A recent experience with a planned c-section has left me discouraged about the future of obstetric care in America. Liz was pregnant with her first baby, and had experienced a normal pregnancy. When her due date came and went, she asked me about induction. I encouraged her to be patient and wait for her body to start labor naturally. Liz had a great attitude about the general aches and pains of late pregnancy, and the frequent bouts of “false labor” that she put up with.
Three days past her due date, by our office protocol, she had an ultrasound to confirm that everything was OK with her baby. Unfortunately, the report that came back from the scan indicated a very big baby–10 lbs, 12 oz. to be exact! Now, late-pregnancy ultrasounds can often be incorrect in their estimates of fetal weight. The report gave a weight range, and stated that the fetal weight could be as low as 9 pounds.
The OB on call came in to talk with Liz. He explained the high risk of shoulder dystocia with a macrosomic baby–a baby that weighs over an estimated 4500 grams, or about 9.9 lbs. Shoulder dystocia occurs when the baby’s anterior, or upper shoulder (as the baby is facing the mother’s side after the head is born) becomes stuck behind the pubic bone and the rest off the baby’s body cannot be born.
Liz accepted the OB’s recommendation for a c-section, and a few hours later, her baby was born. Before I tell you the rest of the story, I’d like to share some facts about shoulder dystocia:
- A large number of babies born with shoulder dystocia are not big babies. It can occur with a baby of any size.
- The frequency of shoulder dystocia is from 0.5 – 1.5%
- Risk factors include a macrosomic baby (bigger than 4500 grams), past history of shoulder dystocia, maternal obesity, and a truly abnormal pelvis–such as deformity from polio or pelvic fracture.
The rates of shoulder dystocia increase with increasing birth weight:¹
| Infant weight | Rate of shoulder dystocia |
| Less than 4000g | 0.3% |
| 4000-4500 g | 4.7% |
| Greater than 4500 g | 9.4% |
Can shoulder dystocia be predicted? This is a difficult question, and the best evidence indicates that we cannot with reliability predict the occurence of shoulder dystocia. There are “red flags” which can raise suspicion for increased shoulder dystocia risk:
- Clinical exam (by feeling the baby and measuring with a centimeter tape) that indicates a large baby is probably better at predicting fetal size than a late ultrasound
- Failure of the baby to descend into the birth canal
- Slowing of progress in late labor (around 8 centimeters dilation) in a woman who previously has made good progress, along with suspicion of a large baby
- Decision to use vacuum or forceps is correlated with higher rate of shoulder dystocia
The 2002 ACOG practice bulletin on shoulder dystocia reported:
1. Most cases of shoulder dystocia cannot be predicted or prevented because there are no accurate methods to identify which fetuses will develop this complication.
2. Ultrasonic measurement to estimate macrosomia has limited accuracy
3. Planned cesarean section based on suspected macrosomia is not a reasonable strategy
4. Planned cesarean section may be reasonable for the nondiabetic with an estimated fetal weight exceeding 5000 g or the diabetic whose fetus is estimated over 4500 g
In my next post, I will discuss more information about shoulder dystocia prediction, prevention, and management. Meanwhile, the rest of Liz’s story–her baby, born by cesarean section, weighed 7 pounds.
That is so sad! I wonder how the mother felt about it? I would have felt so betrayed by my doctor and the medical establishment if I were in her place. I’m sure this happens more than anyone would want to admit, though.
You are correct; this happens quite often. I have seen several cases in the last few months just like this, but this baby’s weight was the most overestimated I’ve seen.
AAARRGGHHH!!! Why does anyone even let ultrasound measurements exist??? Who wrote that number on the report? They should be forced to go and visit the mum and babe in the hospital, and at the very least apologize – now wouldn’t that bring the numbers down?? I can’t tell you how often this happens to my clients. They go for a late ultrasound, are told they have a HUGE baby, and then out comes a perfectly healthy 7 pounder… In the last five years, I have had scores of those, and only ONE case of a baby being bigger than the late ultrasound predicted. ONE case!! I really think the disconnect is partly due to the lack of follow-up care – the person who makes the prediction of baby’s size never meets the baby to see how wrong they were. If it were up to me, I would make that simple change – if you predict the size of babies, you MUST meet them afterward and see the result. I think people would quickly see the limits of technology if they did.
I completely agree with you… BUT
It is the computers that usually estimate the size/weight based on all those measurements it takes. The u/s tech is just a pawn in the whole game. She does whatever she is trained to do, says “9 lbs 4 oz” at the end of your ultrasound visit, and sends you on your way. She then sends your results to your OB where they are examined and OB gets to try and sell a C-section. (this is my story by the way– I haven’t caved but was almost scared into it!!) Unfortunately the computers who do the scanning and measuring don’t care much for mom and baby.
Same thing happened to me. Ultrasound at 42 weeks predicted a 10 lb baby. I refused to have a c-section but agreed to come in two days later for an induction if labor hadn’t started on its own. Thankfully I went in to labor that night and had an 8 lb baby.
The whole Big Baby Scare tactic is so disturbing. I have had so many moms come to me and say, “I have to have my baby (either induction or cesarean) because my baby is too big.” OBs are even starting to plant that idea at the 20 week ultrasound!
I have made a webpage dedicated to Big Baby Bull. I am going to link to this great post you wrote! http://www.pregnancybirthandbabies.com/Big_baby.htm
Thanks for sharing your experience.
