As a home birth midwife, I often help women cope with the after effects of a previously traumatic birth. Among them are women who have had previous caesarean sections because their baby was “too big” to fit through their pelvis, or had caesarean sections because of a failed induction at 38 weeks to “prevent” their baby “getting too big to birth”. Other women tell tales of hours of pushing and several attempts at a vacuum extraction where the doctor has placed his foot on the end of the bed to gain more traction. After their episiotomy tears and extends down into their anus, the doctor says to them that obviously their pelvis was “too small” and with such extensive damage to their soft tissues that they would be “better to have a caesarean next time.” Without exception, every woman I have counselled in this area has so far achieved a very empowering birth, many of them with babies that were bigger than their first. I often wonder at the logic of an obstetric system that continually denies women their power. In the current political climate where women face the likely event of a reduction in their birth choices (and therefore a reduction in their choices for healing) I feel that women are being corralled into an authoritarian and patronising system where their voices are seldom heard. Wouldn’t it be better to empower women to birth powerfully? Wouldn’t it result in better health for mum and bub? Better families? Better society?
As I write this I await news of Sally, who is in early labour with her third child. She is just over 37 weeks. Her first two children were just under and just over 4.5kg (10lb). She was not working with me towards her birth, but was planning on attending her local hospital. A friend of hers had birthed with me, and she had read some of the articles from my book. I received an email after she had just returned from a routine 36week antenatal visit, and left very upset - convinced that there was something wrong with her baby. Apparently her baby was “macrosomic” and that the only option for a safe birth for her was a caesarean section. It seems the Dr had felt a very large tummy and sent her for an ultrasound and the ultrasound had told her that her baby was “already” 4kg. Returning to the doctor she was informed that ultrasounds were 70% accurate in estimating fetal weight and that if she persisted in her push for a natural birth then she would endanger her baby. While probably not exactly what the doctor said, this lady left the office with the impression that they would have to break her baby’s collar bone or arm during the birth because it would get stuck. Two separate doctors on two different days scared this woman silly about the “risks” of a large baby without ever communicating to her things that increased her risk or things that would decrease it. Birthing options such as positions were never discussed. They also left her with the impression that she would experience the complication of her baby getting stuck and that her baby would be temporarily or permanently injured form the experience, and not that she had x% chance of such an occurrence. They certainly did not tell her that it is generally accepted that elective caesarean sections to prevent shoulder dystocia are not proven to be effective.
“In fact, most past studies have found that neither macrosomia nor shoulder dystocia can be reliably predicted in the babies of diabetic mothers.... The bottom line: Predicting macrosomia and shoulder dystocia in diabetic mothers has been as difficult as predicting these factors in the nondiabetic population.” [Lerner, H. (MD); 2006; “Shoulder Dystocia – Facts Evidence and Conclusions” http://www.shoulderdystociainfo.com/index.htm ]
“Babies who are very large (macrosomic - over 4500 g) can sometimes have difficult and, occasionally, traumatic births. One suggestion to try to reduce this trauma and to reduce operative births has been to induce labour before the baby grows too big. However, the estimation of the baby's weight in utero is difficult and not very accurate. Clinical estimations are based on feeling the uterus and measuring the height of the fundus of the uterus, and both are subject to considerable variation. Ultrasound scanning is also not accurate. Induction, if undertaken too early, can lead to babies being born prematurely and with immature organs. The review of trials, assessing induction of women when it was suspected that their baby was above 4 kg, found three trials involving 372 women, none of them with diabetes. There was no evidence of any benefit in terms of caesarean section or instrumental births, or in outcomes for the baby. However, these studies were too small to be sure of the outcomes. Further research is in progress.” [ Irion, O.; Boulvain, M.; “Induction of labour for suspected fetal macrosomia”; Cochrane Database of Systematic Reviews 2007, Issue 3. Art.No.:CD000938.DOI:.1002/14651858. http://www.cochrane.org/reviews/en/ab000938.html ]
Results from large cohort and case-control studies reveal that it is safe to allow a trial of labor for estimated fetal weight of more than 4,000 g. Nonetheless, the results of these reports, along with published cost-effectiveness data, do not support prophylactic caesarean delivery for suspected fetal macrosomia with estimated weights of less than 5,000 g (11 lb), although some authors agree that caesarean delivery in these situations should be considered.” [Taken from the ACOG Guidelines on Fetal Macrosomia . Chatfield, J.; “Practice Guidelines - ACOG Issues Guidelines on Fetal Macrosomia”; 2001; American Family Physician; http://www.aafp.org/afp/20010701/practice.html]
Only now at 36 weeks did this lady receive any nutritional advice during her pregnancy and only because she returned a high blood sugar level reading. While making dietary changes at 36 weeks may have some effect – the time to make these changes and receive this advice is at the beginning of pregnancy where they can have the biggest chance of having an effect on the outcome of her pregnancy and birth – NOT at the end when it is more like shutting the gate after the horse has bolted.
