OBGYNs being trained to break babies collarbones in labour

Charlie - posted on 12/04/2010 ( 119 moms have responded )

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DOCTORS are being trained to deliver super-sized babies, including learning how to break their collarbones to free them if they become stuck during labour.
As the obesity epidemic spirals out of control, the newborns - most of whom are born to obese or overweight mums - are so big their shoulders are becoming stuck.
In the most extreme cases doctors have to carry out the procedure to save their lives.
After delivery the newborn is unable to move its arm until the bone heals, which can take weeks. The procedure is carried out on up to 1000 infants in Queensland each year.
Brisbane obstetrician Dr Gino Pecoraro said an increasing number of cases meant junior doctors now took part in regular mock-up trials.
He said obese and overweight women were more likely to give birth to babies over 4kg, with a greater risk of the babies becoming stuck in a condition known as shoulder dystocia.
"This is far more common in the past five years because of the obesity epidemic," he said.
"It is an emergency situation where the baby's head comes out but the shoulders get stuck, compressing the umbilical cord which delivers oxygen.
"We push down on the clavicle with our thumb and finger to free the baby."
In NSW, a University of Sydney and Royal North Shore Hospital study of NSW midwives data collection reports found that almost one in six boys and one in 10 girls now weighs more than 4kg at birth.
It is estimated that the incidence of shoulder dystocia is 1 to 1.5 per cent of all babies with a birth weight of 2.5 kg (5 pounds 8 ounce).
This incidence increases to as much as 10 per cent in babies weighing more than 4kg (8 pounds 13 ounce) and to 22.6 per cent in babies bigger than 4.5kg (nine pounds 14 ounces.)
Of the 66,097 babies born in Queensland last year, 12 per cent weighed more than 4kg and it is estimated about 960 suffered shoulder dystocia at birth.
Dr Pecoraro said despite the risks it was better to let an obese woman try and labour naturally rather than carrying out an elective caesarean.
Dr Louise Farrell, vice-president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, said doctors often could not tell how big a baby was.
"An ultrasound always carries a 10 to 20 per cent error rate, but in obese women it is even harder to get an accurate weight," she said.


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All I can say ( as a mother to two large babies 10lbs & 11.1LBS ) 5.3 kilo the biggest is I would much rather be torn from asshole to breakfast than have a person purposefully break my child's collarbone and have such a barbaric and violent start to life before they take their first breath .

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Mary - posted on 12/04/2010

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This is not a new technique. It is an emergency procedure of last resort to save a baby's life when the shoulders cannot pass under the mother's pubic bone. In this scenario, a 4th degree has already been cut (if she hasn't already torn) - but they could tear up your entire bottom, and it won't help a shoulder dystocia; this is an issue of bone stuck against bone. Fracturing the clavicle is a means of increasing the flexibility of the infant's shoulders, and will hopefully allow it to then slide under.



Once the head is out, performing a section is the truest last resort; remember, this involves pushing the head BACK IN to pull that kid out through the uterus. In the rare event that an infant survives this, there is not a chance in hell that they wouldn't be severely brain damaged.



For most of us in OB, shoulder dystocias are the scariest fucking thing in the world. They are damned near imposible to predict, and can occur when you least expect them. Yes, maternal obesity, or measurements/sonos indicating LGA increase the odds, but I have also seen it occur with a six pound baby of an average sized woman. Neither mother nor baby was abnormally large - all a shoulder dystocia requires is a baby too big for it's mother pelvis.



I understand that some of you find this procedure horrifying - and it is. That "pop" we hear when the bone goes is absolutely nauseating - but when it means a live baby without brain damage, it is also the most beautiful sound in the world.



The "news" in this article is not about the procedure - it is about the increasing frequency with which shoulder dystocias are occuring.

Mary - posted on 12/04/2010

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Well, maternal obesity is ONE contributing factor for the increase in shoulder dystocias.

