VBAC scare tactics (10): Big Baby, Big Problems

VBAC scare tactics (10): Big Baby, Big Problems

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Many women who want to have a vaginal birth after cesarean (or VBAC, pronounced “vee-back”) in the U.S. and elsewhere have faced some sort of opposition from their care providers when they have expressed their desire to VBAC.  Oftentimes, this opposition comes in the form of ” VBAC scare tactics.”

The (outrageous) statements are often misleading, exaggerated efforts by OBs (and yes, even midwives) to discourage women from VBAC and to encourage them to “choose” a repeat cesarean.  (Of course, it’s not really a choice if your provider won’t even “let” you VBAC, is it?)

If you find yourself up against a barrage of scare tactics–as I once did–it can be exceedingly difficult to stake your claim and argue against the doctor (again, or midwife) who may or may not have your and your baby’s health prioritized higher than medico-legal concerns and who may or may not be insinuating that VBACs are synonymous with driving your child in a car without a car seat.

If you do find yourself facing such scare tactics, and if you do want to have a VBAC, there are some questions that your care provider should be able to answer when s/he hurls those scary and/or outrageous comments and standards your way.  And if s/he refuses to or even cannot answer these questions, then you might want to consider finding an alternative care provider–one who is making medical decisions based on research, evidence, and even respect for your patient autonomy and not on fear, willful ignorance, or even convenience.

I encourage all mothers who read this post (and others in my “VBAC Scare Tactics Series”) to  take the information contained herein as a springboard from which they can 1) continue their research on VBAC, 2) maintain a communicative relationship with their care providers, and 3) find a care provider who best supports the mother’s interests and plans for the birth of her child.

(To read my disclaimers about “why I am not anti-OB” and “why I take the gravity of uterine rupture seriously,” please see my posts on VBAC scare tactics (1) and (2) .)

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Scare tactic #10: Based on this recent sonogram, your baby is getting way too big for a vaginal birth, especially a VBAC.  You can’t safely have a VBAC with a macrosomic baby.  We’re going to need to schedule a repeat cesarean as soon as possible.

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Questions to ask your care provider:

  • How accurate are sonograms at predicting fetal size, particularly at the end of a pregnancy?
  • What special concerns do you have when it comes to a woman birthing a “big baby”?
  • Does fetal macrosomia increase the risk of uterine rupture?
  • What does ACOG recommend when it comes to fetal macrosomia and VBAC?

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A more nuanced analysis:

When a physician or midwife uses terms like “suspected fetal macrosomia” or “LGA” or “large for gestational age” in reference to your baby, what s/he means is that your baby’s estimated weight has exceeded a particular cut-off point: typically, either 4000 g (or 8 lbs. 13 oz) or 4500 g (or 9 lbs. 15 oz).

The reasons for denying women the opportunity to plan a VBAC with a suspected macrosomic baby may vary.  Some care providers might think that this increases the risk of uterine rupture.  Others might want to forego the slightly increased risks associated with fetal macrosomia.  And many might regularly schedule cesarean sections for all suspected macrosomic babies, whether or not their mothers have scarred uteri.

And, to be fair, there are some increased risks associated with fetal macrosomia, particularly if women have diabetes or uncontrolled gestational diabetes/gestational diabetes mellitus/GDM.

For one, fetal macrosomia is associated with a greater risk of shoulder dystocia, a labor complication that is serious but nearly impossible to predict, especially before labor even begins.  (Notably, the overall risk of shoulder dystocia during labor is approximately .6-1.4%.  What’s more, approximately one-half of all cases of shoulder dystocia occur with infants who weigh less than 4000 g–that is, who are not macrosomic.  )

Fetal macrosomia is also associated with a greater risk of cesarean section, although this is likely related (among other things) to the relative immobility with which most women labor in hospitals, to the rising rates of labor induction, and to the fact that many care providers recommend prophylactic cesarean section for suspected fetal macrosomia.  (Worth noting is that labor induction–which does slightly increase the risk of uterine rupture–has not been found improve labor outcomes for women and babies where the fetus is suspected to be large.)

