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Archive for the ‘pregnancy’ Category

a HBA2CS this time!!! Announcing Baby Zen

Although i havent had much time to type, I finally found the time to write a short version of the birth story of our son, Valentine Zenson Lazarus (baby Zen). He was my 2nd VBAC but first HBA2CS (his brother was a VBAC at a free standing birth center 2.9 years ago). As thrilling as his brother’s birth was, this HBA2CS has me on cloud 9…and I know that not many ppl can appreciate my feeling like those here! So, I come to share our story. As a VBAC at 42 weeks, I surely got treated like I had 3 heads! lol!

Forgive the typos! lol!

Announcing VALENTINE ZENSON LAZARUS (aka “baby Zen”)

well, at 42 weeks and 4 days, suffice it to say that i was more than ready for our son to arrive. MORE than ready actually. I had been having braxton hicks contractions for over 4 weeks….they were driving me insane. Baby had been engaged for about the same time. Everything was perfect, except my body kept NOT going into labor!! lol! I started blogging about my days b/c I was literally a watched pot at that point.

On October 16, I began to have stronger contractions around 10pm. I called my MW to tell her that I didn’t think they were going to do anything; however I wanted to call her before 11pm and let her know our progress. I did laundry and was about to fold the last load of towels. As I took the basket upstairs, I felt a lot of pressure. I wanted to wait for as long as possible before getting into the birth tub, but the contractions were getting a bit closer so i thought they may pick up. I took a shower. Around 12:45, I needed relief. I got into the birthing pool that DP had set up and told him to call the MW. I couldn’t communicate very effectively with anyone at that point. The MW asked if I thought she should come over and I told them both I couldn’t make any more decisions for other people..if she wanted to come, them come..if not, then don’t. lol! I was seriously in labor! lol!

This birth was very intense. It was much quicker than my 3 previous births, which were each over 30 plus hours. I consider that labor really began in earnest when I got into the tub. I used all the tools of hypnobirthing to cope with it but mostly, I felt so tired. I just wanted a cat nap but there was no way this birth was going to give me that. Contractions were one on top of the other and nonstop. I kept saying I was so tired. I had to focus very hard on my hypnobirrthing lessons, as the intensity was a bit much. With ds3, I had an opportunity to sleep, to eat, etc. etc. With this birth, there was no time to eat anything…the contractions didn’t stop for enough time to eat. I needed to get out of teh birth pool twice to go to the bathroom. That was indeed difficult, as I knew being out of the water was going to be difficult…and it was. I believe I took one trip to the bathroom and got directly back into the tub (i think i ran! lol!).

The second time to the bathroom though, was much more intense. I was exhausted but ran out of the birth pool to the bathroom and slammed the door to prevent anyone from coming in! DP says i slammed it in one of teh MW’s faces (I didnt mean to!). I was so hot but the MW’s and DP didn’t want to open the window to the bedroom b/c it was chilly outside. When I came back from teh bathroom, the idea of the hot water didn’t seem appealing so I got on the floor, on all fours. Transition definitely hit me then and I felt the “pushy stage” that has always eluded me. I did not push but allowed my body to do it all. It was an incredible, empowering feeling. My body was pushing my baby down teh birth canal and I was only breathing through it. There were some contractions that made me feel like I had to push, but it was so primeval that I can’t describe the difference between those and the ones that I didn’t help my body push through. Totally strange to me. All of a sudden, I felt that I had to get back into the water.

As I stepped back into the birth pool,I felt immediately relief. It was as if all my pain evaporated. I didn’t know how long I was in the birth pool after that re-entry until reading the MW’s notes. As soon as I was back in the water, I was squatting and felt as if there was no end in sight. All of a sudden, our son’s head emerged. No one knew he was earthside except me. The lights were low, there were no flashlights being used, no monitoring of anything at that point (I think my MW checked his heart rate once an hour). Amazingly enough, his head emerged into my hands. I was serioulsy shocked and sat there waiting until his shoulder’s emerged. For almost a minute, no one knew he had arrived other than the two of us. I thought they knew..I thought the MW’s and DP could tell but I guess not. They couldn’t see under teh water. I asked for help and was told to “trust my body”. I think I said something like “well, I do but his head is already out”. lol! It was only another minute until his body emerged from the birth canal and he was completely birthed (after reading the MW”s notes, i found out that i had only been in the birth tub for about 15 minutes!!!).

