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Thursday
Dec302010

An Apology and a Critique of a Birth Maxim

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By Jill

I made a bad judgment call as a moderator a few weeks ago. Sheri wrote up what was truly a beautiful and remarkable story of the birth of her son. I feel protective of birth stories, especially after having front row seats to watching women pick apart a birth story while the woman who submitted it was there on the thread saying I’M RIGHT HERE.

Rather than make a mental note to start the conversation another time, I opened the door for a discussion that wasn’t right for the post. As you’ve probably noticed, there are a lot of maxims that pregnant women are sometimes encouraged to focus on in the last half of pregnancy. Positive thinking is helpful in lots of arenas—public speaking, sports, test anxiety, etc. That portion of the Hypnobabies curriculum that I used was the fear release CD’s, which helped me to turn my head off and combat the fine job that the hospital staff had done at unnecessarily scaring the bejeezus out of me two years prior.

There is the fine line that we walk here on this blog which never really gets addressed. While it’s grown into a great resource for pregnant women, I don’t consider The Unnecesarean a place to come if one if hoping to “gestate in peace.” Everyone processes information differently, though, and I trust that everyone is able to moderate their own internet reading habits. Incidentally, a possible opportunity has presented itself to write about lighter pregnancy topics and, frankly, I relish the thought of writing about the benefits of hydration or folic acid for a change.

I apologized to Sheri in the comments but wanted to do so here as well for making her feel like her birth to a big baby was a fluke. From one mom of statistical outliers to another, I’m sorry.

 

Here is the discussion that was interesting but should have occurred elsewhere. This is me (Jill), Henry Dorn, MD and Well Rounded Mama. Obviously some context is lost because not every comment is included.


Fetal death, etc. mentioned

 

 

Jill wrote:

If you’re in the last few months of pregnancy and trying to stay in that positive-only space, DON’T READ THIS COMMENT.


[Edit: FYI, this was in response to the idea (above) that a baby will never grow too big to birth.]
Babies do grow too big for vaginal birth. Sometimes they won’t come out and sometimes they won’t come out healthy or alive. Instrumental delivery of babies, including craniotomies, was the original benefit of the practice of obstetrics. To pretend that babies will never grow too large to birth (or birth safely) negates the experiences of the women who visit this site who have been handed a dead term infant after a bad delivery, hospital or home, or who endured a prolonged second stage of labor and needed a cesarean. Or in the case of Abi, who commented before I finished writing this comment, who labored for 50 hours with a 13.5 pound baby. To say babies never grow too big is to be one small step away from telling Abi that she did something wrong, which is false. (Abi, sorry to use you as an example here.)

Like with anything, the questions in the case of suspected fetal macrosomia have to do with best evidence, reliability of estimates, risk tolerance (personal, interpersonal, cultural and/or institutional, if relevant) and a myriad of other factors that I could spend a lot of time listing (and have spent the time listing over the last two years). On a personal note, I can relate strongly to Sheri’s story because I personally experienced the difference between giving birth in an environment in which people were absolutely freaking out about the (suspected) size of the baby and in an environment in which similarly mentally and emotionally aggressive tactics were not employed to convey risk. Not only was risk assessed differently in the two environments, but nothing was exaggerated nor sugarcoated at the freestanding birth center. I felt information was presented fairly and I was given the opportunity to decide how to proceed, as it was, after all, my body and my baby. Ultimately, I had an unexpectedly large outlier baby like Sheri, for what that’s worth.

The reason why stories about giving birth to big babies can play an important role is in challenging assumptions about women’s bodies and ingrained attitudes about birth. How many times have you heard something along the lines of “she had a cesarean and, thank God, because the baby was almost nine pounds.” Do I really need to go on about the bullshit that some doctors tell their patients post-cesarean about CPD?