Nonetheless, barring any pregnancy complications that would greatly increase these and other risks associated with fetal macrosomia, the absolute risks themselves are quite low, and certainly not high enough to bar all women carrying fetuses who are suspected to be macrosomic from delivering those babies vaginally.

In this respect, it is exceedingly important to remember that any suspicions about fetal macrosomia are just that–suspicions, estimates, educated guesses.  In fact, weight estimates gleaned via ultrasound can be “off” by as much as one to two pounds!  So even if ultrasound measurements determine that your baby is measuring 10 pounds, you might actually have an average-sized 8 lb. baby (or, to be fair, a larger-than-average 12 lb. baby).  Thus, it is worth asking your care provider why this estimate by itself would disqualify you from planning a VBAC.

To this effect, your care provider might state that fetal macrosomia lowers the likelihood of a successful VBAC and that it increases the risk of uterine rupture.  S/he might even mention the most current ACOG Practice Bulletin on VBAC, which does refer to some “limited evidence” showing a higher risk of uterine rupture associated with “women undergoing TOLAC [a trial of labor after cesarean] without a prior vaginal delivery and neonatal birth weights greater than 4,000 g.”

But this very excerpt from the ACOG Bulletin demonstrates that the issue is more complicated than simply claiming that “fetal macrosomia increases the risks of uterine rupture.”  For instance, while there is evidence suggesting that higher birth weights are associated with higher rates of uterine rupture, ACOG itself acknowledges that this evidence is limited.  (The study I’ve linked to here examined 2586 women, but only 269 had babies with birth weights greater than 4000 g.  This is a fairly small population, especially when one is considering using the study to disqualify women with suspected large babies from planning a VBAC.)

What’s more, although a large baby may lower one’s chance of having a successful VBAC, this does not mean that one has an absolutely low chance of having a VBAC with a large baby.  In fact, in the aforementioned study, the VBAC success rate among women who birthed babies weighing over 4000 g was 62%–not exactly a low success rate!  (And to be clear, the other 38% were simply those women who had cesarean sections following their VBAC attempts–not necessarily those who had uterine ruptures following their VBAC attempts.)

Finally, the current ACOG Practice Bulletin on VBAC also mentions the fact that most (if not all) of the studies examining VBAC success rates, uterine rupture rates, and fetal macrosomia used “actual birth weight as opposed to estimated fetal weight thus limiting the applicability of these data when making decisions regarding mode of delivery antenatally.”  In other words, the data used in these studies pertained to babies who were actually macrosomic–not babies who were suspected to be macrosomic.  It pertained to actual birth weights–not to weight estimates.  Thus, particularly since fetal weight estimates are notoriously inaccurate, it is questionable whether or not one can or even should apply these studies to any sort of prenatal counseling–especially counseling that dictates whether a woman should deliver her baby vaginally or via cesarean section.

In this respect, it is important to take note of ACOG’s most recent recommendation on VBAC with suspected fetal macrosomia:

it remains appropriate for health care providers and patients to consider past and predicted birth weights when making decisions regarding TOLAC, but suspected macrosomia alone should not preclude the possibility of TOLAC.

So if your care provider is denying you the opportunity to have a VBAC based only on suspected fetal macrosomia, you should definitely consider asking why s/he is departing from ACOG recommendations in this matter and/or what other reasons s/he has for barring you from a VBAC.  (You might also consider finding a more supportive care provider!  Or just refuse an unnecessary cesarean, as it is your right to do!)

What’s more, you can always maximize your chances of a successful VBAC with a suspected large baby by walking, moving, and changing positions during labor and by avoiding giving birth on your back.  The more you move and remain upright, the more you take advantage of gravity and of your pelvic flexibility and mobility to help bring your baby into the world.

And suspicions about a large baby should not preclude you from doing just that.



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23 Comments

  1. Mrs. Spit
    Mrs. Spit08-11-2010

    I’m curious, is there a point at which a c/section would be reasonable?

