A few months ago I did something I’ve never done in over five years of midwifery practice; I recommended a primary cesarean section delivery for a patient who had a history of two uncomplicated vaginal births.
It still seems rather shocking to me. I hardly ever advise a patient to have a primary cesarean section (c-section) without sound medical evidence.
When the patient, Mrs. J, had her first child, she had a healthy body mass index (BMI) of 24 at the time of conception and gained the appropriate amount of weight during her pregnancy. I attended the birth of her first daughter – it was uneventful – easy even. Her second pregnancy and birth followed a similar course.
In the 30 months between Mrs. J’s second and third pregnancies, she had multiple medical issues that required surgery. She had lost her mother, and had gained over 100 pounds.
Obesity is considered a significant risk factor in pregnancy; therefore Mrs. J was more closely observed and monitored than in prior pregnancies. Despite diligent counseling regarding diet, exercise, and healthy weight gain in pregnancy, she gained 65 additional pounds. Surprisingly, she did not develop gestational diabetes.
At 37 weeks gestation, the estimated fetal weight by ultrasound was 10 pounds, plus or minus a pound. Given that Mrs. J’s largest child was only 6 pounds 8 ounces at birth, I was concerned.
Generally I do not believe in making huge decisions about mode or timing of delivery based on estimated fetal weight by ultrasound. It is exactly that, an estimate. Honestly, the two-pound range that is fairly standard in late term ultrasounds always gives me pause.
The difference between a 7-pound baby and a 9-pound baby can be monumental. Personally, I tend trust what I feel with my hands and what an experienced mom reports to me far more than a late term ultrasound.
Suspected macrosomia, or a large baby, is not generally enough of reason to induce labor or schedule a cesarean prior to 39 weeks. There are just too many variables that prevent us from knowing how well the baby will fit out of the mother’s pelvis. I believe most women should have, at the very least, a trial of labor, and if macrosomia is suspected, there should be a low threshold to move to cesarean delivery if needed.
In Mrs. J’s case, I felt she was at true risk for shoulder dystocia. The baby felt large to my hands and she said this baby felt much bigger than her first two. We probably still had at least 2 weeks of fetal growth, and even at the lower end of the estimated fetal weight, we were looking at a baby that would be more than 2 pounds larger than her last baby. I was also concerned about the effects of her weight gain of the labor and birth process.
I agonized over Mrs. J’s ultrasound report and when she came in for her weekly appointment, she expressed concern over “fitting the baby out.” We discussed in great detail the risks and benefits of vaginal birth and cesarean delivery.
In the end, I told Mrs. J that it was ultimately her choice, but that I was inclined to encourage her to schedule a cesarean section between 39 and 40 weeks to avoid the very real risk of shoulder dystocia. I reminded her that if she went into labor on her own prior to that point, we could attempt to have a vaginal birth, with very close observation of labor progress.
Mrs. J elected to have a cesarean section at 40 weeks, since she hadn’t gone into labor before that point. The baby weighted 10 pounds 2 ounces, almost four pounds larger than her second child. She was content with her decision and relieved that she was able to have a tubal ligation during her cesarean.
When she came in for her six-week postpartum visit, Mrs. J asked if I still questioned my decision to recommend cesarean for her. I will always wonder if she could have pushed such a large baby out, given her history of two successful vaginal births. However the outcome was good – a healthy mom and a healthy baby – and in the end, that’s the most important thing.
Robyn Carlisle, MSN, CNM, WHNP, works as a full-scope midwife at University Doctors and Kennedy University Hospital in Sewell, N.J.