began nursing. In the "aftermath that followed, my midwife was verbally attacked by the hospital staff for having nearly killed my daughter. Never once did anyone suggest the possibility that it was my decision to induce that put my child in jeapardy, and that my midwife had in fact saved my child's life. No one has ever held me accountable as the catalyst for my child's distress. I swallowed the Kool-Aid. I let our culture and lull me into the false belief that nature didn't know best. I would have gone into labor when my daughter was ready to be born, and she would have come into the world in a much more joyous manner. We need to take back is not a disease to be treated, it is not a crisis to be avoided, it is not an accident waiting to happen. Midwives are allowed to hold their beliefs as much as they want but they are forced to follow the guidelines of the AMA, and carry as much if not more malpractice insurance. What's the point. Something has to change.