For a detailed article on the BIG BABIE ISSUE – go to
As I write this I await news of Sally, who is in early labour with her third child. She is just over 37 weeks. Her first two children were just under and just over 4.5kg (10lb). She was not working with me towards her birth, but was planning on attending her local hospital. A friend of hers had birthed with me, and she had read some of the articles from my book. I received an email after she had just returned from a routine 36week antenatal visit, and left very upset - convinced that there was something wrong with her baby. Apparently her baby was “macrosomic” and that the only option for a safe birth for her was a caesarean section. It seems the Dr had felt a very large tummy and sent her for an ultrasound and the ultrasound had told her that her baby was “already” 4kg. Returning to the doctor she was informed that ultrasounds were 70% accurate in estimating fetal weight and that if she persisted in her push for a natural birth then she would endanger her baby. While probably not exactly what the doctor said, this lady left the office with the impression that they would have to break her baby’s collar bone or arm during the birth because it would get stuck. Two separate doctors on two different days scared this woman silly about the “risks” of a large baby without ever communicating to her things that increased her risk or things that would decrease it. Birthing options such as positions were never discussed. They also left her with the impression that she would experience the complication of her baby getting stuck and that her baby would be temporarily or permanently injured form the experience, and not that she had x% chance of such an occurrence. They certainly did not tell her that it is generally accepted that elective caesarean sections to prevent shoulder dystocia are not proven to be effective.
“In fact, most past studies have found that neither macrosomia nor shoulder dystocia can be reliably predicted in the babies of diabetic mothers.... The bottom line: Predicting macrosomia and shoulder dystocia in diabetic mothers has been as difficult as predicting these factors in the nondiabetic population.” [Lerner, H. (MD); 2006; “Shoulder Dystocia – Facts Evidence and Conclusions” http://www.shoulderdystociainfo.com/index.htm ]
“Babies who are very large (macrosomic - over 4500 g) can sometimes have difficult and, occasionally, traumatic births. One suggestion to try to reduce this trauma and to reduce operative births has been to induce labour before the baby grows too big. However, the estimation of the baby's weight in utero is difficult and not very accurate. Clinical estimations are based on feeling the uterus and measuring the height of the fundus of the uterus, and both are subject to considerable variation. Ultrasound scanning is also not accurate. Induction, if undertaken too early, can lead to babies being born prematurely and with immature organs. The review of trials, assessing induction of women when it was suspected that their baby was above 4 kg, found three trials involving 372 women, none of them with diabetes. There was no evidence of any benefit in terms of caesarean section or instrumental births, or in outcomes for the baby. However, these studies were too small to be sure of the outcomes. Further research is in progress.” [ Irion, O.; Boulvain, M.; “Induction of labour for suspected fetal macrosomia”; Cochrane Database of Systematic Reviews 2007, Issue 3. Art.No.:CD000938.DOI:.1002/14651858. http://www.cochrane.org/reviews/en/ab000938.html ]
Results from large cohort and case-control studies reveal that it is safe to allow a trial of labor for estimated fetal weight of more than 4,000 g. Nonetheless, the results of these reports, along with published cost-effectiveness data, do not support prophylactic caesarean delivery for suspected fetal macrosomia with estimated weights of less than 5,000 g (11 lb), although some authors agree that caesarean delivery in these situations should be considered.” [Taken from the ACOG Guidelines on Fetal Macrosomia . Chatfield, J.; “Practice Guidelines - ACOG Issues Guidelines on Fetal Macrosomia”; 2001; American Family Physician; http://www.aafp.org/afp/20010701/practice.html]
Only now at 36 weeks did this lady receive any nutritional advice during her pregnancy and only because she returned a high blood sugar level reading. While making dietary changes at 36 weeks may have some effect – the time to make these changes and receive this advice is at the beginning of pregnancy where they can have the biggest chance of having an effect on the outcome of her pregnancy and birth – NOT at the end when it is more like shutting the gate after the horse has bolted.