It was the most amazing thing in my life….I delivered my own baby. No one touched me, no one helped me do it…I had alot of support from DP and the two MW’s who attended me but no one was in our space during the birth

As I pulled him closer to my breast to nurse him, we noticed the cord was wrapped around him several times. Once around his neck and twice around his body (this is not a big deal as long as the cord isn’t clamped too soon). The cord was very long and I guess he had been playing with it in utero. We unwrapped the cord and I stayed with him for a few minutes in teh water while he nursed. When he emerged from the water, his eyes were open and alert..he looked direclty in to my eyes and all around. He was the most beautiful thing in teh whole world at that moment. I was simply amazed that this precious little boy was earthside after all the time we waited for him. He is totally worth the wait.

We got out of the birth pool after he finished nursing to deliver the placenta, which is very healthy looking and was birthed relatively quickly. And of course, we waited for the cord to stop pulsating before daddy cut the cord. As for his statistics, he was born at 4:58am, which to me means that my labor was only 4 hours long. For some reason, my MW recorded a different duration of time. He was 9 lbs. 12 oz. and 23 inches long. Big baby indeed!!

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Infant Mortality: U.S. Ranks 29th

U.S. Ties Slovakia, Poland for 29th Place in Infant Deaths
By Daniel J. DeNoon
WebMD Health News
Reviewed by Louise Chang, MD

Oct. 15, 2008 — The U.S. ranks 29th worldwide in infant mortality, tying Slovakia and Poland but lagging behind Cuba, the CDC reports.

The CDC’s latest estimates for international rankings are based on 2004 data. But as of 2005, the numbers haven’t changed much since 2000.

Nearly seven U.S. babies die out of every 1,000 live births. More than 28,000 American babies die before their first birthday.

In Japan, ranked in third place behind Singapore and Hong Kong, the infant mortality rate is 2.8 per thousand live births — less than half the U.S. rate.

In one way, the U.S. has improved since 1960. Back then, 26 in 1,000 infants died. That was good enough to land the U.S. in 12th place.

We’ve advanced since then, but not as fast as many other nations. By 1990, the U.S. had fallen to 23rd place.

“The U.S. infant mortality rate is higher than rates in most other developed countries,” note CDC researchers Marian F. MacDorman, PhD, and T.J. Mathews. “The relative position of the United States in comparison to countries with the lowest infant mortality rates appears to be worsening.”

What’s going on? Racial and ethnic disparities clearly play a role. In 2005, for every 1,000 live births, the infant mortality rate was:

  • 13.63 among non-Hispanic black Americans
  • 5.76 among non-Hispanic white Americans

Premature birth is a factor in more than two-thirds of infant deaths. From 2000 to 2005, the U.S. preterm birth rate went up from 11.6% to 12.7%.

MacDorman and Mathews report the data in the CDC’s October 2008 National Center for Health Statistics data brief, “Recent Trends in Infant Mortality in the United States.”

Infant Mortality Rates by Country

Here is the complete list of infant mortality rates per 1,000 live births for 2004:

1. Singapore 2.0

2. Hong Kong 2.5

3. Japan 2.8

4. Sweden 3.1

5. Norway 3.2

6. Finland 3.3

7. Spain 3.5

8. Czech Republic 3.7

9. France 3.9

10. Portugal 4.0

11. Germany 4.1

11. Greece 4.1

11. Italy 4.1

11. Netherlands 4.1

15. Switzerland 4.2

16. Belgium 4.3

17. Denmark 4.4

18. Austria 4.5

18. Israel 4.5

20. Australia 4.7

21. Ireland 4.9

21. Scotland 4.9

23. England and Wales 5.0

24. Canada 5.3

25. Northern Ireland 5.5

26. New Zealand 5.7

27. Cuba 5.8

28. Hungary 6.6

29. Poland 6.9

29. Slovakia 6.9

29. United States 6.9

32. Puerto Rico 8.1

33. Chile 8.4

34. Costa Rica 9.0

35. Russian Federation 11.5

36. Bulgaria 11.7

37. Romania 16.8

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Suspect Diagnoses Come with Biophysical Profiling

by Gloria Lemay

[Editor’s note: This article first appeared in Midwifery Today Issue 69, Spring 2004.]