Pardon the generalization, but women are not usually not given a reasonable picture of what risks would be associated with giving birth to a large baby if they are even carrying a large baby in the first place. I need to wrap this up, so here is an excerpt from Anne Lyerly’s 2007 Green Journal article on risk and decision making:

Pregnant women deserve care that is both evidence-based and patient-centered. Rather than reinforce the distortions of risk that do such disservice to pregnant women and their fetuses, providers and policy-makers can play a key role in helping to overcome them. They can do so, first, by acknowledging the range of values that pregnant women and their families bring to decisions around pregnancy and delivery, and identifying, where appropriate, a range of well-considered options, allowing women to make decisions in the context of their own priorities and life circumstances.

They can do so, second, by basing recommendations and guidelines on the full profile of risks in the range of comparable clinical scenarios and also by including the legitimacy of maternal well-being as a consideration, both for its own sake and its importance to fetal well-being. They can do so, third, by underscoring the importance of expanding our evidence base so that patients and providers can make informed decisions that do involve the weighing of risk during pregnancy. Most of all, they can do so, not by suspending the usual modes of analysis when confronted with pregnancy, but by giving the same careful, responsible, and comprehensive assessment we hope for in all of medicine.

 

 

Well Rounded Mama wrote:

Wow, definitely a big baby! Look at those adorable folds! Congratulations again.

Jill, what an AWESOME quote from that study, esp the last paragraph. Thank you for sharing it!

Kelli, I too had a CBAC (cesarean birth after cesarean) with a big baby, but the issue was less about his size than his position. In the position that he was in (in combination with his size), he was just not coming out safely. After many hours of pushing we made the prudent decision to go to a cesarean.

For quite a while I thought the issue was really about fetal size, at least for me. I believed others could birth big babies, but not me. I was led to believe my pelvic shape wouldn’t support birthing a big baby, so I was convinced into inducing the next baby a little earlier. He was smaller, but he had a rougher start because of inducing early….and now that I know more stats about how risky it is to induce a VBAC (let alone a VBA2C!), I shiver at the thought that I agreed to that. I did have the VBAC, but because the baby was in a better position, not because he was smaller. It was in SPITE of the induction, not because of it.

I know that because several years later, I gave birth (spontaneous labor VBAC) to a baby that was a pound bigger than my cesarean babies and 3 pounds bigger than my first VBAC baby. It wasn’t size, it was baby’s position. That was the REAL issue.

I agree with Jill; occasionally there are babies that are “too big” to be born safely vaginally. But most often, the problem is the baby’s position in combination with his size. What helped me get a better fetal position was regular chiropractic care with someone who was well-trained in pregnancy, Webster Technique, and pubic symphysis issues.

And remember, you never have the same birth twice. Just because you had position issues last time doesn’t mean that you will have them next time. Be as proactive as you can, but remember that each birth is different and new.

If you don’t already know about the CBAC support group on yahoogroups, I hope you will search them out and join for some special support from other CBAC moms.

 


Jill:

WRM, how perfect that you’re here! I’ll send you the study. So, I was rambling there but the whole point was that, yes, catastrophe CAN occur. Nothing is risk-free and how risk is conveyed is critical.

 


Henry:

Wanted to say how much I appreciate Jill’s comment and thanks to Sheri for sharing her birth experience. It is wonderful to see the range of human experience.

I was hesitant to post so as not to throw a damp towel on a happy thing, but wanted to reflect on Jill’s statement.

Although there is no doubt that women can deliver fairly huge babies, which this one certainly qualifies as, there is also no doubt amongst midwives and doctors that there is increased risk involved. 
I was glad to hear that Sheri’s weight gain was normal and that she was eating a good diet, since looking at the baby I assumed she had unrecognized gestational diabetes due to the amount of body fat present. Clearly though, she has a “birthin’ pelvis” as we say down South, and was able to get this one out without difficulty.

Until however you have attended a prolonged dystocia where a baby’s head is out but the shoulders are stuck, knowing that every minute that passes increases the chance of severe hypoxia, or that the nerves in the neck may get injured from trying to release the shoulder, resulting in permanent damage, you can’t understand why maternity caregivers get so nervous about this sort of thing. It may only happen in 1 out of every 500 births, but for someone like myself that means at least 10 times.