There are many reasons why women are growing babies that are too big for their pelvises. Unfortunately, good prenatal care (including prenatal vitamins), as well as less women smoking is another. Advances in obstetrical knowledge/care, as well as women taking better care of themselves does mean bigger babies. While this is not a bad thing for the baby, it should be noted that those SGA or IUGR babies usually don't have trouble with "fitting" to get out.

Another issue is the increase of gestational diabetes. Some of this is a result of maternal obesity and diet, but another contributing factor is the increase in "older" women having babies. Age, in and of itself, is factor in your potential for developing GDM. Unfortunately, even if your are perfect in your diet, with the most tightly controlled sugars, you can still end up with bigger baby.

Now there are women like Loureen and Erin H whose family has of history of big babies, as well as a pelvis to accomodate them. However, there are many of us who simply don't have that kind of pelvis. Over a hundred years ago, those women with indequate pelvises either died in childbirth themselves, or their babies did. In essence, when a poplulation was fairly self-contained and did not inter-breed, those "poor" pelvises were simply bred out of existence within their societies. However, as varying ethinic groups and races began intermixing, combined with obstetrical advances like the c-section emerged, those inadequate pelvises were able to not only produce viable offspring, they were able to pass down that smaller sized pelvis as well.

It would take entirely more time than I have to cover everything, but I hope that at least marginally anwers your question about why shoulder dystocias are occurring more frequently.

Mary - posted on 12/06/2010

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I definitely believe in the correalation between foot size and pelvic size. Anyone below a US size 6 worries me, and above an 8 is golden. I'm only 5'2.5 ", but wear a size 9 shoe - and my daughter pretty much slid right out. Height and weight don't mean much when it comes to pelvic size - for example, other than my feet, I appear pretty petite - my wrists and hands are absolutely tiny (I wear a children's sized watch).

As you all sit and discuss possible causes for shoulder dystocia (and the epidural witch hunt that I knew would ensue), I do want to throw a few thoughts out there.

First is that there are varying degrees of dystocia - not all require the same degree of intervention (if any), and some are truly severe. Whether or not a an OB calls it dystocia after the fact is subjective (unless of course, it is severe, and requires drastic intervention). this alone makes data and statistics on shoulder dystocias difficult to discern.

And yes, McRobert's manuvers, Gaskins, the Wood's screw and suprapubic pressure are all attempted before the clavicle is fractured. I also want to say that sometimes the clavicle fractures on it's own, without intervention from the practicioner. Nature's way of fixing the fit problem.

As for the effects of maternal movement and positioning during labor and pushing...I agree, it is a good thing. However, I want to remind you it is NOT something all women can, or are willing to do. The uterus is a muscle, and childbirth is similar to running a marathon. As well, some women's bodies simply have to work harder, and require more force to push a baby out than another. For many, they are simply too physically (and/or emotionally) exhausted by the time the end comes. This is true for those that have an epidural, and those that don't. I've seen many an unmedicated laboring woman fall apart at the end, and push for crap, simply because she is spent, both physically and mentally. And with those really big girls...remember, they are not obese because they are in great physical shape to begin with...trust me, they aren't all about being up and moving while contracting and pushing, epidural or not.

We could sit here and dissect this forever, but the bottom line is that every woman's body is built differently, as is each baby she births. Every labor can be different as well - and it's hard to compare them, since there are so many different variables that can impact outcome. There is no one simple answer that is going to work for every woman.

Mary - posted on 12/06/2010

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Nikki - it's caused by the exess adipose tissue above the pelvis - simply put, all the excess fat gets in the way and prevents descent.

Now, I cannot speak for everywhere, but I have (subjectively) noticed over the past few years that our obese patients are not as routinely having 'huge' babies, but I think this is because our perinatal center has been very aggressive in treating them as gestational diabetics, and tightly controlling their diets and sugars. They strongly encourage the morbidly obese woman to follow a carb-restrcted diet even before the one-hour glucose challenge in the second trimester. If that one hour is even borderline, they don't wait for a follow-up three hour to begin dietary changes, and monitoring her am, pm, and post-meal sugars. For those who are compliant with dietary modifications from the beginning, it has greatly helped - not just in preventing an overly large baby, but in their own overall health.