    I’ve seen lots of my friends accept their c/section and have nice small 7 pounders, even after the LGA threat.

    I’ve also seen a girl friend who had a vaginal birth of a 11 pound baby and all sorts of complications (baby was fine, she tore from stem to stern, split her hips and broke her tail bone).

    Based on this, I know she really struggled with the decision about a c/section. In the end she chose it for a bunch of reasons, and her next babe was 13(!) pounds. But like she’s said, she’ll never know what could have been otherwise.

    But I’m curious, is there a point at which you think it might be reasonable to have a c/section for LGA?

    • Iva
      Iva08-11-2010

      I’ve been thinking along the very same lines… My first baby was 11lb, born vaginally with a bad tear. By your description, it wasn’t as bad as your friend had it (hips and tailbone intact), but still it makes me wonder.

      I am hoping to be pregnant soon with a second baby (maybe already am!), and I really do not want to have a c-section. But I’m not going to be surprised if this one is big, too… And how big is too big? I know that ultrasounds are not very reliable in this aspect, but if I have one and they say 11lb, I can be the case where they err on the lower side… just repeating to myself that my body is not going to grow a bigger baby than I can birth is not going to work. I truly do respect my body (hasn’t always been so), but I think it is a real possibility.

      ok, sorry for pouring all this out here – don’t even know if I’m pregnant yet and I already worry about birthing – but it’s just that you touched the exactly the “hot spot”

      • BirthingBeautifulIdeas
        BirthingBeautifulIdeas08-12-2010

        Iva, I think that it’s perfectly understandable, normal, and reasonable to feel the need to balance your respect for your body and your concerns about birthing another big baby. In fact, neither one cancels out the other.

        I don’t know if you saw Navelgazing Midwife’s comment, but she just wrote a blog post addressing dietary concerns and maternal/fetal weight gain. There might be some information in there that could be very useful to you as you plan for your next baby! Your body might very well make bigger-than-average babies all on its own, but there might also be steps you can take to ensure that it doesn’t grow a baby bigger than you can (comfortably) birth.

        Happy ttc-ing! :-)

        • Iva
          Iva08-13-2010

          Thank you for pointing this out to me. I’ve actually been doing some reading on this, too, since I was surprised after the delivery when all the nurses were asking if I was diabetic… I simply answered no… I’m 5’10, was 140lb prepregnancy, 167lb the day before labor started, “passed” GTT, and already followed most of Navelgazing Midwife’s recommendations – except for the juice, vit D and walk after every meal (even though I swam and walked a lot through the whole pregnancy, just not immediately after eating)

          but that seed of doubt was there since they asked and after some reading (including NM’s post) I guess there might be some insulin resistance. I’ll try to work with it this time around

          too bad about the juice though! :(

          PS Thanks for writing these… I haven’t had a c-section (hopefully never will), but I think your posts and comments are very valuable to birthing women in general too. (I’ve already forwarded a few of them to friends)

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas08-12-2010

      According to the ACOG Practice Bulletin No. 22 (on Fetal Macrosomia), current evidence does not support prophylactic cesarean section unless the baby is expected to weigh more than 5000 g (11 lbs.). So if a baby is estimated to weigh more than 11 lbs., I think it is perfectly reasonable for a care provider to recommend (though not force) a cesarean section. (In my lay opinion, those recommendations can, and probably should, be stronger in cases where babies are expected to be +5000g and there are additional major complications that might increase the risks associated with FM. In my doula opinion, women who are expecting to birth very large babies vaginally should also be counseled about remaining as upright and mobile and even drug-free as they can during labor so that they can effectively “move the baby down” as much as possible.)

      But more than this, I think that it is not only reasonable but also essential for care providers to leave the decision about whether to pursue a vaginal birth or a cesarean section to the pregnant woman herself. She should be apprised not only of the (relatively low) risks associated with delivering a macrosomic baby but also of the relative innacuracy of ultrasound weight estimates, the (still relatively low) risks associated with cesarean section, and the benefits of vaginal birth. (And hopefully, she gets all of this information in the least overwhelming way possible!)

