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Monday
Jun212010

Contemporary OB/GYN on Suspected Macrosomia and Taking Responsibility

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Reader Lori found a copy of Contemporary OB/GYN at her 29 week appointment and read the article ”How should we respond to the trend of increasing cesarean delivery?” On behalf of all of the women who sat through appointments listening to over-the-top tales of how giving birth would result in shoulder dystocia and endured descriptions during labor of fetal death in an attempt to encourage them that giving birth vaginally was too dangerous for them without any solid evidence for such a recommendation, I applaud Marci G Adams, MPH, Emmet Hirsch, MD, Scott N MacGregor, DO, Carolyn V Kirschner, MD, and Richard K Silver, MD, for their work on this commentary.

 

Here are a few excerpts that caught my eye: 

CD for suspected macrosomia

 Although avoiding shoulder dystocia and permanent brachial plexus injury are appropriate goals, performing CD for suspected macrosomia is limited by the inaccuracy of ultrasound estimations of fetal weight. The ability to predict shoulder dystocia is poor, and the likelihood of permanent brachial plexus injury associated with shoulder dystocia is low.37 The reported incidence of shoulder dystocia ranges from 0.6% to 1.4%. Frequency of brachial plexus injury after shoulder dystocia ranges from 9% to 26%, and most cases resolve without permanent disability.38,39 For example, in the experience at a tertiary center during a 23-year period that included almost 90,000 deliveries, brachial plexus injury occurred in 1 in 1,000 births with vaginal delivery, and permanent injury occurred in 12% of those cases.38 In other words, permanent brachial plexus injury occurred once in every 10,000 deliveries.

Among infants weighing more than 4,000 g, and even more than 4,500 g, the frequency of brachial plexus injury is low, even in diabetic pregnancies.40,41 Estimates suggest that more than 1,000 prophylactic CDs would be required to avoid a single permanent brachial plexus injury in both diabetic and nondiabetic populations, making the objectives of prediction and prevention untenable.37,39 An alternative strategy of team training in shoulder dystocia management is gaining popularity.42 Skills, drills, and simulation programs appear effective and probably should be propagated into all obstetric facilities. An alternative strategy to be tested prospectively would be to establish more stringent labor-management criteria for suspected cases of macrosomia, predicated on progress in both descent and dilation during the first and second stages. Using separate guidelines for such patients could reduce the CD rate in these women, especially when ultrasound fetal weight estimates exceed the actual fetal weight. A randomized study evaluating this strategy would only need to demonstrate that laboring these women with revised guidelines results in a modest reduction of abdominal delivery without increasing the frequency of shoulder dystocia.

 

From the conclusion:

Obstetric providers must take our share of responsibility for the tremendous increase in the CD rate and the associated life-threatening maternal complications that result from multiple procedures. We must not continue to consider obstetric interventions in a laboring patient in the context of the index pregnancy alone. Rather, the maternal risk of the initial and each subsequent abdominal delivery must be integrated into management decisions. This framework resembles an internist’s approach to hypertension, in which the decision to institute therapy is less predicated on its short-term effect than on the subsequent years of improved health and greater survivability associated with reduced blood pressure.

[…]

Nothing short of a public health campaign orchestrated by our specialty, with significant investment of resources, will turn this tide.

 

What do you think of the article?

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Reader Comments (11)

I really wish I'd known all this before my c-sec.....and wish I'd listened to that midwife that said I could have my baby vaginally, although that was all questioned with her 15 inch head....who knows.

June 21, 2010 | Unregistered CommenterRachel

Baby #1 - 10 lb 13 oz, 21 1/2 inches long - continuous EFM, stirrups, episiotomy, vacuum, 4th degree laceration (yes, 4th...not a typo)
Baby #2 - 11 lb 4 oz, 23 1/2 inches long - home waterbirth, midwife attended, delivered kneeling in the tub, very slight tear (no stitches necessary; tore due to son's compound presentation) easy recovery

While these are just my personal birth stories, I cannot stress the importance of comprehensive childbirth education, with particular emphasis on positions for labor like squatting, hands and knees, etc. as well as in-depth conversations about suspected large babies, whether or not to induce and how to communicate openly and honestly with one's doctor or midwife if and when the "we think your baby may be getting too big..." conversation takes place so that women can make informed decisions about labor and birth.

Thanks for posting this article!

Ami Burns
Birth Talk LLC

June 21, 2010 | Unregistered CommenterAmi

Here's hoping we'll see that "public health campaign orchestrated by our specialty" to bring down the C-section rate very soon.

June 21, 2010 | Unregistered CommenterDelia

Generally I dig it, but I do worry about this sentence: An alternative strategy to be tested prospectively would be to establish more stringent labor-management criteria for suspected cases of macrosomia, predicated on progress in both descent and dilation during the first and second stages. Would this indicate that women with suspected macrosomia (which seems to be a fairly high number these days) would be placed under more stringent requirements? Especially when we're talking about first-time mothers and potentially longer labors, I worry about "more stringent labor-management criteria." I do appreciate the statement, however, that sections should be looked at in the long-term and short-term, and the risks and benefits clearly and completely given to the patient, who should retain choice.