Jodi - posted on 12/05/2010

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Erin, I did find a couple of sources in my brief google :)

"The incidence of cesarean section for dystocia, however, was significantly higher (10.3 percent) in the epidural group than for those in the other group (3.8 percent)."
http://www.birthsource.com/scripts/artic...

"An epidural is a type of anesthesia that is administered to help the mother during labor. It reduces the pain of labor but contractions still proceed as normal for a pain free vaginal birth. As a result of the epidural, the mother loses most of her sensation to push. When this happens, the pushing is not done naturally, which can cause the fetus to descend improperly into the birthing canal. This in turn results in an impacted shoulder, thus causing shoulder dystocia."
http://ezinearticles.com/?Causes-Of-Shou...

Interesting that one article is suggesting that an epidural could CAUSE the occurrence of SD, which also may explain the increase in incidence. I haven't checked into that further, but thought it interesting enough to throw out there.

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[deleted account]

I have to agree with Cathy, I'm sure in an emergency as a last resort they use it here, it's just not publicised!

[deleted account]

Erin I guess I've never given this subject any thought before really as it isn't used here. I guess doctors should do anything in order to get a baby out.

Ez - posted on 12/08/2010

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Forceps or ventouse will not help in these cases though Jennifer, and a c-section would require pushing the baby back up through the birth canal (risking brain damage). By the time shoulder dystocia becomes an issue, the head is already out. It is the shoulders that are stuck behind the mother's bone.

Scheduling c-sections for every case where the baby us expected to be over 9lbs is not an option either (and nor should it be IMO). And even if it was, it wouldn't eradicate the problem because SD can happen in babies of any size. This is why this technique, as well as other manoevres, must exist. They are a last ditch resort to save a baby from brain damage or death. I'm sure no birth attendant wants to have to break a baby's collarbone. But sometimes there is no option left.

[deleted account]

They'd only just introduced it last november at the Townsville hospital which is in QLD and my OBGYN was all for doing it until i asked him what he was doing which was breaking my child's collarbone and thats when i screamed no...lucky for him id had an epidural so i couldn't kick him in the face but my oh my did he deserve one

[deleted account]

Yeah I guess there'd always be the risk of that happening. My friend's mam is very petite and she developed gestational diabetes. She had to have a c-section 4 weeks early and he weighed over 9lb then...god knows how big he would have been full-term! I'm assuming this technique isn't used in the UK as I've never heard of it - they generally use forceps, ventuose, or an emergency c-section in that situation here.

[deleted account]

aaahhh Jennifer you see thats the problem half the time they realise bub is too big and its too late. mind you they nearly ripped my baby's head off because i refused them to break his collarbone and they made what they call an "honest" mistake despite the fact my GP and lazy-arse OBGYN told me that there would be no way I could have a baby over 7 pound because i had a tiny frame and stature and a multitude of problems concerning my blood pressure and iron beats me why they didn't order one at my 40 week ultrasound when the songrapher told my OBGYN that my baby looked to be about 8 pound *le sigh*

[deleted account]

I'm a size UK 9 (US 12) and I'm 5 foot 11 so I was told by my midwife that I should have no problems giving birth as I'd have a nice wide pelvis. Logan was only 6lb 12oz and came out no bother! I honestly believe it has more to do with pelvis size than the weight of the woman. Personally I find breaking any bone of a baby on purpose slightly barbaric! If they know the baby is going to be big or suspect it then they should do a planned/emergency c-section rather than breaking their collarbone!

Vegemite - posted on 12/07/2010

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It's not a matter of not being able to fit through the opening but getting stuck on the excess fat and bone. If I were in that position I'd rather a baby with a broken bone that'll heal in a few weeks than a baby with brain damage for all it's life or a dead baby.