      If a woman has this information, then she can do something more than make a reasonable choice–she can make an informed choice. This information cannot predict the outcome of her birth. And in most cases, it cannot even make the decision all that clear-cut for her. And even if she defers her decision to her care provider, at least it will have been her choice to do so. This sort of empowerment is what I would like to see in any decision regarding pregnancy, labor, and birth, actually.

      Not sure if this answers your question, but I hope it at least addresses it tangentially. :-)

      • Amber
        Amber08-12-2010

        I have no personal experience with cesarean birth or larger-than-average babies. However, I think what you’re saying about informed choice is bang on in pretty much every case. We need to allow mothers to make the best choices for themselves. And I firmly believe that we can trust them to do so.

        Women have the best interests of themselves and their babies at heart – much more so than anyone else reasonably can. They are also the ones who will bear the consequences for whatever happens. We need to be empowering them and informing them, and I don’t think we do a very good job of that a lot of the time. It’s so disappointing.
        Amber´s last blog post ..Share Your Story- Feed My Dream

  2. NavelgazingMidwife
    NavelgazingMidwife08-12-2010

    Re: women having a large baby history, there are *absolutely* ways to keep your next baby from being so big. (Not here to push my blog at all, but my most recent post is about this exact topic.)

    My own personal experience includes several babies over 10# and a couple over 11# (both of which were severe shoulder dystocias and subsequent hemorrhages)… a few of the 10#ers also had shoulder dystocia or, more frequently *very* “sticky shoulders.” These women were homebirthing, upright, moved every which way in the universe to get the baby out (I have found lunging to be one of the best positions, but McRobert’s continues being *the* best… used, of course, after everything else).

    Even with allll that said, this post is so right on I want to scream “Halleluja!” Just fantastic. I not only put it on my FB page, but will be sure to share it with future clients. I do a lot of monitrice and even doula work, so *do* have clients that endure the “your baby is too big” speech.

    Just wonderful. Thank you so much!
    NavelgazingMidwife´s last blog post ..Barb’s Advice to Quell GDM and-or Humongous Babies

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas08-12-2010

      Thank you, NGM!!! I’m a big fan of yours, and it means a lot to know that you like this post. I’ll definitely share your last post with people who have concerns similar to Mrs. Spit and Iva’s.

  3. MotherWit Doula Lesley Everest
    MotherWit Doula Lesley Everest08-12-2010

    Fantastic Post! I have seen women, hoping for VBACs, sectioned for their suspected 11 pounders, only to have babies under the macrosomic “boundaries”. I have seen uterine rupture and fetal death..not due to a big baby, but due to iatrogenic causes. My colleague a couple of years ago saw a baby who was 12 pounds, 8 ounces born easily, with no perineal or vaginal tearing. I have personally only seen 3 babies born 10 pounds or over vaginally, but those babies were fast and easy, one actually coming out in 1 push with no tear. The slower ones were sectioned because they were assumed to be huge, and the hugeness was the assumed reason for the slowness. Maybe it was, maybe it wasn’t. We’ll never know. I had a woman VBAC over her toilet in an accidental unassisted birth after one hour of labour, having a baby who was a good pound over her previous baby’s weight…and she was sectioned for that birth because baby was “too big”.
    One of the most difficult births I ever saw, requiring hours and hours of pushing, vaccuum, THEN forceps, (the woman only got an epidural after several hours of pushing…instead of a section, they recommended a rest, then starting pushing again after some relaxation) resulted in a baby only 4 pounds, 12 ounces (at 36.5 weeks). The mother went closer to term with her next baby, and opted for an elective Cesaerean, presumably because this baby was bigger (though her little vaginally birthed guy had been posterior, which could have contributed to the great difficulty).
    It’s a crazy world, and there is just no guarantee of anything. As a doula, I help women work through the seeds of fear planted and watered every time she visits her OB, guiding her to research evidence. But that OB pull is a very powerful thing….a woman can be extremely well read and informed, but any whiff of a “weird” heart rate or going past her due date, or having a long labour, and BOOM, those seeds often explode in a large percentage of even the fiercest woman into a redwood forest of terror, all logic and evidence going out the window and the statement, “what if my OB is right?” resonating throughout the room. Those who choose midwives here usually don’t have this fear to contend with. Sadly, only about 35% of women who desire to give birth with a midwife in Montreal end up doing so, because the demand far outweighs the supply.