Many North American women are being told at the very end of their pregnancies to go to an ultrasound clinic and have a biophysical profile done. Most are impressed by the thoroughness of their practitioner and have no idea what this test involves or what sort of harm could follow from consenting to this diagnostic procedure. They will probably not be told that there is no scientific basis for having faith in the test results and that no improvement in health has been proved from large numbers of fetuses being “profiled.” Certainly, no one will mention that the only benefits of the procedure are: 1) the ultrasound clinic will earn $275; and 2) the medical practitioner will be able to cover themselves legally in the very rare instance that a baby might die in utero.

Until recently, physicians and midwives would tell women who were carrying their babies beyond 41 weeks gestational age to do “kick counts.” If the baby has 10 distinct movements between the hours of 9 a.m. and 3 p.m., it is widely accepted that the baby is thriving under the mother’s heart. In a culture that loves technology and with the push to expand the commercial use of ultrasound, it was inevitable that someone would come up with a more complex strategy to provide reassurance of the baby’s wellbeing in late pregnancy. Thus the biophysical profile (BPP) was born. Here is the content of the testing, as it appears on the Family Practice Notebook Web site (www.fpnotebook.com/OB44.htm):

  1. Cost: $275
  2. Criteria (2 points for each)
    1. Fetal Breathing
      1. Thirty seconds sustained breathing in 30 minutes
    2. Fetal Tone
      1. Episode extremity extension and flexion
    3. Body Movement
      1. Three episodes body movement over 30 minutes
    4. Amniotic Fluid Volume
      1. More than 1 pocket amniotic fluid 2 cm in depth
    5. Non-Stress Test
      1. Reactive
  3. Scoring
    1. Give 2 points for each positive above
  4. Interpretation
    1. Biophysical Profile: 8-10
      1. Low risk or Normal result
      2. Repeat Biophysical Profile weekly
      3. Indications to repeat Biophysical Profile biweekly
        1. Gestational Diabetes
        2. Gestational age 42 weeks
    2. Biophysical Profile: 8
      1. Delivery Indications: Oligohydramnios
    3. Biophysical Profile: 6
      1. Suspect asphyxia
      2. Repeat Biophysical Profile in 24 hours
      3. Delivery Indications
        1. Repeat Biophysical Profile less than or equal to 6
    4. Biophysical Profile: 4
      1. Suspect asphyxia
      2. Delivery Indications
        1. Gestational age 36 weeks
        2. Lung Maturity Tests positive (L/S Ratio 2)
    5. Biophysical Profile: 0-2
      1. Likely asphyxia
      2. Continue monitoring for 2 hours
      3. Delivery Indications
        1. Biophysical Profile ‹ 4

“Breathing” above refers to movements in the lungs that show activity of the lungs in preparation for life outside the womb. The baby’s oxygen supply in utero comes via the placenta and umbilical cord while in the mother’s womb.

In the past year, I have had a number of letters and phone calls from doulas, midwives and childbirth educators about a flaw in this testing method. An unusually large number of diagnoses seem to be made that “there is not enough amniotic fluid.” This seems to be the factor in this outline that is most often used as an excuse for induction. It is important for parents to know that this is likely an inaccurate assessment. What the ultrasound technician is doing could be compared to viewing an adult in a see-through plexiglass bathtub from below the tub. In such a scenario, it would be difficult to assess how much water is in the tub above the body that is resting on the bottom of the tub. You might be able to get an idea of the water volume by measuring how much water was showing below the elbows and around the knees, but if the elbows were down at the bottom of the tub, too, you might think there was very little water. This is what the technician is trying to do in late pregnancy—find pockets of amniotic fluid in little spaces around the relatively large body of an 8 lb. baby who is stuffed tightly into an organ that is about the size of a watermelon (the uterus). If most of the amniotic fluid is near the side of the uterus closest to the woman’s spine, it can not be seen or measured. This diagnosis of low amniotic fluid frightens the parents-to-be into acquiescing to an induction of labour. Even though the official BPP guidelines do not require immediate induction for a finding of low amniotic fluid, in practise, the parents are pressured to induce. Stories abound of mothers who are induced for this indication and then report having abundant fluid when the membranes released in the birth process. The risks of induction, which can be catastrophic, and the resulting increase in the need for pain relief medication and cesarean section are usually not discussed with the parents prior to embarking on induction of the birth. Be warned that this latest suspect diagnosis using ultrasound is increasing in frequency and causing increased harm to mothers and unborn babies through aggressive use of induction.