Isobel - posted on 12/06/2010

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with mine I thought the difference in their births was not their size but the size of their softspot...Q was 10 ounces bigger than Eve, but her softspot was only the size of a quarter...his took up a third of his head.

so three hours of pushing with her (and eventually an epesiotomy (sp?) ) and 10 minutes with him.

granted I was induced with her and had no sleep for 2 days and was pretty much bagged and he came by surprise in the middle of the afternoon...that may have had something to do with it too :)

[deleted account]

I don't know about the foot size thing I know some small people with small feet and they had some big babies with no complications.

But "they" say men with big feet and big hands are well endowed and thats not true, who knows.

Amanda - posted on 12/06/2010

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mine are only 6.5-7..... interesting that we look for men with big feet and if they want a real breeder they should be looking at women with big feet also!!!
(totally joking!)

Krista - posted on 12/06/2010

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That's really interesting about the foot size bit. My feet have actually gotten bigger. I wore a 7.5 when I graduated from high school, and then an 8 as an adult, and since having Sam, I pretty much always wear an 8.5.

If this keeps up, my next kid is going to have enough room to come out of my vagina sideways while playing a tuba.

[deleted account]

I remember the doctor eventually having to vaccum extract marshall i only have an 8 1/2 foot so no wonder he was stuck his feet are almost as big as mine. poor baby though had a third degree burn on his scalp from where his head kept grinding on my pelvis during the ordeal he now has a permanent bald spot

Caitlin - posted on 12/06/2010

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I dunno about the foot size thing.. My daughter was tricky coming out (she has a large head) and I have size 11 feet... doesn't add up, though honestly I don't remember what her head measured..

[deleted account]

I like this foot size thing. My feet are, depending on brand, anywhere from a 10 to 12! No wonder i find having babies fairly easy!
OMG on eof my friends had a baby yesterday and her babies head was 49cm! My biggest babies head was 36cm. I'm really not to sure how she did it!

[deleted account]

I'm a little relieved about the foot/ pelvis size thing being true too. I'm a UK size 8 which converts to 10 1/2 in US sizing so I have big feet and should have a nice big pelvis :-) As Jessica said I always thought my feet were big and ugly at least now there is a purpose for them being big!

Jessica - posted on 12/06/2010

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That is interesting about the foot size. I'm small (5'3", was 105 pre-kids) but wear a size 8 shoe, and they're wide... I always thought my feet were ugly, but here its a good thing!

My son was 8 lbs 3 oz, I don't remember how big his head was, but he was posterior which is typically harder because of the angle it comes out at. However, I would not have known it if the doctor hadn't told me.

Lady Heather - posted on 12/06/2010

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Ooo. If foot size and pelvis size correlate, then my sister in law will not have fun. She wears a size 5. I'm a 7.5 and managed to birth a large-headed baby pretty well (she was small in weight, but 90th percentile in head circumference). Well...I had to have an episiotomy, but that was mainly because she was in distress so we sped it up with the vacuum.

Caitlin - posted on 12/06/2010

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Mary - It's interesting because my first was coming down when I pushed, but moving back up when I stopped pushing.. she was delivered by forceps just fine, her head was the huge thing, her shoulders weren't big at all, big heads run in my fmaily (I have a huge head - too bad there's no brain to go with it). On the other hand, she wasn't estimated to be a big baby, they said 7 pounds estimate (she was 8 pounds 8 oz..) the tearing and bruising on that one was incredible! The reason they used the forceps is because her HR started to drop a lot when I had contractions, so I guess she was partly stuck on my pelvis, so I guess should consider myself lucky she was fine!

