Small for Gestational Age baby and not engaged at 40 weeks

Pallavi Mohapatra

Small for Gestational Age baby and not engaged at 40 weeks

Hi Henci,

I had a growth scan for my baby at 36 weeks and learnt that it's SGA. The baby corresponded with the actual age during the initial scans done in the 13th week. A two week lag was detected in the TIFFA scan done at 22 weeks. The same lag continued until the growth scan done at 36 weeks. However, another scan done at 39 weeks now reveals a lag of 3.5 weeks from the actual gestational age. I have one subserous fibroid measuring 4 cm and two intramural fibroids not more than 3 cm, one of which is located in the right cornu. The fetal presentation is cephalic with adequate AFI of12.5 cm at 39 weeks. The doppler tests are normal and so is the NST. However, baby has not engaged yet at 39 weeks 4 days. Cervix is closed and presentation high. My Ob-gyn says we should not wait after 40 weeks for the onset of labour as she feels baby will not engage. I would prefer the natural course of birth. Kindly advise.



Henci Goer

RE: Small for Gestational Age baby and not engaged at 40 weeks
(in response to Pallavi Mohapatra)

I am neither a midwife nor a doctor, so I cannot advise you what to do. I can, however, suggest questions for you to ask that will help you make informed decisions about your care. To help you remember, they form the acryonm BRAIN. I don't know who originally came up with this acryonym, or I would give them credit.

Benefits: Why is this being recommended? From reading your story, I would ask the doctor to clarify the connection between inducing labor and the baby not being engaged, meaning the head is below the pelvic brim. The fact that your baby is not just small but is falling behind over time and the presence of fibroids means that everything isn't as you and your doctor would wish, and inducing labor may be the right thing to do. However, it isn't uncommon for the head to engage only after labor is well established, and the contractions press the baby lower in the pelvis.

Risks: What are the potential harms, including the need for further medical intervention? How likely are they to occur? I can tell you that inducing labor, especially inducing labor in a first-time mother whose cervix, the neck of the womb, isn't ready for labor* greatly increases the likelihood that the labor will end in a cesarean. If you do decide to agree to induction, discuss with your doctor whether you can wait for a favorable cervix if it isn't already. 

Alternatives: What are the alternatives, including watchful waiting? What are the benefits vs. harms of the alternatives?

Intuition/instinct: After you have considered the information you have been given, what is your heart or gut telling you to do?

No or not now: You have the right to say "no." Informed consent is meaningless without the option of informed refusal. If you do decide to say "no," I recommend discussing the circumstances under which you would change, or consider changing, your mind.


~ Henci 

 *In pregnancy, the cervix is long, thick, firm, and closed like the neck of an old-fashioned Coca-Cola bottle. In preparation for labor, it softens, thins, shrinks back into the body of the uterus--purse your lips and then draw them back against your teeth to see what I mean--and begins to open.

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