So definitely not saying that everyone with a big baby needs a CS by any means (I have delivered several 10 pounders recently, at least 2 were VBACs), but just wanted to put a little perspective on it.

I would love to hear if any midwives out there agree (or disagree) with me.

So congrats again to Sheri and family.

 


Henry (to Well Rounded Mama):

In reference to Well Rounded Mama’s comments, position is crucial. A 7 pounder can get stuck in a “10 pound pelvis” (if you know what I mean) if the head is OP or asynclitic.

I send all my patients to the Spinning Babies website (www.spinningbabies.com) which has excellent advice on optimal positioning methods.  In fact Gail Tully (the Spinning guru) & I were just communicating on developing some protocols for care providers to help turn babies, especially when moms present in labor in OP position.

 


Well Rounded Mama:

Dr. Dorn, if you haven’t already, I would suggest you communicate with Dr. B.L Shaffer and Dr. Aaron Caughey, who have done several studies in SF on how to reduce the cesarean rate in OP babies by manually turning them. I’m sure they’d be happy to share their technique with you. The latest study will be coming out next month, www.pubmed.gov/20350240. There’s also a French study about it, www, pubmed.gov/17906022. And Penny Simkin wrote an interesting-sounding review of the topic of OP babies in Birth this year, www.pubmed.gov/20402724.

Having had 2 cesareans (after long hard labors) for OP babies, I surely wish my care providers would have known these techniques. Of course, an OP baby can simply be a variation of normal and not a big deal, but sometimes it is, and knowing how to prevent and/or turn them could certainly ease a lot of long hard labors and bring down the cesarean rate too.

Although it has not been studied well at all, chiropractic care is also anecdotally very effective at lowering the rate of malpositioned babies. What research there is (which is not high-quality yet) shows it is helpful for breeches but anecdotally many of us have had great success with it for OP babies too. In particular, in women with a history of car accidents, sports injuries, falls, or significant back/pelvic pain, it can do wonders. Of course we need data to back up the anecdotal observations, but we’ve seen how helpful it can be in VBAC women many times in ICAN. Definitely something that deserves more study.

 

Feel free to add to the discussion here. 

 

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Reader Comments (20)

I second what Jill said and am sorry if I sometimes tend to focus on the anatomical and not on the emotional aspects of birthing, but that's probably why I am a surgeon and not a midwife - equal but very different fields.

December 31, 2010 | Unregistered CommenterHenry Dorn MD

My Cesarean was due to OP positioning too. He was a mere 7 lbs., but thanks to my narrow pelvis, was just not coming out. I birthed a face-down 8 lb. baby with little trouble 4 years later.

It is CRUCIAL that care providers work more on preventing malposition/malpresentation BEFORE it's too late instead of slapping the Cesarean band-aid on it or pretending like it's no big deal (which it is for some women, but for others it's the difference between a vaginal delivery and the OR). If I had known what I could have done to turn my son facing the right way, I might not have this scar.

Jill, I am, as always, impressed at your humility. <3

December 31, 2010 | Unregistered CommenterJill P.

I gave birth to a 4400g (9lb 11 1/2oz) baby. The delivery took 40 minutes. Other than a seriously LONG labour (50 hours), everything was uncomplicated, and nothing happened during delivery to make me think that he was bigger than average. He was my first child. They weighed him, and I didn't believe that he was as big as they told me.
I have since decided that I must have 'birthing hips', because of the number of women I hear saying 'that baby just wasn't coming out - and at 8lbs 2oz, I wasn't even going to try! Too big!'.
I was lucky enough that my doctor didn't tell me how much they thought my son weighed at his last ultrasound (4 days before his birth), and seemed content to just let me labour him out. Had my doctor told me that the baby was suspected to be 'too big to birth', I would have given in to a Cesarean long before my 50 hours of labour was up.