Gloria Lemay has been attending births in Vancouver, B.C., for 25 years. She is an advisory board member of the International Cesarean Awareness Network (ICAN), as well as a contributing editor for Midwifery Today and contributing expert for the Birthlove Web site. Visit her Web site at www.glorialemay.com.


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October 12th, 2008 by Judith Lothian

The Milbank Report, Evidence-Based Maternity Care: What It Is and What It Can Achieve, was released on October 8. This report should shake the world of maternity care to its very core!

The authors of Evidence-Based Maternity Care, Carol Sakala and Maureen Corry, have a  long involvement with evidence-based maternity care including planning and leading Childbirth Connection’s national program to promote such care over the past decade.

Childbirth Connection, the Reforming States Group and the Milbank Memorial Fund collaborated in planning, developing and issuing the report, including formulating policy recommendations.

The Millbank Memorial Fund is a foundation that works to improve health by helping decision makers in the public and private sectors acquire and use best available evidence to inform health policy. The Reforming States Group, organized in 1992, is a voluntary association of leaders in health policy from all 50 states, Canada, England, Scotland and Australia. Childbirth Connection (formerly the Maternity Center Association), founded in 1918, is a national not for profit organization that works to improve the quality of maternity care through research, education, advocacy and policy.

Many national policy, quality and maternity care leaders provided detailed feedback on report drafts and further strengthened the report.

In a nutshell, the report finds that despite the good intentions of health care providers and huge  expenditures (by Medicaid, private insurers and women themselves) the quality of US maternity care is poor. Evidence-based care practices are underused and poor quality practices, like procedures, tests, and medications that are not needed, are overused. The report highlights best evidence that, if widely implemented, would have a positive impact on many mothers and babies and would improve value for payers.

USA Today quotes University of Wisconsin’s Douglas Laube, a former president of the American College of Obstetricians and Gynecologists, who blames “very significant external forces” for the overuse of expensive technologies in maternity care.

“I don’t like to admit it, but there are economic incentives” for doctors and hospitals to use the procedures, says Laube, who reviewed the new report before its release. Dr. Laube goes on to say that some doctors might get bonuses for performing more labor inductions, which adds costs and increases the risk of C-sections, which, in turn, increase hospital profits because they require longer stays. Some doctors order unnecessary tests because of fear of litigation.

Consumer Reports had this to say: “When it’s time to bring a new baby into the world, there’s a lot to be said for letting nature take the lead. The normal, hormone-driven changes in the body that naturally occur during delivery can optimize infant health and encourage the easy establishment and continuation of breastfeeding and mother-baby attachment. Childbirth without technical intervention can succeed in leading to a good outcome for mother and child, according to a new study.” We couldn’t agree more!

The full report plus ongoing press coverage can be found at Childbirth Connection. Every women in America needs to read this report. Every insurance provider needs to read this report. Every health care provider and hospital needs to read this report. Making the changes necessary to improve outcomes and make birth safer for mothers and babies is a collaborative responsibility. Evidence-Based Maternity Care is a call to action, for all of us.

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By GERADINE SIMKINS
Posted: July 17, 2008

One wonders what process the American Medical Association House of Delegates used to determine that its resolution on home deliveries was prudent and reasonable.

AMA resolution 205 attempts to outlaw a woman’s choice to give birth at home or in a freestanding birth center by calling for legislation to establish hospitals and hospital-based birth centers as the safest place for labor, delivery and postpartum recovery. Further, it seeks to establish that hospital-based midwives who work under the control of physicians are the only safe midwifery practitioners.

