How big is TOO BIG?
There are two potential problems with a “too big” baby: a stuck baby and an injured baby. Stuck babies are delivered by cesarean section, safely. Injury to baby can occur during a cesarean section OR a vaginal delivery. The primary goal of labor care is to Prevent birth trauma to the baby.
The Best test to figure out whether a baby will “fit” or not is Labor. History has repeatedly shown that No Test Can Predict which babies are too big. Studies have included physical examination of the maternal pelvis, ultrasound estimate of fetal weight, XRAY of the pelvis, CT scan of the pelvis, and more.
- We can not prevent a cesarean section for a baby which is Too Big.
- The first goal is to deliver by cesarean section Only if Necessary.
- The second goal is to prevent Birth Injury.
The strategy of inducing labor early, before the baby gets too big, to prevent cesarean section, Does NOT Work. Multiple studies showed that early induction actually INCREASES the chance of cesarean delivery.
BIRTH INJURY: How does it happen, and how do we prevent it?
Sometimes the head delivers, but the shoulders get stuck. This situation is RARE and potentially serious. The maneuvers necessary to deliver the shoulders can break the collarbone, bread the upper-arm bone, and damage nerves going to the arm and hand. Those nerve injuries can be permanent.
There are TWO strategies for preventing birth injury:cesarean section without labor AND “very conservative” management of labor. There are published guidelines to define a too big baby and when to offer a patient cesarean section without labor. The American College of OB/GYN (ACOG) says too big is more than 10 pounds/4500 grams if pregnancy is complicated by diabetes, or more than 11 pounds/5000 grams in any pregnancy.
The second strategy relies mainly on Clinical Judgment ,so it is more difficult to define. Put simply: if it looks like labor is not progressing, or that the baby may be stuck, we can do a cesarean section a little earlier than usual. Another way of saying this is: we will do cesarean section when indicated, rather than letting things go on too long.
Delaying an necessary cesarean section for a baby who is stuck can lead to extra complications during labor and the cesarean section. We can see fetal distress in babies who are otherwise fine, but have suspicious heart rate patterns during contractions, when they get stuck for too long. There can be extra bleeding after delivery because the uterus gets “worn out” if it keeps contracting on a stuck baby. And there can be distortion of the internal organs, including the bladder and the blood vessels feeding the uterus when labor is allowed to keep going even when the baby is stuck. The bladder and uterine blood vessels are more commonly injured during cesarean section which was significantly delayed.
Clinical judgment or individual decision making can go both ways. There can be problems with a delayed cesarean delivery as well as with a cesarean delivery done early without a true medical necessity. A cesarean section without a necessary reason may be seen as an unnecessary surgery. But the topic is much more complicated than that.
There is a growing trend in obstetrics which is elective primary cesarean section. A doctor and a patient may agree on cesarean delivery without a necessary maternal or fetal reason, in a woman who has Not had a previous cesarean section. Doing a cesarean section for a baby which is too big and that does not meet the ACOG criteria May be seen as an elective primary cesarean section.
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