• The Fit Midwife

The Terrifying Tale of "The Big Baby"......

If you are a midwife, hand’s up if you have heard (or said - I am guilty here) “ooohhh that feels a good size”. Cue look of absolute terror on mum to be’s face… We all saw that One Born Every Minute shoulder dystocia (and I know a fabulous Doctor who was present) and yes, it terrified every prospective parent alive.

If you are a midwife, hands up if you have seen “Big Baby” as the reason for Induction of Labour.

Yeah my hand is tired from raising it too.

Let me take you back to a weekend where a lovely lady I have been consulting with was told “you cannot deliver in the pool because your baby is 3.8kg”. In English money…. around 8lb 6oz. What a giant. Call the Guiness Book of World Records. Oh wait? You’re reading this and had bigger babies with no problems? Yep, that’s what I thought.

I researched "biggest baby ever born' and there are stories everywhere however he Guines Book of World Records sates that Baby Jasleen, a girl born in Leipzig, Germany, on July 26. Weighed in at 13.47 lb (6.1 kg), she is the heaviest baby ever born in the country - and delivered vaginally. For comparison's sake, the heaviest baby ever born weighed 22 lb 8 oz (10.2 kg) to mother Carmelina Fidele of Italy in September 1955. Surely this one came out the sunroof right?

My sensible colleagues and I are so sick of hearing this kind of rubbish. I mean, being told to get your woman in lithotomy for a normal delivery in case baby gets “stuck” is one of the most irritating things known to midwifery practice in Dubai. And what is worse is this is not evidence based practice. Which is what we should all be using. Patient comfort and choice always comes first and this should be used to make shared decision with your Doctor.

Let’s just go over the terminology used in these situations.

- Big Baby: Not a real term. A matter of opinion. Often complete rubbish.

- Large for gestational age (LGA): Commonly accepted as birth weight measuring above the 90th centile for age. However, it has been suggested that the definition be restricted to infants with BW greater than the 97th percentile, as this more accurately describes infants who are at greatest risk for perinatal morbidity and mortality. In real terms (depending on the national average 90th centile is around 4kg and 97th centile is 4.4kg.

- Macrosomia: Macrosomia refers to excessive intrauterine growth (growth whilst baby is inside) beyond a specific threshold regardless of gestational age (GA). Royal College of Obstetricians and Gynaecologists (RCOG) and The American College of Obstetricians and Gynecologists (ACOG) both support the use of the 4.5kg threshold for diagnosis of macrosomia because morbidity (illness) increases sharply beyond this weight.

So we all know the scare tactic “the shoulders might get stuck”. Personally I find scare tactics crass and not actually accurate. Shoulder dystocia is most certainly serious. But it is not going to happen with every delivery of a baby that appears larger than what some practitioners deem normal. Contrary to popular belief; ultrasound scanning is not always an accurate indicator of baby’s weight (especially towards the end of pregnancy) and so should not be used to predict a shoulder dystocia. It more accurate when used with Symphysis Fundus Height measurements (when the midwife measures your tummy) and a personalised growth chart using mum's biometric measurements (height, weight, previous history).

What happens when the baby gets “stuck”?

Shoulder dystocia is when the baby’s head has been born but one of the shoulders becomes stuck behind the mother’s pubic bone, delaying the birth of the baby’s body.

Does it happen more in larger babies?

Whilst it occurs in around 1 in 150-200 deliveries. It is slightly more likely yes. But remember that many a woman has birthed a baby at 4.5kg with no problems. And 50% of all shoulder dystocia's happen to babies weighing in under 4kg.

I have been offered and Induction of Labour (IOL) because my baby is big... Do I take it?

The results of many studies support IOL in pregnancies with LGA babies, because of its association with decreased risk of shoulder dystocia and fractures, without an apparent increase in risk of CS. The 'Big Baby' Trial is currently underway to investigate whether a policy of IOL at 38 weeks gestation, or soon after, in women with babies with predicted macrosomia (more than 90th customised centile of EFW) will reduce the incidence of shoulder dystocia; it is scheduled to conclude in June 2021. So we have a little bit to wait. Whilst some of the studies suggest reduction in shoulder dystocia it is important to remember that IOL increases the risk of epidural and instrumental delivery which subsequently increase the risk of shoulder dystocia. So discuss all of this with your Midwife or Doctor;.

If the doctor or midwife is telling me I have a big baby and it may get stuck, what is the best position for delivery?

There are some great positions you can use if you are mobile and want to open up the pelvis….

  • The all 4’s position is brilliant for increasing the pelvic outlet. This is often best done over the back of the bed.

  • Delivering on a birth stool, leaning back in to your partner with your legs wide.

  • Hands and knees

If you have an epidural a great position is to be on your side, with your top leg resting in a lithotomy pole (supported) and your bottom leg bent up towards your tummy. Almost appearing like a squat position if you were upright.

Having your legs in stirrups is notoriously NOT a good position for pushing nor delivery of any baby. It restricts the movement of the bones in your pelvis and does not actually increase the diameter of the pelvis outlet. Though clinically sometimes we will require you to get in to this position (usually emergency situations or if you have an epidural and your legs are extremely heavy).

I am not going to go in to all the things that we do in a shoulder dystocia. That needs it’s own post. This post is just about cleaning up the rubbish spouted out about big babies and ‘getting stuck’ being used as a reason to induce prematurely or to force you in to a position the physician is comfortable with (i.e. sitting at delivery is easier if you are compliment and stuck in stirrups). Mobilise, stand, sit on a stool, go on all 4’s and get that pelvic outlet opening in the way nature intended. Characteristically mum’s grow babies that fit them. So next time someone comments on the size of your baby, think about what you have just read and remember how much control you have to facilitate the best delivery for you!

Nikki xx

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