advice on scheduled cesarean births
Hello - can I first say how excited I am to have found this forum.
I can't wait to be more involved!! Thanks Amy for pointing me
I am a LCCE in MI and I have a question about OB's doing elective
c/s for the "fear" of large babies. In my area of MI, it is quite
common for elective inductions to be done for fear of large babies
(even though we know it's not supported by research).
But over the past several months, I have been noticing some
disturbing findings about some local health providers. I've had
about 3-4 women in my
recent classes who've emailed after their birth or have contacted
their labors to ask for help in talking to their OB's about how
"not to have
a cesarean birth" because their doctors are worried that the babies
might be too big. I definitely spend a good amount of time on this
my classes but for some moms, it doesn't sink in until it happens
My latest report is this....I have a mom who is due in a few
weeks and her OB "thinks" she'll have a 9-10 pound baby and so
schedule a cesarean. This mom is coming to me for some advice.
is getting so common in my area, I think it be great for me to
stack of research that negates the use of scheduled c-sections just
"fear" of having a large baby.
I know ACOG released a statement about induction indications and
baby" is not on there, but do they have one about c-sections as
been on their sight and can't seem to find anything. I know there
out there but was wondering if anyone has specific citations that I
Welcome! We're glad to have you! As it happens, I just responded on
this issue by listing a couple of reviews addressing whether
planned cesarean surgery for suspected macrosomia (usually defined
as weighing more than 4000 g or 8 lbs 13 oz or as greater than the
90th percentile for gestational age) is a good idea. While you'll
want to get those reviews, I'll save you the suspense: the answer
is "no." The title of the thread is "Caesarean prescribed for
potential shoulder dystocia." Let me add to that list the question
of how well can we predict macrosomia. Here is the story on
Studies consistently report that ultrasound imaging and clinical
estimates predict macrosomia poorly. Predictions are wrong 1/3 to
1/2 the time (Chervenak
). If a clinician thinks the baby is going to be
macrosomic, he or she might as well flip a coin as order a
But there's still more: two studies looked at the effect of
ultrasound diagosis of macrosomia on outcomes (Levine
). Both found that when ultrasound led the ob to
believe that women were carrying macrosomic babies, half had c/secs
vs. less than 1/3 of women not thought to have macrosomic babies
but who actually did. In other words, the ob's belief
woman won't be able to birth the baby because it is too big
substantially increases her risk of cesarean. With a tip of the hat
to Stephen Colbert of Comedy Central's Colbert Report, this is a
prime example of "truthiness" in obstetrics at work. My advice to
your students would be to think twice and maybe three or four times
about staying with a care provider who doubts their ability to give
birth vaginally because of estimated fetal weight. Even if they
turn down the cesarean, they're by no means out of the woods.
It is also worth noting that the cesarean rate for birth weights
greater than 4000 g in the U.K. in 1958 was . . . drum roll . . .
) or an order of magnitude less than it was in these 1990s
studies even in the low cesarean rate group.
By: Henci Goer
Thanks so much for your response, Henci. I really appreciate it and
the article citations.
Sara By: saraf
You're welcome! I hope you will continue to hang out here and put
your 2 cents in as well.
-- Henci By: Henci Goer
I was advised to come to this board. I would like some advice as to
how to approach my doctor when I go back in 3 weeks...
Background: I am 32 weeks 3 days pregnant. Have had absoultly no
complications what-so-ever. Infact, I was not even sick during my
first trimester. I plan to have a natural childbirth and I am
taking classes so I can acheive that goal.
I was at the doctor this past Wed. for my monthly check up, and she
measured my fundus and said that it was measuring 35 CM instead of
32 CM. She then proceeded to tell me that I 'might' be having a big
baby. And if they baby seems to be over 10 pounds she wants to
schedule me for a c/s. I told her that I really did not want to
have one and she told me that she has delivered babies that were 10
pounds before (vaginally), but she wants to schedule me for an
ultrasound to find out more information. She didn't seem to be
concerned with anything else going on (health).