  4. Jenny
    Jenny08-14-2010

    Without even reading this post I can ALREADY tell you this is going to be one of my favorites. My biggest pet peeve is when people tell me that their doctor’s have said the baby is going to be too big. Everyone kept asking me how big Ollie was when he was in utero and I always said I don’t know – my doctor and midwife never really paid much attention to measurements because they know they can be very inaccurate.

  5. Juliette
    Juliette08-15-2010

    My sister-in-law just fell victim to this. She had diagnosed GD, and was threatened all the way through the pregnancy that she was going to have to be induced early because she’d have a “big baby”. Every ultrasound showed a baby measuring SMALL, and her measurements were also small, but yet the OB still pushed her into being induced on her due date.

    She had the typical nasty induction story – the Cervadil didn’t work until a second dose, then she went 0-60 into labour, the baby didn’t descend, and she ended up with a c-section, which has become infected. She has been told that her body type “doesn’t support childbirth” and that she’ll need c-sections from here on in. I am so angry for her!! I am waiting until she is over the trauma and then will be directing her to some VBAC stories so she can see how much misinformation she’s received. Oh – and her baby was 6lb on the nose. Gorgeous and tiny, and so clearly not quite ready to be born.

    Luckily through sheer determination and the support of an LC she pulled a rabbit out of a hat with respect to breastfeeding, no thanks to the nurses telling her she should supplement after 12 hours.

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas08-16-2010

      Oh Juliette, I’m so sorry to hear that this happened to your SIL. I find it so infuriating that she is now being told that her body type “doesn’t support childbirth.” What does that even MEAN?! Obviously I don’t know all of the ins and outs of her birth, but it seems ridiculously apparent that her body wasn’t ready to be induced!

      So glad to hear that breastfeeding is going well, though…

  6. Anne
    Anne08-16-2010

    Great article! I’ve added it to my VBAC favourites folder.

    Just wanted to add that in 2008 I had a drug free VBAC of a 12lb 11oz (5.76kg) baby girl under the care of a marvellous OB here in Australia. So, NGM, I’ve also bookmarked your recent post too, just in case we add to the family – I really don’t want to set a new personal best when it comes to birthweight!

  7. Best of the Birth Blogs – August 9-22 | ICAN Blog
    Best of the Birth Blogs – August 9-22 | ICAN Blog08-22-2010

    [...] a thought-provoking post on birth trauma and violence.  Birthing Beautiful Ideas breaks down the VBAC scare tactic of large babies. Read all her posts on VBAC scare tactics here.  The Unnecessarian tells us what we learn from the [...]

  8. Another Anne
    Another Anne06-08-2011

    Hi!

    Thanks for this post!

    I just had a 9lb 15 oz baby by c/sec after he turned breech, kicked my waters, and started ascending (had a 2x nuchal cord). I was told at the hospital that large BREECH babies can be more of a problem, so the breech issue may need to be considered in the estimation of fetal weight and weighing of birth options. They would have possibly been amenable to a breech birth of an estimated smaller baby. (To be fair, I did not really rely on their u/s measurements so much in making my decision, as I know how inaccurate they are…it played a small part in my own assessment though.)