For a detailed article on the BIG BABIE ISSUE – go to
As women are reduced to walking “risk factors”, medical analytical thinking poses a real threat to the normality of birth. This fact becomes obviously clear when dealing with certain issues in particular around birth. One of these issues is your baby going past his/her “due date”; one is birthing vaginally after a previous caesarean section; and another obvious candidate is “large babies”. Despite there being a lack of evidence that having a large baby is a “risk factor” for shoulder dystocia (the baby’s shoulders getting stuck during the birth) it seems it has become a mandate for the medical profession to scare women silly about how large their baby is. After 15 years working with birth I have come to the conclusion that the medical understanding of the physiology of birth (what happens naturally) is just plain wrong – they only know how to manage. (When you need their “management” it is lifesaving – but most labours don’t need management, just support). They simply don’t get how birth works. I have seen women’s uteri, pelvii and fanny’s do some AMAZING things. Just a couple of months ago a lady had a 4.8kg baby who was in a direct posterior position. Her labour was 2 ½ hours long and she received NO perineal trauma. I have assisted a lady birth naturally a baby who was 5kg – a 40 cm head – with NO perineal trauma. Just this morning I returned from a birth where the woman was having her fourth baby. (I have only had one hour sleep since yesterday morning so I do hope I am making sense with my ramblings). All three previous babies had got a little stuck in her pelvis where the midwife had to help them out. Last night she did it all herself – she was amazing as her baby slid out and she picked her up from the water and said “I did it! I did it! I did it!!!” All three of us were crying (mum, dad and midwife). Bub was quietly looking around the dimed room.
LADIES – CLAIM YOUR BIRTHING POWER!!!!!!!!!
LADIES – CLAIM YOUR BIRTHING POWER!!!!!!!!!
Excellent post, Claire - I too have seen cases where women have been told they have "CPD" which truth be told is really a case of "Care Provider Dysfunction" rather than a defect in the woman. Yet the women have been told their birthing bodies are defective - not the care they received. One of my lovely clients had a VBAC at home earlier this year, supported by two midwives and two doulas. She'd been given the usual "CPD" and "Failure to Progress" as the reasons for her primary c/s. As her baby cork-screwed himself out into the world, the midwife said, "See now that just makes a mockery of what they told her last time." Another client this year was told, after being given a c/s at 1 cm, that her cervix was deformed, that she would never be able to go into labour spontaneously, and that she her cervix was not capable of dilating, so she would always need caesareans. At 36 weeks she decided to plan a VBAC homebirth. She went into labour spontaneously, and dilated to 7 cm before transferring to hospital where she had an epidural. A short time later, she pushed her baby out all by herself. So much for the "broken" cervix. Australian women deserve the option of the kind of services midwives like you provide. More power to you!
ReplyDeleteAn update on Sally - after nearly 2 days of on again/of agan contractions with her waters broken, she stayed calm and focused at home. Once labour kicked in she and her support team (husband and friend) went to Hospital. Armed with knowlege and preparation and aware of her rights, Sally simply got about to birthing her beautiful daughter without any intervention and no trauma - she was just over 4.5kg I beleive, and once active labour kicked in, lasted about 5 hours. I am so proud of her for staying strong, and she proved those doctors wrong - see her body DIDN'T grow a baby that was too big for her to birth!!
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