Sarah - posted on 12/06/2010

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No wonder I struggled with my eldest.....my feet are only a size 4!!! ;)

[deleted account]

my sister only does it cos she goes to a lot of musical festivals and it's a shorter line to the trough....she's 19

Jodi - posted on 12/06/2010

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And I thought my daughter was the only one perfecting peeing like a boy......seriously, my 5 year old daughter does it so she can be like her brothers.......yes, disturbing to say the least :)

[deleted account]

@Jodi idk my sister seems to of perfected the art of peeing like a man...quite disturbing but yeah back to childbirth, like urination if you're squatting gravity is working with you therefore it should help you more...as my midwife said i disproved this theory as bouncing on a gym ball did nothing for me and neither did squatting

Jodi - posted on 12/06/2010

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@ Sarah, I dunno, it's a bit easier to pee squatting than standing...... :P

[deleted account]

i had a 40 week ultra sound and a 41 week ultrasound and the sonographer told me 6 pounds both times lol he was wrong 9 pounds :P but i must say one thing why birth a baby lying down i mean have you ever tried to pee lying down and not get it on yourself?? much easier if your standing

Nikki - posted on 12/06/2010

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Mary do they know the reason why the head doesn't descend in some obese woman?

Mary - posted on 12/06/2010

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Actually, what we more commnly see in obese women is what we refer to as a "fat dystocia"...the head doesn't descend AT ALL. They dilate, but the head never descends. I guess that's a blessing, since it does eliminate the whole shoulder dystocia thing, but remember, surgery on a morbidly obese woman is fraught with all other kinds of risks. It's why OB's still do their damndest for a vaginal delivery with bariatric patients - sections aren't exactly a great alternative.

Mary - posted on 12/06/2010

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Erin - one of the things about instrumental deliveries and shoulder dystocia -

It's not so much about the babies positioning (a skilled practicioner is not just pulling, but also rotating with forceps). It is more that they are pulling out a head not knowing if the shoulders will fit. If you go back and read Jodi's link, it mentions the "turtle sign" - where the head continually comes down some with pushing, but fails to STAY down. This does occur when the baby is simply too big for the pelvis. It's part of the reason why routine use of mid-forceps (late 60's and 70's) fell out of favor. You could wedge that head out, and then the shoulders got stuck. It's why any sane doc will only do a low forceps delivery, and rarely on a first time mommy with an unproven pelvis and a suspected big baby.

Ez - posted on 12/06/2010

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Mary do you see SD more commonly in obese mothers? Or big babies, for that matter?

Nikki - posted on 12/06/2010

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I never had to worry about my daughters shoulder's, BIG heads run in my hubby's side of the family, after the head I didn't feel a thing! She was born at 38 weeks and her head size was off the charts for a 41 week baby! She looked so funny, her head was almost as big as her whole body.

Charlie - posted on 12/06/2010

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I was talking about this with my friend her son had shoulder dystocia interestingly she is tiny , I mean an Aussie size 6 and had a 6 pound baby , she ended up with a spiral tear from how the baby came out eeek.

[deleted account]

I hate the whole pressure of big baby stuff. I think i need to find a new DR to though. I had GDM. So i was monitored very closely in all ways. My DR said by fundal height we were looking at a big baby. My last ultrasound at 37weeks said he was about 7p11. For me that was considered rather big. ( my 1st 2 were 6p7 and 6p12) so they were concerned. I'm not sure why considering i had GDM and he was only measuring average. Anywho at the last appt with my ob/gyn ( only because of the GDM) as i was fixing myself after and examination he was caloling the hospital to organise for me to be induced. I was furious and didn't knwo any better. I was induced 3 days early and my son was born quickly because they pushed me the whole way i was stuck on the bed due to having 3 drips in me ( of which i kept crimping the cords on and they were getting mad)even when i was saying no lets wait at 7p11. Average bloody average and yet they swore he would be big.
So if i ever go back for another baby i will find a DR that supports me and my natural birthing ways and not induce me and let me move and do what nature intends.

Ez - posted on 12/06/2010

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Flat on her back, legs in stirrups... typical Hollywood movie stuff lol.

Nikki - posted on 12/06/2010

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I have never heard the foot size thing, interesting. Jodi, my feet have shrunk since I had my daughter, I used to be an 8 now I am a 7, I have also shrunk in height by 2cm. How/why I have no idea!