The Midwives Alliance of North America, which has represented midwives since 1982 and whose members are specialists in homebirth, finds the resolution arrogant, patronizing and self-serving.

We have three major objections. First, the resolution patently ignores the vast body of scientific evidence that has documented home birth to be a safe, cost-effective and satisfying option for women who prefer it. Second, it is seriously out of step with the ethical concept of patient autonomy, encompassing both informed consent and informed refusal. Third, it distracts from other critical issues, including increasing access to care, improving perinatal outcomes, reducing health disparities and fostering client satisfaction. The resolution is anti-home birth, anti-midwife, anti-choice and is unsupported by scientific evidence.

Why is the AMA not asking real questions instead of trying to debunk existing evidence on the safety and efficacy of homebirth and attempting to corner the market on maternity care? For example, why are midwife-attended births far more likely to have fewer interventions, fewer postpartum infections, more successful breast-feeding rates and healthy infant weight gain and to result in more satisfied, empowered mothers? Why are so many women left emotionally traumatized by childbirth experiences in hospitals and consequently why do rates of postpartum depression, anxiety and post-traumatic stress continue to escalate?

It is ironic that the AMA should have a quarrel with a known safe birth option while the epidemic rise in coerced or elective Caesarean sections puts healthy mothers and infants at greater risk and strains our health care system. The rate of Caesarean sections in the United States is unacceptable — one in three pregnancies end in major abdominal surgery — and the decline in availability of vaginal birth after Caesarean is deplorable. It is past time that the AMA and the American College of Obstetricians and Gynecologists realize that women and their partners are choosing home birth and freestanding birth centers to avoid ethically unsupported obstetric interventions.

In almost all areas of modern medicine except obstetrics, control in decision-making rests firmly with the patient and not with the medical provider. Informed consent has appropriately become the gold standard.

Why then do the AMA and ACOG believe that they can promote legislative efforts to deny women choices in maternity care providers and childbirth settings?

All maternity care providers should band together to reduce the rates of maternal and infant mortality and morbidity in the United States, increase access to maternity care for all women, reduce unnecessary Caesarean sections, encourage vaginal birth (including after c-section) for healthy women, reduce health disparities of women and infants in minority populations and promote breast-feeding. These would improve the health of mothers and babies far more than reducing the rates of home birth.

The Midwives Alliance joins the other individuals and organizations, including individual AMA and ACOG members, who have grave concerns about the stance articulated in this resolution, and calls for the AMA to abandon this resolution. Midwives everywhere honor and respect the numerous friendly physicians with whom we already partner and look to the day when midwives and obstetricians consistently will work collaboratively to support women’s choices in childbirth and provide the best and most appropriate range of services.

Geradine Simkins is president of the Midwives Alliance of North America.

http://www.jsonline.com/story/index.aspx?id=773731

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I finally finished compiling my list of parenting, pregnancy, etc. related books. So, I thought I would share the list with whomever reads my blog. Feel free to recommend additional books…I do love books

Those related to Natural Child Birth and Pregnancy (in no particular order):

  1. Aromatherapy During Your Pregnancy, Fances R. Cliffford
  2. Unassisted Homebirth, An Act of Love, Lynn M. Griesemer
  3. The Thinking Woman’s Guide to a Better Birth, Henci Goer
  4. Birth Over Thirty-Five, Sheila Kitzinger
  5. The Natural Childbirth Book, Joyce Milburn & Lynnette Smith
  6. A Good Birth, A Safe Birth, Diane Korte & Roberta Scaer
  7. The Birth Partner, Penny Simkin
  8. Unassisted Childbirth, Laura Kaplan Shanley
  9. Water Birth Unplugged,Proceedings of the First International Water Birth Conference, Edited by Beverley A. Lawrence Beech
  10. Pushed,, Jennifer Block
  11. Taking Charge of Your Fertility, Toni Weschler
  12. Birthing From Within, Pam England & Rob Horowitz
  13. Hypnobirthing: A Celebration of Life, Marie F. Mongan (2 copies)
  14. Hypnobirthing, Marie Mongan
  15. Heart & Hands, A Midwife’s Guide to Pregnancy & Birth, Elizabeth Davis
  16. Ina May’s Guide to Childbirrth, Ina May Gaskin
  17. Emergency Childbirth, A Manual, Gregory J. White
  18. Birthing From Within, Pam England & Rob Horowitz

