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.