She told us that she was totally on board with me having a natural
childbirth and then after she measured me it seemed as though her
view changed a little bit, but again, she stated that she has
delivered 10 pound babies vaginally.
I put a call into her this morning, because I feel like I left the
other day with few answers and more worries. If there is any advice
you can give me that would be great.
Thanks! By: Anonymous
This doctor seems to fall in the category of "I don't want you to
worry, but . . . ." And, of course, you do worry. Your confidence
in yourself is undercut, and the process that sets you up to agree
to unnecessary interventions is underway.
Your ob's behavior is a huge red flag. You need more solid
information than her vague assurances that she supports your desire
for natural childbirth. You need to know her cesarean rate
immediately, because if it is what I suspect it will be, your best
bet for the birth you want to have (and the birth that will be
safest and best for you and baby) will be to change care providers,
and many care providers won't take women late in pregnancy. The way
to phrase the question is: "How often do you find it necessary to
do a cesarean?" If you hear an answer of more than 15%, a
percentage that is supported by a substantial body of research as
being achievable without increasing harm to babies, you will know
that you cannot rely on this ob's judgment about when a cesarean is
necessary. Unfortunately, few obs have c/sec rates in this range. I
expect yours will be at or exceed the national average, which is
29%, although I hope you will be pleasantly surprised. If she
doesn't know or won't tell you her c/sec rate, that is also a bad
If you want information on choosing a new provider, go to the
thread "pelvis too small," and you will find a list of links in my
response. Likewise, you will find information on how women
anticipating big babies can maximize their chances of a
problem-free birth in the thread "big baby?"
By: Henci Goer
If you want to email me, I can send you the screen shot I took of
the ACOG newsflash entitled "Cesarean Delivery More Likely with
Labor Induction of a Large Baby" from November 1, 2002 that I saved
before they removed it from their website...
http://www.cherishbirth.com By: Anonymous
Thanks for the offer, but I think I probably have the underlying
study. -- Henci
Sanchez-Ramos L, Bernstein S, Kaunitz AM. Expectant management
versus labor induction for suspected fetal macrosomia: a systematic
review. Obstet Gynecol 2002;100(5 Pt 1):997-1002.
OBJECTIVE: To systematically review and summarize the medical
literature regarding the effects of expectant management and labor
induction on mode of delivery and perinatal outcomes in patients
with suspected fetal macrosomia. DATA SOURCES: We supplemented a
search of entries in electronic databases with references cited in
original studies and review articles to identify studies assessing
management of patients with suspected fetal macrosomia. METHODS OF
STUDY SELECTION: We evaluated, abstracted data, and performed
quantitative analyses in studies assessing the outcome of patients
with suspected fetal macrosomia. Observational studies and
randomized trials were included in this systematic review.
TABULATION, INTEGRATION, AND RESULTS: Twenty-nine studies were
identified, 11 of which met our criteria for systematic review and
meta-analysis. These 11 studies included 3751 subjects. Of these,
2700 were managed expectantly, and 1051 underwent labor induction.
We calculated an estimate of the odds ratio (OR) with 95%
confidence intervals (CIs) for dichotomous outcomes, using random-
and fixed-effects models for outcomes. Summary statistics for the
nine observational studies showed that, compared with those whose
labor was induced, women who experienced spontaneous onset of labor
had a lower incidence of cesarean delivery (OR 0.39, 95% CI 0.30,
0.50) and higher rates of spontaneous vaginal delivery (OR 2.07,
95% CI 1.34, 3,19); however, significant differences in these
outcomes were not noted when the two randomized trials were
assessed. No differences were noted in rates of operative vaginal
deliveries, incidence of shoulder dystocia, or abnormal Apgar
scores in the analyses of the observational or randomized studies.
CONCLUSION: Based on data from observational studies, labor
induction for suspected fetal macrosomia results in an increased
cesarean delivery rate without improving perinatal outcomes.
Although their statistical power is limited, randomized clinical
trials have not confirmed these findings.
By: Henci Goer
All Times America/New_York
Please note that this Forum is intended to help women make informed decisions about their care. The content is not a substitute for medical advice.