December 31, 2010 | Unregistered CommenterMiyo

I always discuss position with my doula clients, and send them to Spinning Babies, although I have tempered it somewhat after reading some of Pamela Hines' thoughts on optimal fetal positioning. I don't want this to become a source of anxiety/obsession for women, or for them to worry if the baby turns out to be malpositioned that they did something wrong/didn't do enough. I have mulled over whether to discuss getting regular chiropractic care. Like WRM says the evidence just doesn't exist yet for whether or not it could prevent malposition. Of course if one of my clients asked about it, or had other issues that I thought could be resolved with chiro, we would talk about it; and I might consider discussing it as one of the options for a mom who has a history of malpositioned babies (probably 95% of my clients are primips so it doesn't come up much).

I'm intrigued by WRM's info on manually rotating posterior babies. One of the benefits of my frequent moves have been the ability to see practice styles in different hospitals and different parts of the country. In Denver I saw several babies manually rotated from OP to OA with good resolution of a stalled pushing phase. I have never seen this done or mentioned elsewhere.

I do think the "your body won't grow a baby you can't birth" maxim can be very unhelpful. Sometimes at the hospital where I work I help moms who transferred after planning an out-of-hospital birth. Often I will spend an extended amount of time with patients while I observe a whole feeding, and we start talking. I remember one mom a few months ago who had a c-section after transferring, and she was processing the experience while I listened. She had very much bought into the idea that we can all go overboard on sometimes - c-sections are always the result of something that was done incorrectly in the birth process, and all babies can be born vaginally. Yet she felt like they had done absolutely everything they could before transferring. She wasn't so much grieving (although those feelings may have come later) as puzzled - just couldn't figure out why she had needed the c-section, and whether she would need another one in the future. I mentioned position as something that can change from baby to baby; I didn't say "maybe the baby was too big" (it wasn't that big) - but who knows, maybe there was something about her pelvis and the baby was too big for her. But it reminded me to always keep room in our heads for the very real fact that some babies ARE too big, or positioned poorly, and just cannot come out no matter what we do.

Oh man, I'm sorry Jill. Why do I keep screwing up the html tags??

IMO (as a birth doula) I see a LOT of doctors scaring women into induction because she may or may not have a big baby. Taking into consideration that during the last term of pregnancy an ultrasound can be off by about 2lbs either way, it's not exactly a reliable way to guess at the baby's weight. Secondly, in most cases (not all) large babies are due to things like gestational diabetes, and poor diet. A low carb, high protein diet is recommended for most if not all pregnant women. This has shown to not only decrease the chances of "big baby" but it also decreases the likelihood of pre-eclampsia and the host of complications that comes with it. All of that taken into consideration, when you have chosen a skilled caregiver who knows about maternal positioning in labor to maximize fetal positioning you would be quite amazed at how capable a woman's body is to birth a "big baby" This being taken into consideration as well...I will NEVER fault a mother for opting for a cesarean for a true case of a large baby. IMO (again) a c-section is less violent than what a doctor will do to your body if it is in deed a large baby. This includes, radical episiotomy, forecepts or suction (which injure the baby) and separation of mother an baby regardless that the baby was born vaginally because of all the medical intervention that occurs in cases like this. I have seen first hand one of these births and I can tell you right now that this vaginal birth was far more violent than any c-section that I have seen...including my own. If I personally had a choice between mutilating my genitals and recuperation from a c-section I would most certainly choose the c-section. It's a personal choice, and neither one is pretty when faced with the medical standard of practice. However, I am certain that someone like Ina May Gaskin or many other skilled and compassionate OB's and Midwives would have the where with all to give women a fighting chance at birthing her "big baby" vaginally and with minimal or no injury to the mother. Problem is, mainstream medicine tends to think that maternal positioning and all of that is a a bunch of bunk. Quite a huge disconnect really.

December 31, 2010 | Unregistered CommenterEmily

I'm so glad you brought this here. I think there needs to be more discussion on the "big baby" theme, and sometimes it's hard to avoid one happening where perhaps it shouldn't.

I like to tell people - with all the authority of my non-medical self - that you cannot decide a baby is too big to be born until there's been a trial of labor. If there are issues in labor, then the baby may truly be "too big" (or in less than optimal positioning, or too early or too late, or any of a number of things), but let us let the babies decide when they should be born (obviously, barring actual issues) and then help them as needed.