Ez - posted on 12/06/2010

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Birthing in the lithotomy position is the most ridiculous thing in the world. It narrows the pelvis and has the mumma working against gravity (they have to get around the s-bend lol). I agree that a better understanding of optimal birthing positions for suspected large babies would be the closest thing we have to prevention of SD.

Stifler's - posted on 12/06/2010

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I think it's positions too. One of the midwives told me it's better to birth standing up than lying down.

Stifler's - posted on 12/06/2010

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Wow I had 2 scans my entire pregnancy. Not fair. I didn't tear at all with Logan and he had no trouble coming out!! We knew he was going to be big the whole time and no one said anything about ability to birth :S

Jodi - posted on 12/06/2010

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If it is to do with foot size, I was only a 7 1/2 before babies (it has actually increased since I had my kids, ironic when related to the size of the pelvis, huh?). Anyway, I struggled with a 3.5kg baby....so that makes sense!! Bone structure?

Ez - posted on 12/06/2010

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This article by the American Journal of Obstetrics and Gynaecology explains the unpredictability of SD, and makes no mention of maternal weight.



There is a significantly increased risk of shoulder dystocia as birth weight linearly increases. From a prospective point of view, however, prepregnancy and antepartum risk factors have exceedingly poor predictive value for the prediction of shoulder dystocia. Late pregnancy ultrasound likewise displays low sensitivity, decreasing accuracy with increasing birth weight, and an overall tendency to overestimate the birth weight. Induction of labor for suspected fetal macrosomia has not been shown to alter the incidence of shoulder dystocia among nondiabetic patients. The concept of prophylactic cesarean delivery as a means to prevent shoulder dystocia and therefore avoid brachial plexus injury has not been supported by either clinical or theoretic data.



http://www.ajog.org/article/S0002-9378(05)01463-8/abstract



I also found a lot of research linking instrumental deliveries with SD, which makes sense since the baby is being pulled out possibly before they have positioned themselves properly. There was also a lot of mention of epidurals making the use of other, less extreme techniques impossible (as someone else mentioned above) leaving the doctor with limited options.

Ez - posted on 12/06/2010

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Toni that's what my OB told me too when we were discussing my ability to birth my big baby. He said pelvic size correlated with foot size and laughed when I told him I am a size 10-11!

[deleted account]

As Heather said they do routine scans up to 20 weeks because after that it becomes difficult for the scans to be useful, they only do further scans if they need to check things further (such as size, fluid levels and positioning etc). I have yet to meet a woman who had a late scan that was accurate at sizing the baby, they told me my son was over 6lb in reality he was 5lb 6oz, it is just incredibly difficult to be accurate.

I don't know how true this is but I have heard that they look at your foot size to gauge your pelvis size.

Ez - posted on 12/06/2010

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Most fertility doctors already have guidelines in place for obese/significantly overweight patients. These women are often to told to go away, lose x amount of weight, and then come back to start treatment.

But I am not convinced that maternal weight is to blame for macrosomia and SD anyway. I personally know more than 10 women who have had babies in this size category (myself included) and none of us were obese.

Anyway, I'm going to try and find some data on epidurals and SD. I think that may be where the answer is.

[deleted account]

@Krista...i was given a full dose so i couldn't feel anything but i still gave birth sitting up with support of the bed. don't think it helped much though he was stuck before i even had the epidural i had wavering contractions that indicated he was stuck and i was sitting on a gym ball for most of my labour

Lady Heather - posted on 12/06/2010

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Scans closer to the date of birth aren't always any more accurate. I had ultrasounds every month, then two weeks, then ever week for the last month and in the last week there was one every other day. The day before my daughter was born a very experienced obstetrician estimated her weight at a pound and a half more than it really was. She was supposed to be well over six pounds and she came out 5 lb 3. That's quite a big difference in a smaller baby. Someone would have to invent something more accurate than we already have.

I'm not sure if anyone knows if 3D ultrasounds have better size estimations? There isn't one available where I live so we never had one. In any case, I'm not sure how easy it would be to ensure the baby was smaller AND could fit through mum's pelvis. Some things just can't be known I guess. Sure is scary.

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