Big Babies and Homebirth

Do 9-plus pound babies need to be born via C-section? That’s the thing that stood out for me after reading Samantha M. Shapiro’s story in this week’s New York Times Sunday Magazine. I read this reprise on the homebirth debate with interest (and some dismay, since I talk about a visit to Ina May Gaskin on the Farm in my book). There are several things I liked about the article (the tone for instance), and several I didn’t (the title – ugh). But undoubtedly the strangest thing about the story was this:

“When I reached my due date, an ultrasound estimated that my baby weighed 9.4 pounds. I didn’t have gestational diabetes and had gained an average amount of weight, and fetal tests showed my baby was thriving. But the baby’s estimated size, combined with the fact that he hadn’t yet descended into my pelvis, worried my midwife.
She wanted the baby out by 41 weeks, and to my surprise, she suggested I consider going straight to surgery without labor. She sent me to be evaluated by a doctor she worked with. “One way or another, this baby will be a C-section,” he said.”

Shapiro doesn’t go for the prophylactic C-section, and that prophecy comes true:

“I was told I wasn’t progressing. The midwife pressed for a C-section, saying if I continued to labor I risked the chance of infection or shoulder dystocia. Bigger babies are at a greater risk for this complication, which in rare cases results in stillbirth or injury to the baby. … The midwife told us, “You don’t want to wait until the baby shows signs of distress — at that point it’s too late.” I negotiated for two more hours, made no further progress and then, under pressure, agreed to surgery. It was the kind of coercion by dint of not offering any other options that Gaskin talks about.”

Here I wanted to know one more thing: Was this midwife (and the doctor) making good recommendations backed by evidence? In this story it sounds like the medical consensus is that C-sections should be used to prevent shoulder dystocia. It makes intuitive sense that big babies will be harder to deliver, but everything I could remember on the subject said that because it was so hard to estimate the fetal weight it didn’t make sense to do preemptive C-sections unless the baby was a real orca (I’m allowed to say that: 11 pound baby right here). Nine and a half pounds is still solidly in the bell curve–if C-sections are a forgone conclusion for all of then, whew, that’s a lot of surgeries.

I asked Amy Romano, who has a new book out on precisely this sort of thing if the weight of evidence supported a prophylactic C-section for 9.5 a pounder. Basically, no, she answered:

“Some birth injuries would be averted if all women with suspected macrosomia [big babies] had c-sections, but the number needed to treat is in the thousands. (Thousands of women would need to have c-sections to prevent one permanent injury related to shoulder dystocia).”


The problem with this is that every C-section causes damage to the mother and increases her risk down the road, as well as the risk to any more babies she might have. These are small risks, but when you are talking about thousands, they add up. That’s why the American College of Obstetricians and Gynecologists says this:
“A policy of planned cesarean delivery for suspected macrosomic fetuses in women who do not have diabetes is not recommended … if all fetuses suspected of being macrosomic underwent cesarean delivery, the cesarean delivery rate would increase disproportionately when compared with the reduction in the rate of shoulder dystocia”

(ACOG notes that there is some evidence to support a C-section if it looks like the baby is over 11 pounds.) This is not some fringe group here–this is the main representative of the specialty reviewing the sum total of the science. Contrast that with the doctor saying “One way or another, this baby will be a C-section,” as if trying to give vaginal birth to a 9.5 lb baby was just crazy. In other words, this wasn’t a case of clinicians being somewhat coercive, this was a case of clinicians being totally anti-scientific (at least it seems that way, maybe there’s more to the story).

When I was reporting on childbirth I would see this kind of variation in care all the time. At one hospital they’d proudly assure me, (let’s see, to keep it simple I’ll use a made up example) say: “Oh, yeah, we paint every baby red within 5 minutes of birth. No exceptions.” And then at the next hospital down the road. “Of course we paint every baby blue, because we’ve known for years that red doesn’t work.”

Case in point, a month ago my sister in law gave birth to a 10.5 pound chubster. No one pushed her to have a C-section. And a prophylactic C-section for all babies over 9.5 lbs? The midwifes and doctors on her team (at UCSD) probably would think that was crazy talk. What do you think accounts for this difference? East vs. West medical culture? The legal culture? Or was there maybe something going on that we don’t know about with Shapiro?

5 thoughts on “Big Babies and Homebirth

  1. A few months ago, I was a doula at two births a week apart. One mom had been told the whole 3rd trimester that her baby was going to be huge and had weekly ultrasounds. The other mom was told (by midwife's guesses) she'd have an 8 pound baby. Mom #1 had a 2 day labor that ended in a cesarean. Mom #2 had a 6 hour labor and pushed for 10 minutes. Both babies were ounces shy of 10 pounds. I think attitude was everything.

    • I mean, clearly attitude isn't literally *everything* (if the Mom has a ricketts-deformed pelvis attitude isn't going to change that) – but I think you're just saying that attitude is important. There's certainly a lot of evidence for that. Everyone would agree that oxytocin is important, and that's a hormone that depends on feelings and attitude for release.

  2. Also, in the Times piece did she confirm that after the c-section the baby was in fact large? She doesn't say which makes me wonder if they were off with the weight. We know that weight estimates can be off a pound in either direction so the baby could have been 8.5 lbs, which is well within the range of normal.

  3. Attitude certainly is a factor (but I agree it's just one of multiple factors). There are a few studies that show that a baby large baby is more likely to be born by c-section if the provider suspected it was large (ultrasound or clinical estimate 8lb 14oz or more) than if it actually weighs that much, but the provider didn't suspect it. I think the attitude that “you're going to have a c-section one way or another” almost certainly biased the providers, but of course it's impossible to know what the outcome would have been with a more trusting provider. I, too, was left curious what the actual birth weight was.

  4. As a mom that vaginally delivered a 9lb 4oz baby, at home, I am very glad that I did not have a clue about her size. I knew that she had a growth spurt at 37 wx, but all 3 of my previous babies were in the 7lb range so I assumed that she would be no bigger than 8 lbs. So, when laboring to bring her into this world, my only concerns were positioning myself into an excellent position, and focusing on remaining mentally strong and confidant. I KNEW that I could get her out, because we ALL knew that I could get her out.
    It was never a question.
    My labor was 2 hours and 2 minutes from start to finish.
    With this in mind, I say “guessing” a baby's weight is not necessary and in fact detrimental to the NATURAL birthing process.

    Just my 2 cents anyway.