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Everyone here probably knows that I am not a fan of ACOG (I pretty much have alot of distain for them, considering their attack on homebirths and midwives).  however, I love using their statements against the OBs that they brainwash.   Many OB’s will tell women “oh you have a big baby…we need to induce, or schedule a cesarean”.  Sound familiar?  Probably does if you have had an ultrasound later in pregnancy.  😦

these quotes are important to note (I think they will surprise you):

Nonetheless, the results of these reports, along with published cost-effectiveness data, do not support prophylactic cesarean delivery for suspected fetal macrosomia with estimated weights of less than 5,000 g (11 lb), although some authors agree that cesarean delivery in these situations should be considered.

and

In cases of term patients with suspected fetal macrosomia, current evidence does not support early induction of labor

ACOG Issues Guidelines on Fetal Macrosomia
Joanne Chatfield

The Committee on Practice Bulletins–Obstetrics of the American College of Obstetricians and Gynecologists (ACOG) has issued new clinical management guidelines on fetal macrosomia. ACOG Practice Bulletin No. 22, which replaces Technical Bulletin No. 159 issued in September 1991, appears in the November 2000 issue of Obstetrics and Gynecology. These guidelines discuss risk factors and complications, and suggest clinical management for the pregnancy with suspected fetal macrosomia.

Diagnosis, Risk Factors and Complications

The term fetal macrosomia implies fetal growth beyond a specific weight, usually 4,000 g (8 lb, 13 oz) or 4,500 g (9 lb, 4 oz), regardless of the fetal gestational age. Results from large cohort studies support the use of 4,500 g as the weight at which a fetus should be considered macrosomic.

Weighing the newborn after delivery is the only way to accurately diagnose macrosomia, because the prenatal diagnostic methods (assessment of maternal risk factors, clinical examination and ultrasonographic measurement of the fetus) remain imprecise. Leopold’s maneuvers and measurement of the height of the uterine fundus above the maternal symphysis pubis are the two primary methods for the clinical estimation of fetal weight, according to ACOG. Use of either of these methods alone is considered to be a poor predictor of fetal macrosomia; therefore, they must be combined to produce a more accurate measurement. Ultrasonographic measurement of the fetus serves as a means to rule out the diagnosis of fetal macrosomia, which may aid in avoiding maternal morbidity, but is considered to be no more accurate than Leopold’s maneuver.

According to the ACOG committee, the risk factors (excluding preexisting diabetes mellitus) for fetal macrosomia, in decreasing order of importance, are as follows: a history of macrosomia, maternal prepregnancy weight, weight gain during pregnancy, multiparity, male fetus, gestational age more than 40 weeks, ethnicity, maternal birth weight, maternal height, maternal age younger than 17 years and a positive 50-g glucose screen with a negative result on the three-hour glucose tolerance test.

Pregestational diabetes and gestational diabetes are also associated with fetal macrosomia. Data from one study demonstrated that women with untreated borderline gestational diabetes had an increased risk of delivering infants weighing more than 4,500 g, compared with women who had normal glucose tolerance levels (6 percent versus 2 percent, respectively). If gestational diabetes remains undiagnosed and untreated, the risk of macrosomia may be as high as 20 percent.

ACOG emphasizes that an increased risk of cesarean delivery is the primary maternal risk factor associated with macrosomia. Results from cohort studies demonstrate that the risk of cesarean delivery in women attempting a vaginal delivery at least doubles when the fetal weight is estimated to be more than 4,500 g.

Although rare (complicating 1.4 percent of all vaginal deliveries), shoulder dystocia is the most serious complication associated with fetal macrosomia. When birth weight is more than 4,500 g, however, the risk is increased to 9.2 to 24 percent in pregnant women without diabetes and to 19.9 to 50 percent in pregnancies complicated by diabetes. However, while macrosomia increases risk, shoulder dystocia also occurs unpredictably in infants of normal birth weight.