    The other thing I would like to know, and I don’t know if there is any data on this, is if weight is really the best indicator of potential delivery problems. I would think that head circumference and shoulder circumference, as well as the ratio of head to shoulders, would have more to do with baby being too big than weight. Heads mould, but they’re still bone…fat squishes. Case in point, my 9lb 15oz baby had the smallest head of all my babies and huge fontanels (had he been able to descend I imagine he had the perfect head for a vaginal breech birth)…although his shoulders were big so that might’ve been a problem. Either way, with him he came the way he needed to come…but I sure wish we saw more research into head/shoulder size and ratio and how that compares to weight in predicting problems…both actual size and estimated size. Then people could hopefully stop freaking out over large babies (11lb!…but with a 13 in head and alot of fat, it might be an easy birth) and have a real discussion!

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas06-08-2011

      That’s a really, really fabulous question, Anne. I don’t know of any research on that topic, but that doesn’t mean that there isn’t any.

      In that same vein, I don’t know how the accuracy of those measurements would compare to the accuracy of fetal weight estimates (which isn’t all that great). My gut tells me that they would be at least a little more accurate, but again, only good research could back that up. Do let me know if you find any relevant info on your own!

  9. MamaMereMere
    MamaMereMere07-10-2011

    Wow, this all resonates with me! I had been using Hypnobirthing and a (not so great fit for me in hindsight) observant doula. When I was 41 weeks, they all threw the ‘dead baby card’ and I finally was so scared and upset we went for an induction. 4 days! finally after at the middle of day 4 I gave in and got a dose of Stadol, then that wore off and I thought perhaps an epidural would relax me. They did an AROM as well. Never got past 4 being tethered to all that. C/S due to FTT, failed induction, suspected macrosomia (9 13). SO frustrated! DD was fine, no decels, etc. But they told me I just couldn’t get her out and should have c/s in the future cause I grow big babies and have CPD. What??!
    SOOOOO I started our local ICAN chapter and am still nursing @ 17 months!

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas07-10-2011

      Way to go on starting a local ICAN chapter!!! I think that so many of us find that our birth experiences lead us on the road toward maternity care advocacy. It’s great to give back to others, but it’s also nice to create our own safe spaces for healing and processing.

  10. Amaryska
    Amaryska09-12-2012

    Hi there, i had an emergency c-section in 2008 for “macrosomie” baby and dystocia written on my file. I laboured allnight and finally realise now what i didn know then. I am desiring a second baby to complete my family and i am scared of having a repeat c-section aswell because the 2nd might be large. Any opinions on this? Can i really vbac safely.

  11. amaryska
    amaryska09-12-2012

    I just wanted to add that i put on 25kgs , almost over 50IBS. I am now a personal fitness trainer. I have worked damn hard to get where i am now. so of course, thoughts of being HUGE again with a second to throw me off edge. I am wondering though if the second is always bigger. Or if i keep up my workouts will this help my chances of a vbac? and weight gain under control?

  12. Lica
    Lica10-08-2012

    First baby was high induced was told prob c section 5hr labour 3 pushes she 7lbs3ozwas out. 2 baby breech c section no choice. 10 lbs 3ozs. Third baby water broke said they think I might have slight abruption was not sure scare me into emergency c section 8lbs. 4 th baby planned c section no choice head down 6 lbs14oz one week early. 5th. baby breech midwife labor at home meconium with water discharge. 12Hr labor feet out tired decided to do c section but once I got to hospital had a hard time holding him in but did so they would not do emg cesar. Iprob could of had him. 9Lbs. 6Th baby head down big baby not sure what to do have a planned c section in a few weeks but want to deliver naturally one more time if not my last baby via c section. If my fifth was head down would of been a smooth delivery. He had great heart rate I should of held out but the meconium concerned me. If they would of let me deliver breech in hospital I would have.

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas10-08-2012

      Wow, it sounds like you have really had a variety of birth experiences! It can be so easy to look back on our births and say, “I should have done x, y, or z,” but I think that most of us make the best decision that we have given the circumstances and knowledge that we have in those moments. It is never too late to explore your options with your care provider and/or to seek out a care provider who is on board with your wishes for your next birth! Good luck.

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