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    Mar 03

    advice on scheduled cesarean births

    Archived User
    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 here!

    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 increasingly
    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 me before
    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 topic in
    my classes but for some moms, it doesn't sink in until it happens to them.
    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 wants to
    schedule a cesarean. This mom is coming to me for some advice. Because this
    is getting so common in my area, I think it be great for me to compile a
    stack of research that negates the use of scheduled c-sections just for the
    "fear" of having a large baby.

    I know ACOG released a statement about induction indications and "large
    baby" is not on there, but do they have one about c-sections as well? I've
    been on their sight and can't seem to find anything. I know there is info
    out there but was wondering if anyone has specific citations that I could
    start with.

    Sara Foster
    By: saraf
    Archived User
    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 that:

    Studies consistently report that ultrasound imaging and clinical estimates predict macrosomia poorly. Predictions are wrong 1/3 to 1/2 the time (Chervenak 1989; Combs 1993; Delpapa 1991; Johnstone 1996; Levine 1992; Pollack 1992). If a clinician thinks the baby is going to be macrosomic, he or she might as well flip a coin as order a sonogram.

    But there's still more: two studies looked at the effect of ultrasound diagosis of macrosomia on outcomes (Levine 1992; Weeks 1995). 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 that a 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 . . . 3% (Francome 1993) or an order of magnitude less than it was in these 1990s studies even in the low cesarean rate group.

    -- Henci

    By: Henci Goer
    Archived User
    Thanks so much for your response, Henci. I really appreciate it and the article citations.

    Sara By: saraf
    Archived User
    You're welcome! I hope you will continue to hang out here and put your 2 cents in as well.

    -- Henci By: Henci Goer
    Archived User

    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
    Archived User
    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 sign.

    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?"

    -- Henci
    By: Henci Goer
    Archived User
    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...

    Delilah By: Anonymous
    Archived User
    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

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