Fracture of the clavicle and damage to the nerves of the brachial plexus are the most common fetal injuries associated with macrosomia. In macrosomic infants, the risk of clavicular fracture and brachial plexus injury is approximately 10-fold and 18- to 21-fold, respectively, when birth weight is more than 4,500 g.

Clinical Considerations

The ACOG practice bulletin discusses the following clinical considerations:

Clinical Intervention. Clinical interventions for the treatment of suspected macrosomia (in pregnant women without diabetes) have not been reported. In pregnancies complicated by diabetes, one small clinical trial evaluated the effect of dietary intervention with or without the addition of insulin. Results suggest that the addition of insulin might be of benefit in treating early macrosomia (between 29 and 33 weeks of gestation). The data revealed a decreased likelihood of birth weight greater than the 90th percentile from 45 percent among the study participants treated with diet only to 13 percent among those receiving insulin in addition to dietary intervention.

Excessive weight gain during pregnancy is associated with fetal macrosomia, and results from large cohort studies confirm this. However, no data are available on the role of dietary restrictions during pregnancy to prevent macrosomia in obese women who do not have diabetes.

Cesarean Delivery. The role of cesarean delivery in suspected fetal macrosomia remains controversial. While the risk of birth trauma with vaginal delivery is higher with increased birth weight, cesarean delivery reduces, but does not eliminate, this risk. In addition, randomized clinical trial results have not shown the clinical effectiveness of prophylactic cesarean delivery when any specific estimated fetal weight is unknown. Results from large cohort and case-control studies reveal that it is safe to allow a trial of labor for estimated fetal weight of more than 4,000 g. Nonetheless, the results of these reports, along with published cost-effectiveness data, do not support prophylactic cesarean delivery for suspected fetal macrosomia with estimated weights of less than 5,000 g (11 lb), although some authors agree that cesarean delivery in these situations should be considered.

Induction of Labor. 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, although the results are affected by small sample size and bias caused by the retrospective nature of the reports. Results from one randomized clinical trial reveal similar cesarean delivery rates in the induction group (19.4 percent) compared with the expectant management group (21.6 percent), with five cases of shoulder dystocia in the induction group and six cases in the expectant management group.

Suspected Fetal Macrosomia and the Management of Labor and Vaginal Delivery. Midpelvic operative vaginal delivery is the most important consideration for labor and delivery in the case of suspected fetal macrosomia. With the exception of extreme emergencies, a cesarean delivery should be performed for midpelvic arrest of the fetus with suspected macrosomia. If a decision is made to perform a cesarean delivery in the presence of suspected macrosomia, the incision should be large enough to avoid a difficult abdominal delivery.

Summary of Recommendations

The ACOG committee provides the following recommendations for the management of fetal macrosomia:

Recommendations based on good and consistent scientific evidence (Level A):

  • The diagnosis of fetal macrosomia is imprecise. For suspected fetal macrosomia, the accuracy of estimated fetal weight using ultrasound biometry is no better than that obtained with clinical palpation (Leopold’s maneuvers).

Recommendations based on limited or inconsistent scientific evidence (Level B):

  • Suspected fetal macrosomia is not an indication for induction of labor, because induction does not improve maternal or fetal outcomes.
  • Labor and vaginal delivery are not contraindicated for women with estimated fetal weights up to 5,000 g in the absence of maternal diabetes.
  • With an estimated fetal weight more than 4,500 g, a prolonged second stage of labor or arrest of descent in the second stage is an indication for cesarean delivery.

Recommendations based primarily on consensus and expert opinion (Level C):

  • Although the diagnosis of fetal macrosomia is imprecise, prophylactic cesarean delivery may be considered for suspected fetal macrosomia with estimated fetal weights of more than 5,000 g in pregnant women without diabetes and more than 4,500 g in pregnant women with diabetes.
  • Suspected fetal macrosomia is not a contraindication to attempted vaginal birth after a previous cesarean delivery.

Copyright © 2001 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

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