December 31, 2010 | Registered CommenterANaturalAdvocate

Hi, this is Sheri’s midwife. I have been following this discussion and wanted to share a few of my thoughts. First of all I do want to say that I wasn’t bothered or offended by your remarks about the dangers of big babies and I agree completely that even though we love birth and think of it as completely natural and safe, it isn’t. I never walk into a birthing situation thinking that nothing will ever go wrong. Why would I bother learning infant resuscitation or bring oxygen to a birth if I thought nothing bad could happen? I know firsthand the dangers lurking in normal birth and I respect it, plan for it and thank God for the guidance he gives me when I have to put those parts of my skills to work.
I started to attend home births in 1979, trained as a midwife from then to 1983, and I have assisted in the births of about 2300 babies. I attended my first HBAC in 1983, and since then I have cared for and assisted in the births of over 150 HVAB’s. Earlier this year was the first time one of my VBAC moms had a repeat C-section, and it was at her request, not because she was physically unable but rather mentally worn down by exhaustion and self doubt . I would accept her as a client in a second if she wanted to try again with her next baby. That is a success rate of over 99%.
As a home birth midwife I work very hard to accept only healthy, low risk mothers as clients. Of course, my idea of low risk does vary slightly from what is sometimes considered low risk by the medical profession. Hence, my love of VBAC moms, and other women tossed to the side by obstetricians and treated like their variation of normal is abnormal, such as breech presentation.
What is rather interesting about Sheri’s birth is that about a month or so before her birth a doula and I had a conversation about birth size. Of all the babies I have assisted in birth,f I have never seen a baby over 12 lb. 4 0z. I have seen several babies at exactly 12 lb. 4 oz. and of course dozens and dozens of babies in the 11 lb. to 12 lb. range. Interestingly, many of these babies have been VBAC’s…and all of those women had c-sections because they were told their previous babies were “too big”. My conclusion was that I feel that there is a “soft ceiling” of normal birth size for women free of medical conditions that can make babies bigger than that. As a side note, I am often times referred to in our area by other midwives, doulas and childbirth educators as the “Queen of the Juicy Babies.” A title I cherish.
As a home birth midwife I have a confidence about large babies that I imagine a obstetrician might not feel. My women are motivated to birth vaginally; my women are undrugged and can change positions at will and can push harder if need be. I have handled a few severe shoulder dystocias with success….surprisingly none of the 12 lb. babies are in that group. The thought of catching a 12 lb. baby for a mom lying flat on her back with legs in stirrups and an epidural would scare the crap out of me. So, I respect and understand how a doctor would feel with that situation staring at him.
Sheri was a remarkable woman to serve. She had been scared both physically and mentally from her first experience at birth. We spent many hours during her pregnancy discussing her expectations for this birth, her need to eat well (she had been diagnosed with “borderline” gestational diabetes with her first baby), which she excelled in, the importance of surrounding herself with supportive people and her fears. She prepared herself by attending ICAN meetings and educated herself to the max. She was a pleasure to be around and even though we knew it was getting to be a large baby I never doubted her ability to birth the baby she made. I want people to know that Sheri and I didn’t go into her birth blind, we both knew exactly what our roles were and we were rewarded with a lovely birth of a rather huge baby.
I absolutely love The Unnecesarean, and I refer women to it all the time. You have nothing to apologize for Jill, keep up the great work.

December 31, 2010 | Unregistered CommenterMargie Dacko

Eww. Banned commenters just don't get that no means no. Creepy.

Carry on.

December 31, 2010 | Registered CommenterJill

I was wondering about ways that midwives and doctors can identify a malpositioned baby *before* labor begins. I had an OP baby - I was lucky enough to be able to deliver him vaginally after 3 hours of pushing (the nurse said it was the first vaginal OP birth she'd ever seen) - but none of us knew he was OP until I started pushing. I was really lucky not to have any back labor. Is there a way to identify an OP baby early? The midwife tried several times to move him during pushing but to no avail.

December 31, 2010 | Unregistered CommenterErin
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