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    Questions? Ask Henci!


    Find out what other moms-to-be are asking. Join in the discussion with Henci Goer, whose expertise is determining what the research tells us best promotes safe, healthy birth. If you would like to contact Henci outside of the Ask Henci forum, send an email to Goersitemail@aol.com.

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    Archived User

    Hi, Henci. I am planning a VBAC with my second baby this fall. I had a c-section with my first because I was convinced that she was going to be 11 pounds and "too big." She was in fact 9 pounds, but as a 6 foot tall woman, I feel confident that this is a "normal" baby for me. I'm currently measuring big and I'm starting to get the "big baby" talk from my new, pro-VBAC doctor. She is concerned about VBAC with a big baby. I can't find much about VBAC with macrosomic babies. Can you help me find evidence to show my OB, please? Thanks

    Henci Goer

    Here are the facts from the manuscript of the replacement for my first book, Optimal Care in Childbirth: The Case for a Physiologic Approach (to be published by Classic Day Publishing), which my co-author Amy Romano and I are in the process of completing:

    Macrosomic baby: 59-68% range in VBAC rate with birth weight  4000 g. Three of the studies reported that birth weight remained a factor in reducing VBAC rates after adjusting for confounding variables. Another study reported VBAC rates with birth weight greater than or equal to 4000 g according to whether the woman had had no prior vaginal birth (48%), a vaginal birth prior to the cesarean (70%), a prior VBAC (89%), or both (87%). Among women with no prior vaginal birth, the VBAC rate did not fall below 50% until birth weight exceeded 4249 g. This study too found that increasing birth weight had an independent effect after adjusting for confounding variables. 

    Cameron CA, Roberts CL, Peat B. Predictors of labor and vaginal birth after cesarean section. Int J Gynaecol Obstet 2004;85:267-9.

    Elkousy MA, Sammel M, Stevens E, et al. The effect of birth weight on vaginal birth after cesarean delivery success rates. Am J Obstet Gynecol 2003;188(3):824-30.

    Goodall PT, Ahn JT, Chapa JB, et al. Obesity as a risk factor for failed trial of labor in patients with previous cesarean delivery. Am J Obstet Gynecol 2005;192(5):1423-6.

    Gyamfi C, Juhasz G, Gyamfi P, et al. Increased success of trial of labor after previous vaginal birth after cesarean. Obstet Gynecol 2004;104(4):715-9.

    Jastrow N, Roberge S, Gauthier RJ, et al. Effect of birth weight on adverse obstetric outcomes in vaginal birth after cesarean delivery. Obstet Gynecol 2010;115:338-43.

    Landon MB, Leindecker S, Spong CY, et al. The MFMU Cesarean Registry: factors affecting the success of trial of labor after previous cesarean delivery. Am J Obstet Gynecol 2005;193(3 Pt 2):1016-23.

    Zelop CM, Shipp TD, Repke JT, et al. Outcomes of trial of labor following previous cesarean delivery among women with fetuses weighing >4000 g Am J Obstet Gynecol 2001;185(4):903-5.

    But you must keep in mind that the decision to go to a cesarean is very much a judgment call. I won't pretend that the baby's size doesn't matter, but a number of studies have all found that when doctors think the baby is going to be large (over 4000 g or 8 lb 12 oz) based on ultrasound estimates, they are far more likely to perform a cesarean than when the baby actually is that big, but they didn't suspect it. In other words, as I just wrote in my post to the woman just before you in this thread, your best chance for VBAC lies in having a practitioner who believes you can do it until proven otherwise and is willing to be patient with a longer labor.

    -- Henci

    Archived User

    Thank you, Henci. Do you have any statistics or research concerning an increase in risk of uterine rupture when attempting a VBAC with a large baby?

    Henci Goer

    As it happens, I do. Here is an excerpt on that from the manuscript for my forthcoming book, Optimal Care in Childbirth: The Case for a Physiologic Approach:

    Suspected macrosomia: 0.7-2.8% scar rupture rate with birth weight ≥ 4000 g. No VBAC study looks at scar rupture rates in women suspected of carrying macrosomic babies, which is problematic because many babies suspected to weigh > 4000 g turn out to weigh less. Elkousy et al. (2003) reported a rate of 2.8% but did not adjust for confounding variables such as greater likelihood of labor induction when macrosomia is suspected.32 Zelop et al. (2001) reported a scar rupture rate of 1.6%,103 and while investigators performed a multiple logistic regression, they did not adjust for induction, and, moreover, the study encompassed a time period in which VBAC labors were induced with misoprostol. Jastrow et al. (2010) reported a rate of 2.6%. After adjustment for confounding factors, including induction, the odds ratio compared with babies weighing < 3500 g barely achieved statistical significance (CI 1.001 – 6.9). Data in this study too came from a time period in which misoprostol was used for induction. Landon et al. (2006) reported a scar rupture rate of 0.7% and did not find birth weight ≥ 4000 g to be a risk factor for scar rupture.

    Elkousy MA, Sammel M, Stevens E, et al. The effect of birth weight on vaginal birth after cesarean delivery success rates. Am J Obstet Gynecol 2003;188(3):824-30.

    Jastrow N, Roberge S, Gauthier RJ, et al. Effect of birth weight on adverse obstetric outcomes in vaginal birth after cesarean delivery. Obstet Gynecol 2010;115:338-43.

    Landon MB, Spong CY, Thom E, et al. Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. Obstet Gynecol 2006;108(1):12-20.

    Zelop CM, Shipp TD, Repke JT, et al. Outcomes of trial of labor following previous cesarean delivery among women with fetuses weighing >4000 g Am J Obstet Gynecol 2001;185(4):903-5.

    -- Henci

    Archived User

    Henci,

    I just wanted to give you a follow up to my amazing birth. I had a relatively easy labor that began at 1 am. It began slow and didn't pick up until the afternoon when I finally called my doula. When my water broke at 530 pm, my labor really picked up and my doula came over. I labored on my ball until we left for the hospital at 8pm. My plan was to labor at home as long as possible and I was already at 7 cms when we arrived! The doctor and nurses all asked for my birth plan and complied with it almost without question. Maggie was born at 12:04 am 100% naturally, only 3 hours after arriving at the hospital. She was 8 lbs, 15 oz and born with minimal dammage to my perineum.

    I had no IV, (although I did consent to a heparin lock), no pain medication, no pitocin after the birth and I pushed her out after only 20 minutes while laying on my side.

    Thank you for your expertise, knowledge and support. It's people like you who help people like me truly believe to trust in our bodies.

    Henci Goer

    I am sooo happy for you! Congratulations! I'm happy, too, to have been a help to you in your journey to this birth.

    ~ Henci


    All Times America/New_York

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