June 21, 2010 | Unregistered CommenterANaturalAdvocate

Finally someone making some fucking sense. I don't know about the constant monitoring of descent and dilation though. How about just letting women labour in peace and only doing something if something goes wrong?

June 21, 2010 | Unregistered CommenterMerrie

That's what bugged me so much about my second cesarean. I couldn't get anyone to consider my intention to have a large family! Medical staff refused to talk to me about anything except THIS "birth", and then the decision was made on my behalf, not even by my doctor, but by a hospital administrator. If I experience a serious placental problem resulting in a hysterectomy, I'm tempted to make someone put their money where their policy is, and sue for damages. Except I would never have the money for a lawyer, and I hope I'll never be put in that position.

June 21, 2010 | Unregistered CommenterHeather

To me, attending to the signs of impending shoulder dystocia is a more reasonable tact to take... far preferable to early induction and subsequent c/s.

SD *does* (often) present itself in second stage (sometimes we can see the trend in late first stage, but that is less predictive, imo)... so instead of assuming before labor even has a chance to get its groove on, I like that they suggest/request that labor might actually be the time to guess if the baby might be a sd or not. (And it IS a guess.)

I also am very, very glad to see more and more teams doing sd drills; we midwives do it, too. But, it is really important to know that the brachial plexus palsy is hardly the ultimate reason people freak out about sd; it is that babies can and do die during them. Personally, I know two women who lost babies to sd, one a UC. (And we *are* a product of our experiences, right?) So, all the drills in the world won't save the truly, forever-ly impacted baby. The drills WILL give more babies a chance at getting out, however - out the vagina.

I really like this article a lot. It's amazing to see OBs actually going against the tide of the cesarean epidemic. Finally. Maybe, just maybe, someone in charge might hear us down here... the last Who's in Whoville.

June 21, 2010 | Unregistered CommenterNavelgazingMidwife

I've had three big babies, one by RCS and two by VBA2C. My VBA2C babies were 8 lbs 10 oz and 10 lbs 8 oz, with 15" and 15.25" heads respectively and linebacker shoulders on both. My RCS baby was 10 lbs 6 oz with a 15" head, posterior. The difference between success and c/s in those births was positioning and patience. In my RCS labor, I was ordered to begin pushing immediately as soon as I was complete (in fact, I was told to push past a lip). I was pushed into coached pushing on my back, with wasted effort, and he got stuck. In my first VBA2C labor, I had two very long stalls, where labor seemed to stop almost completely. One was right before seriously active labor kicked in, allowing me to get a nap first. The second stall was after transition; my contractions completely backed off to 15 minutes apart and very light, and stayed that way for almost 2 hours until I started pushing involuntarily. In my second VBA2C labor, my contractions were irregular and spaced, 7-15 minutes apart, all the way up until the birth. I also had to do some odd hip-wriggling during second stage in order to get his shoulders past my pelvis (I felt a pop as they slipped through); it was good that I was upright and floating in water at the time!

I've said for years that these stalls and slower labors are needed for big babies in order for the baby to get the head molding needed to pass through easily, and to make the tiny adjustments that allow for a swifter passage. I pushed for only 30 minutes with my VBA2Cs with their stalls and "poor labor patterns", and had easy births with minimal tearing. I pushed for 5 hours with my RCS baby and still couldn't get him out. Putting stricter progression and pattern restrictions on moms with suspected big babies is going to be counterproductive.

But if they do a randomized study on it, as the author suggests, they'll see the increased c/s rate. Maybe that will open some eyes?

June 22, 2010 | Unregistered Commentersolinox

"An alternative strategy to be tested prospectively would be to establish more stringent labor-management criteria for suspected cases of macrosomia, predicated on progress in both descent and dilation during the first and second stages."

I agree that this statement is problematic...it would be okay if what they meant is that women would be allowed to move around and progress at their own pace...but that's probably not what they mean at all.

In general the article seems to have the right idea, though, and the last statement about a public health campaign orchestrated by the obstetric field is definitely true, I think. If obs stopped pushing c-sections and told women that they weren't as good for them as vaginal birth, most women would not want them and would not view them as just an alternative birthing method.

June 22, 2010 | Unregistered CommenterSara

I was impressed with the following statement:

"Obstetric providers must take our share of responsibility for the tremendous increase in the CD rate and the associated life-threatening maternal complications that result from multiple procedures."

Finally!! Providers taking some responsibility for their share in the c/s rate increases! For years, we've heard everything but that.....blaming it on women wanting elective cesareans, fear of liability, blaming it on women being too old or too fat or whatever. I've been waiting for a LONG time for doctors to take responsibility for their own role in the increase....what a refreshing thing to read.

May we hear a groundswell of chorus from other doctors echoing this......but I'm not holding my breath.

June 22, 2010 | Unregistered CommenterWellroundedmama
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