An excerpt from the Our Bodies, Ourselves Health Resource Center section titled Women of Size and Cesarean Sections: Tips for Avoiding Unnecessary Surgery.
Do Not Intervene for a Big Baby
Choose a provider comfortable with the possibility of a big baby
Although most big moms do not have big babies, statistically as a group they do have a higher rate. The fear of big babies is one of the strongest factors driving the high rate of cesareans in women of size; however, having a big baby is not in and of itself a valid medical reason for having a cesarean. Whether or not you actually have a big baby, your best bet is to find a provider who is comfortable with the possibility of a big baby and who will not intervene based on possible fetal size.
Do not be overly restrictive to get a smaller baby
Many providers follow guidelines that restrict weight gain in obese women. Some providers fear big babies so much they place women of size under draconian dietary restrictions or tell them not to gain any weight. However, the safety of these restrictive policies has not been well-established; some research shows that very low weight gain in obese women is harmful. It is unclear how much control we have over how much weight we gain in pregnancy. Instead of trying to manipulate weight gain and fetal size through caloric restriction, it makes more sense to focus on eating healthy and getting regular exercise and letting your baby be its intended genetic size.
Don’t estimate fetal weight
Many care providers order ultrasounds to estimate the baby’s weight. Research shows this is inaccurate at predicting big babies; simply the prediction of a big baby causes a strong increase in the cesarean rate, even if the baby was truly small instead. Choose a caregiver that does not do fetal weight estimates.
Labor spontaneously if a big baby is suspected
If a big baby is suspected, many providers induce labor early, thinking it’s a good idea to start labor before baby gets “too big.” However, research clearly shows that this strongly increases the risk for cesareans instead.33Other doctors insist on elective cesareans for big babies; research has also found this harmful.34 Big babies are more likely to be born safely if labor is spontaneous and if the mother can move around freely during labor and pushing. Ask your provider if he or she would induce early or do a cesarean for a big baby, and if so, find another provider.
In contrast, the Letter to Mag Mutual Insured Obstetricians encourages doctors to use ultrasound liberally to protect them from litigation while simultaneously noting that shoulder dystocia is unpredictable. The following are their recommendations to minimize malpractice risk for shoulder dystocia related injuries.
SD is an unpredictable high-stress medical situation for which there is no uniformly helpful protocol. In addition, some ob/gyn doctors define SD’s occurrence when basic maneuvers are required; others call it SD when more difficult measures are required. All ob/gyns frequently encounter these situations so strict definitions are somewhat arbitrary. Most ob/gyns have encountered many a case of significant shoulder dystocia where there are absolutely no risk factors. There are various guidelines that are for handling such deliveries well-known to the practicing ob/gyn including ACOG educational bulletins on the subject.
Despite studies dating back over thirty years that attempted to define reliable predictors of SD, there are no management protocols that, if followed, will consistently prevent SD-related brachial plexus injury. For example, the most recent ACOG practice bulletin states, “shoulder dystocia is most often unpredictable and unpreventable…. In each case, risk factors can be identified, but their predictive value is not high enough to be useful in a clinical setting.”
To minimize the risk of a SD related injury claim, the medical record should contain evidence that the physician (or nurse midwife) has addressed known risk factors for shoulder dystocia during antepartum care. Such factors should include at least the following checklist:
- Screening for gestational diabetes.
- Method of testing maternal glucose levels from the onset of diagnosis of GDM.
- Evidence that unsatisfactory glucose control is addressed (e.g. Hgb A1C in cases of poor monitoring, and compliance.)
- In any case of prior SD, an informed consent discussion describing the risks and benefits of vaginal birth in the current pregnancy. This discussion should be documented in the patient’s medical record.
- Liberal use of ultrasound (despite its own limitations) in situations where macrosomia is suspected or more likely e.g. non-compliant gestational diabetic patient.
Mag Mutual recommends using the following shoulder dystocia checklist for intrapartum records:
Before undertaking vaginal delivery note that the pelvis seems clinically adequate.
In cases of prolonged second stage labor the physician should evaluate and note that the risk for SD is low.
When SD is encountered, document:
Which shoulder is anterior.
The time of onset of SD and the time the impacted shoulder delivered (perception of “frantic” or “chaotic” not favorable).
Clear detailed description of the maneuvers employed to dislodge the shoulder (suprapubic pressure, McRobert’s, direct fetal manipulation, such as Rubin, rotational maneuvers or delivery of posterior arm). Dictated note is desirable; legible and detailed more important.
That the traction force did not exceed the quality used in your standard procedure for non-SD deliveries.
If dystocia was anticipated, whether pediatric support was or was not requested.
Suprapubic pressure by experienced nurse. Do not use or make mistake of stating “fundal pressure” when you mean suprapubic pressure. As you know, fundal pressure is frowned upon although it might be used in clinical practice in appropriate situations. It is possible to worsen the dystocia by use of fundal pressure.
Whether episiotomy is done. There is no consistent evidence that an episiotomy is needed, although it does help in certain situations; this is a judgment call. If no episiotomy is done, it may be reassuring to state your reason. (e.g. that the patient’s body habitus or introitus would negate the effectiveness of an episiotomy as in the markedly obese patient with large buttocks that obliterate or extend past the introitus.)
- If usual measures are exhausted and the physician suspects that brain damage is imminent, it is reasonable to so state and proceed to deliver using whatever measures seem appropriate at the time.