One of the biggest challenges I face as an Obstetrician is determining how to handle big babies. Currently 10% of women deliver babies that weigh more than 4000 g (8lbs 13oz), which is the medical definition of ‘big’ (macrosomia). For first time moms especially, this can be a dilemma. If you await labor, the baby continues to grow even bigger during that interval. The bigger the baby, the more likely the need for cesarean section. Alternately, induction can often subject the patient to a prolonged labor that may end in cesarean section regardless. Despite delivering babies for over 10 years, I can’t always accurately predict whether the baby will fit through the mom’s pelvis. Until I can invent the Magic 8 Ball of labor, I will have to rely on studies and clinical judgement.
Some situations are straightforward, if the baby is actually a toddler (>11lbs), then the recommendation is to perform a cesarean section. Period. The big debate lies in how to manage those pregnancies with babies between 9-11 pounds. The current recommendation is to wait for these women to go into labor on their own. Statistically, induction increases the risk of cesarean, so the thought has always been to let nature take its course.
The current recommendations are based on studies looking at induction versus spontaneous labor. But that is not really a fair comparison. When I see a woman at 39 week who has a suspected 9 pound baby, my choices aren’t really induction versus spontaneous labor. If they were, I would obviously choose spontaneously labor. But I can’t just wave my magic wand and make contractions appear out of thin air. In first time moms spontaneous labor is almost always better than induction. My actual choice is between induction or waiting for labor to occur. Labor can be elusive, it might not occur for several more weeks.
A recent large study has finally looked at this issue. Cheng et al (BJOG 2012;1119:402-409) looked at 130,000 labors of first time moms with big babies. They found that induction at 39 weeks actually lowered the cesarean section rate. The rate for women who were induced was 35% versus 41% for those who awaited labor to occur. One of the key statistics was that in the wait and see group, 30% did not go into labor by 41 weeks. I told you labor can be elusive.
This study is not perfect. It does not take into account the patient’s BMI or cervical dilation, which we know to effect the success of induction. Additionally, the best tool we have for estimating baby size is ultrasound which can often overestimate the size of the baby by up to 10%.
Honestly I was surprised by this study. I have always been more of the wait and see type. Is induction the right choice for all women with big babies? Of course not. Each woman’s pregnancy and labor is unique. Therefore, I do not think this study should cause women to decide if induction is right for them. As always, we encourage you to discuss your options and your unique case with your provider.
Did you give birth to a big baby? If so, were you induced or did you wait to go into labor?
Photo credit www.jenniepyfferoen.com
1st baby:
Induced at 40w5d. Labor for 25hrs. Pushed for 3 1/2 hrs.
10# 2oz boy 21.5 inches long
3rd degree tear
Uterine atony, postpartum hemorrhage
Blood transfusion and 4 day hospital stay
2nd baby:
Water broke at 39w3d. Labor 7 hrs. Pushed 25 mins.
8# 8oz boy 21.5 inches long
2nd degree tear
Must easier recovery 2nd time.
Both babies were delivered in posterior position
If I could do my 1st over, I would wait a few more days to see if I would spontaneously go into labor.
In my experience, spontaneous was much, much easier than induction.
This is something I think and pray about all the time- my doc is already concerned about a “big baby” because my last was 9 lbs 3 oz and I’m already measuring 2 weeks ahead at 30 weeks (still within normal limits). I would love to hear your thoughts on this article, as I’ve been pointed to it quite a few times from friends: http://evidencebasedbirth.com/evidence-for-induction-or-c-section-for-big-baby/
Can you shed some light on all of this for me? Thank you!
Has ACOG issued new fetal macrosomia guidelines more recently than these released in 2001? http://www.aafp.org/afp/2001/0701/p169.html
According to these ACOG guidelines, suspected macrosomia is not an indication for induction or cesarean, and in cases where estimated fetal weight is over 11 lbs, a cesarean may be *offered* but is not by any means “straightforward,” as you state above. This is due, as the guidelines linked to above state, to the fact that ultrasound is notoriously inaccurate at estimating fetal weight at term, and because induction and cesarean surgery do not improve outcomes.
Signed,
Tara, mother of two naturally-born macrosomic babies – 10lb, 5oz and 8lb 14oz (and one 8 pounder).
ACOG has not changed their guideline. This is just one (very large ) study looking at the issue. As you correctly pointed out the management of macrosomia is rarely straightforward. I am glad you were able to have your babies vaginally.
My baby was exactly 9 lbs and my doctor didn’t believe in inducing so I went to 40w5d when my water broke. I was terrified and if I could have chosen I would have been induced at 39 weeks but she didn’t yield no matter how much I begged. It all worked out in the end, I did end up being induced because labor didn’t start 24 hours after my water breaking. But I was able to have a vaginal birth with only a tiny episiotomy (one stitch!).
We stumbled over here from a different web page and thought I may as well check things out. I like what I see so now i’m following you. Look forward to looking over your web page yet again.
I had my baby girl 3 days before my due date and she was 9 lbs. Labor went smoothly and I ended up deciding late to get an epidural, at 9cm, and then only pushed 20 minutes before she was born. I had quite a bit of tearing though, both down and sideways, and am pretty scared about that happening again if we have another… But do you think my getting an epidural had any affect on the amount of tearing?
Our first was 9 lbs. 9 oz. and 22 1/2 inches and was born 8 days early! I was actually supposed to be induced that day (because of high BP) but went into labor spontaneously. After laboring naturally for 18 hrs and dilating beautifully he just would not drop and had to have a c-section. I dont know if it was because of his size or being posterior or if he was just cozy in there but I am hoping for at least a little bit of a smaller baby next time around so that fingers crossed I can have a successful VBAC.
Our first was an 8 lbs., 2 hours at the hospital birth. I had third degree tearing. When we chose a homebirth for second I was very concerned about size, tearing etc. Feeling like this little guy was quite a bit bigger. They did strongly suggest I try water birth. Amazingly, I popped a 9 1/2 lb. boy out without needing any stitches. – Oh and total labor time was 5 hours. Half the time as first. I certainly noticed the difference in baby weight. Any suggestions/studies for having smaller babies?
Sorry, no proven way to (safely) have smaller babies!
I went into labor two days after my due date, and my son was 9 lbs 9 1/2 ounces and 20 1/2 inches long. My labor progressed steadily, but after about 4 1/2 hours of pushing we decided to do a c-section. He was also ‘sunny side up’ which probably made things harder. We were expecting him to be about 8 pounds, so he was obviously much bigger than that! I’m 5’7, have an average BMI, and I gained about 30 pounds during the pregnancy. The option of an induction never came up with my midwife. I hope for a VBAC in the future, but we’ll see!
Wow 4 1/2 hours of pushing! You are a champ. Hopefully the next one will be smaller !