Not only should the techs and radiologists see the disconnect, but administrators should know this happens. This strikes me, plain and simple, as a misdiagnosis. A Misdiagnosis leading to inappropriate treatment. It’s no different than treating someone for a cancer they never had.
My OB predicted my baby would be high 7’s low 8’s by measuring and feeling my abdomen and she was right; my daughter was 7 15. In your experience can you predict the approximate size of the baby? Also, can’t shoulder dystocia be remedied while in labor by placing the mothers legs up until her feet are close to her ears?
Ha Ha Ha! I just had my third child, my second HBAC who was 10 pounds 12oz. I am heavy too. Absolutly no shoulder issues during birth, perfect agpars for baby and no tears for me. My other two children were 9 pounds and some ounces. I did not have GD either. I also never had an ultrasound during this pregnancy. Obviously it can be done. I wish some people were not so driven to cut.
I am surprised that she did not push back. I had dystocia with my second. The mw helped him out. It was very painful, and he broke my tailbone, but I would imagine that a cesarean would be much worse! He was 8 lbs, 13 oz. I’m about 120 lbs normally and 5′4″ so pretty small framed. Interestingly, the ultrasound said he’d be around 7.5 lbs but I knew he’d be bigger. They’d said his big brother would be 5-6 lbs and he was 7 lbs, 9 oz when he was born. Ultrasound measurement is SO inaccurate!
Obesity has been found to be correlated with shoulder dystocia in SOME studies, but these studies were not controlled for diabetes and/or macrosomia.
In other words, the supposed connection to SD in women of size may simply have been a higher rate of diabetes or macrosomia in women of size, rather than the woman’s actual weight. The women’s WEIGHT may not have led to higher rates of SD, but rather may simply have been a marker for more diabetes and macrosomia, both risk factors for SD.
In studies where they controlled for diabetes and/or macrosomia, obesity itself has NOT been found to be a risk factor for shoulder dystocia. References: Neumann 2001, Jensen 2003, Poggi 2003, Robinson 2003
If a woman of size is not diabetic and is not bearing a large baby, she is at NO more risk for SD than any other woman.
Thank you for your comment. It is important that readers understand that an association is not the same thing as cause. Simply because obesity has been reported as being associated with higher risk of SD does not mean that it causes the SD. I have delivered many babies for women of size who maintained optimal health during pregnancy and had uneventful labors and births.
Induction and c-section because baby is measuring “big” according to ultrasound is extremely common in Omaha, NE where I am a Doula. Its something that I talk to my clients about quite often. In the 4 months I have had 6 ladies whose have been encouraged to induce early or have a c-section because their baby is going to be soooo big, over 10 pounds. Out of all of those women 1 baby was 8lbs 8oz and the rest were under 8 pounds. I try to use my own experieince with ultrasound measurment as a good example. With my second daughter I had many, many ultrasounds during the 3rd trimester becuase my little girls was not a great grower. In fact they were sure that she was going to be 5 pounds or smaller. She was born a nice, normal 6 pounds 9 ounces, nothing close to what they had been estimating! I want them to know how inaccurate ultrasounds can be!
I had a shoulder dystocia with my second child which I believe was due to bad positioning. She was coming down at a slightly diagonal angle. Had I been in the care of a midwife, I’m sure that would have been caught and addressed, as my midwives for my other births were much more aware of positioning.
With my youngest, I was under dual care of a homebirth midwife and an OB as we tried to clear up risk factors related to a blood disorder I have. A month before he was born, I had a blood transfusion and an ultrasound. The transfusion changed me back to a low risk patient by clearing up my extreme anemia, but the ultrasound made the OB immediately start pushing a c-section. He predicted my son was already 10 pounds, 6 ounces and because of the SD with my daughter, he didn’t even want to give me a chance at a vaginal delivery. I finally did get him to agree, but in my heart, I knew if I set one foot in that hospital, I would end up in surgery because I would be limited in positioning.
Had a lovely, safe, dystocia free homebirth of my 10 pound, 3 ounce boy (a month AFTER the ultrasound said he was 10, 6). I gave birth on hands and knees, listening to my body the entire time. It told me to move constantly, so I did, and we got that big baby inched out the way he needed to be.
“Slowing of progress in late labor (around 8 centimeters dilation) in a woman who previously has made good progress, along with suspicion of a large baby”
My miracle vaginal birth…up to this point I never knew this was a red flag for shoulder dystocia but that is what happened to me. I dilated to an 8 by 7 a.m. and stopped/regressed. After a midwife advocating for me to not have a c-section (the baby was not in distress) I pushed for 3 1/2 hours, went in for vacuumed assistance before a c-section, and the baby was born on the third attempt. I remember my midwife jumping on the table at one point and pushing down on my pelvis. Apparently my 11 lbs. 5 oz. baby had shoulder dystocia.
I am secretly glad no one accounted for this red flag to have an immediate c-section. I would have taken it not knowing that although there is shoulder dystocia..the baby can still come out with assistance.
I am scared for my expected birth in February. I am afraid the attempts for a unecessarian will be against me because of my previous history. I don’t know what to expect. I do feel confident that my midwife will advocate for me again…
Any advice for how to approach this birth?
I should also add, that the OB was also very accommodating. They aren’t all section hungry and want to do what’s best.