Biggest Misconception in Maternity Care that No One is Talking About!
As an Evidence Based Birth® Instructor and Certified Birth Doula specializing in over 10 years in the hospital environment, no other topic creates such frustration and strife for myself, my business partner Marnie, and our clients preparing for birth at The Hospital Doulas & Associates than being told by their health care provider that they are pregnant with a “Big Baby”. To be clear in this post we are talking about low risk pregnancies such as those without the diagnosis of gestational diabetes – which can in fact increase the risk of carrying a large baby.
It’s so disheartening to Marnie and I when we hear that seed of doubt that gets implanted and grows in the hearts and minds of our clients when they hear that their baby may be “Big” and we are hearing this with alarming frequency! At the mere mention that they are carrying a “Big Baby” our clients’ thoughts go from an empowered place of working on a well thought out birth plan to a totally fear based urge to get the baby out as soon as possible with whatever means possible. Their thoughts go to the terrible pain of trying to birth a baby that isn’t going to “fit”, their baby getting stuck and unavoidable tearing. What could be scarier? They suddenly feel that all their hopes and dreams for their birth are dashed. This is terribly disheartening and actually completely unnecessary!
A diagnosis of expecting a “Big Baby” presented as a fact is simply NOT TRUE
Who can blame you for being devastated and scared? This “diagnosis” of a “Big Baby” is presented as fact and you accept it at face value as being the truth that your baby is measuring big for gestational age in your prenatal office visit or through an ultrasound finding.
The only way to 100% tell if you have a “Big Baby” is to weigh it at birth! Yet so many women are being told they are carrying a “Big Baby”. An important study, Listening to Mothers, showed that 1 out of 3 pregnant individuals were told they were carrying a Big Baby but in fact only 1 out of 10 babies were actually born “big”!
The REAL Problem with Expecting a “Big Baby”:
Perhaps the hardest truth here is the mere suspicion that a” Big Baby” carries more risks and has proven to be more harmful than actually delivering a “Big Baby”.
This is simply because it changes how you and your care provider perceives and manages your labor and birth. In a total of 9 studies which all showed that it’s the SUSPICION of a big baby – not the big baby itself that leads to HIGHER INDUCTION RATES, HIGHER CESAREAN RATES, and HIGHER DIAGNOSIS OF STALLED LABOR. One study actually showed it tripled the induction rates, more than tripled the cesarean rates, and quadrupled maternal complications compared to women who were not suspected of having a big baby and actually ended up having one anyway!
How Did This Happen?
There’s a perfect storm of faulty assumptions about predicting and managing the birth of “Big Babies” working together to create this mythical problem of epic proportions.
Assumption: Ultrasound Weight Predictions are Accurate
There is no way to diagnose a big baby before birth! Ultrasounds are right about 50% of the time when they predict a big baby and wrong about 50% of the time! They have a 15% margin of error above and below! For example, if an ultrasound reports a 8 lb baby, it can actually range from 6 lbs 13 oz to 9 lbs 3 oz. For the record, big babies are defined by some as 8 lbs 13 oz or more and some say 9 lbs 15 oz or more.
Assumption: Early Induction of Labor recommendation is Based on Evidence and will be Beneficial
The thinking is that scheduling a labor induction before the baby can grow larger will lower the chance of shoulder dystocia (something obstetricians are trained to manually manage when the second shoulder gets stuck during birth). It can slightly lower the risk from 7% to 4% risk but does not have any impact on nerve injuries or NICU admissions and cesareans. There is no medical reason behind this early induction recommendation! The official current stance of ACOG (American College of Obstetricians & Gynecologists) is that “more research is needed to determine if there is a significant enough medical reason for early induction”. Shoulder dystocia can actually happen to small babies as well. In any event, it may be wise to ask your obstetrician about his or her training and confidence in handling shoulder dystocia.
Assumption: A Planned Cesarean recommendation is based on Evidence and will be Beneficial
A “Big Baby” diagnosis before birth is the 5th largest reason for a cesarean. Unfortunately, it would take 3,700 unnecessary cesareans to prevent one case of permanent injury due to shoulder dystocia in a baby suspected of weighing 9 lbs 15 oz or greater! Elective cesareans carry both benefits and risks. Cesarean risks include potential complications for patient, baby and future pregnancies including postpartum hemorrhage, NICU admissions for baby, wound infection, and placenta accreta in future pregnancies. ACOG does say that an elective cesarean “may” be considered with an estimated weight of 11 lbs or greater.
The BOTTOM LINE:
Since the only way to diagnose a “Big Baby” is to weigh your baby at birth, you’ll need to consider that any intervention offered to manage this prediction is based on an educated guess on your health care provider’s part. Shoulder dystocia is a rare birthing complication that can happen to big and small babies alike, so it’s important to ask your provider his or her training and confidence in managing it. Even if your baby does weigh in as “Big” there is no conclusive evidence that the risks of an early induction or planned cesarean outweigh any potential benefits in low risks pregnancies. However, several studies have shown that the mere perception or suspicion of carrying a “Big Baby” results in higher risks of interventions and harm than those who actually did give birth to a Big Baby!
WHAT YOU CAN DO:
If you are told you are expecting a “Big Baby” please do your evidence based research about the reliability of this diagnosis before agreeing to any interventions. Ask your care provider how the research applies to your particular case and think about how any recommendation fits into your own goals and values. There are actually 3 pillars of trying to receive Evidence Based Care for you and your baby that act much like a 3 legged stool:
1. Knowledge of the Evidence Based Research
2. Consider Your Provider’s Experience & Application of the Evidence to Your Case
3. Consider Your Own Goals & Values
One would assume that ALL maternity care is Evidence Based when in fact some of it is not. There exists an “Evidence Practice Gap” which refers to the 15 – 20 year period between when research shows something to be beneficial or not beneficial, until that research is actually implemented into routine hospital care in the United States. It’s shocking to learn that the United States has one of the worst maternal mortality rates among developed countries. Even more egregious, the maternal mortality risk for women of color jumps to 4 times the rate of white women. While we have seen great strides being made in our 10 years of serving as certified doulas in the hospital setting, such as reduced episiotomy rates, there is still a long way to go! For the record, as hospital doulas we don’t see any intervention as being inherently “good” or “bad”. We’ve seen them be beneficial and even life saving when done at the right time, for the right reasons, with full consent.
Lisa Collins, MA., CD(DONA), ProDoula, Evidence Based Birth® Instructor
Marnie Lea, RDH., CD(ProDoula)
Co-Founders of The Hospital Doulas & Associates LLC
For the Gold Standard of Online Hospital Birth Preparation please go to:https://www.thehospitaldoulascircle.com
For list and discussion of all risks and benefits see:
EBB® pdf Evidence on: Big Babies Rebecca Dekker, PhD., RN
EBB® Signature Article – Evidence on: Induction or Cesarean for a Big Baby 2019