Ask the Doula - the "too-big baby"

A week has gone by already, so quickly. I am involved in many interesting projects, more about them in a few days...
It's Ask the Doula time again!
Please keep sending in your questions. You can add them as comments below, or send your questions to our facebook page, or twitter @montrealdoula.

Today I am going to be looking at the question of cephalo-pelvic disproportion, or the "too-big baby". This mother generously agreed for me to print her question and the response.


Question Number Three 


"I had my first baby three years ago. I am expecting again and I would like to have a doula to accompany me. I am not sure how it will go. My doctor told me that my pelvis is too small to give birth. My first baby was born by cesarean after I was in labor for two days. I had contractions all day on the first day, then by the next morning they were so painful I couldn't even talk. We went to the hospital, where they broke my waters, and then I took an epidural. My baby didn't come out after two hours and they said she was too big. She ended up weighing seven pounds thirteen ounces, and had an Apgar score of 9 and 10. I have a very small pelvis and a narrow pubic arch. Do you think this is a good reason for a cesarean?"

First of all, let's understand how birth stories work. A woman will tell me her story, and it will be just that - her story about what happened to her. It is a story in the first person, about a primal experience she had. I will listen to the details but I will also listen to the tenor, the resonance, of the story.

This story is about a normal labor that somehow went wrong. The first hint is that she labored all day and after 24 hours had contractions "so painful I couldn't even talk." This is normal labor. Mothers will have contractions for a few hours, or a few days, and they will be uncomfortable and even painful. Then the body gets down to work and contractions become so intense that she cannot speak through them. Then she gets to the point where she doesn't even want to speak in between contractions, and this is when the doula knows that the laboring woman is definitely in good labor.

But in this story, the woman was not prepared for the intensity, and she went to the hospital soon after she entered the beginning of active labor. She doesn't say why they broke her waters, but usually it is done because there is a perception that labor isn't moving quickly enough.

In this case, it appears that the breaking of the waters did stimulate labor, and this stimulation increased the intensity of the contractions to the point where the laboring woman decided to take an epidural for pain relief. She was probably quite tired by now, as well, as no one had told her to rest during the night in between the contractions.

The epidural probably helped in terms of her energy, and her body obviously did the work of opening so that she reached the pushing phase. Then what happened? She pushed for two hours. The staff told her the baby was too big and she went to surgery. I cannot extrapolate too much, but here is a possible scenario:

The pelvis is narrow and small. The body made a baby that, in fact, was a perfect size for this pelvis. Her labor was progressing normally and the baby was doing the appropriate moves to navigate through the bones of her mother's body. At a certain point, she had moved her head to a sideways plane so that she could get some leverage to push it down further.

Imagine one of those wooden toys, where the child has to push blocks through different-shaped holes. The child will turn, and turn, and turn the block until it finally pops through. He learned this at birth.

But suddenly, the amniotic fluid drained, and she found her head stuck upon the bone in a awkward position. She still instinctively pushes her head to the other side, to straighten it in order to descend further. As she is doing this difficult work, she feels her mother's helpful body go limp. She has no more help from the outside, just uterine contractions that are pushing her more and more into a position that will be very difficult for her to move from.

The cervix becomes fully dilated, because the body is doing what it should. But the combination of the narrow pelvis, the crooked head, the epidural, and the impatient staff adds up to an unfortunate turn of events.

If she had decided to stay at home longer, until labor was more active, she may have avoided getting her membranes ruptured. If she had a wider pelvis, the baby may not have gotten stuck. If she had a doula by her side, she may have managed to avoid or at least postpone the epidural. If she had not taken the epidural, vertical or forward-leaning positions could have helped the baby come down. If the staff had patiently waited another hour, she may have pushed the baby out.

But we do not know. We really can never know what could have happened, had things been otherwise. But if we agree that we could never know what might have happened, then we have to also admit that we do not know if another baby, perhaps with a slightly smaller head, in a better position, without an epidural, with a doula assisting the mother, could successfully navigate through the birth tunnel and be born vaginally.

My answer? I do not know the reason for your first cesarean. But I do know that you do not have any conditions that definitely preclude your giving birth vaginally. There is a saying: "labour is the best pelvimeter". In layperson's terms, this means that the best way to measure your pelvis is with a baby's head, when you are in labor.

My advice? Hire a doula. Make sure you have a good relationship with your doctor or midwife.Stay positive and open. I wish you the best of luck!


Comments

  1. I too have a question about cephalo-pelvic disproportion. I was able to give birth to my first born after 3 days of labor. However, the delivery experience was fairly traumatic, and I was left dazed, very cold, violently shaking, and feeling rather removed in the immediate aftermath. It turns out that delivery separated my pelvis in the front, cracked my tailbone, and created 4, first degree tears, that I suppose would be described as posterior, anterior, and... on 1 on either side. I also developed a very uncomfortable tingling sensation throughout the area. It took 7 months for me to resume normal activities, but I still, 2 years later, have lower back pain (sciatica), and the front area of my pelvis is still tender to pressure. I have a couple of questions. First, can a person rightly be diagnosed with cephalo-pelvic disproportion, even if a child could fit? And two, considering that my family has a history of giving birth to large babies, should I choose a C-section to avoid a repeat of my first experience?

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  2. This is a complicated question and I can only start to answer it by knowing more details about the birth. First of all, I want to congratulate you on your strength! And I will make some suggestions on my next "Ask the Doula" about healing after a difficult birth. But, some questions:

    What position were you in when you delivered? What positions were you in while you were pushing? Did you take an epidural? Did you go into labor spontaneously or were you induced? Finally, do you know what position your baby was in?

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  3. First, I'd like to share that I had planned to labor at home, with a doula, as long as possible, knowing that there was a possibility of an "oops" home birth. The midwives at the hospital were fully supportive of this plan. I did go into labor spontaneously, and I did labor at home, in peace, for 2+ days. I can't remember the name of the position of the baby at this time, but she was "fairly well tipped" to the left side, head down, and I could feel lots of kicking and hand movements in the upper right quadrant of my abdomen, in front.

    I arrived at the hospital, and in short, a series of bad interactions with the nursing staff that brought my labor to a halt. Then I was urged first to take a dose of Fentanyl. Followed then by an epidural. Which meant an IV was inserted (poorly). Followed by a Pitocin drip.

    Pushing took an hour and a half, and sometime in there, something happened to the epidural, and I began to feel quite a lot of pain. In the beginning they had me inclined in the hospital bed, my legs held up in front of me. For some reason, somewhat urgently, the midwife told the nurses to lay me back flat on my back, and pinned my legs back. That is the position the midwife had me deliver in.

    The nursing staff seemed somewhat surprised at my little one's size. I suppose I wasn't very large to start, and I only gained 25 pounds during my pregnancy. Little one was 9 lbs 1 oz, and her head circumference was in the 90th percentile.

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  4. It sounds like you really had a difficult time - it's so hard to interpret stories from the mother's point of view. But I imagine what happened was that the epidural in fact reduced your sensation of the pubic bone and your whole pelvic girdle being stretched too far - not by your little one's head but by the nurses' force on your legs.
    My advice is that you can certainly give birth naturally - you have already done so, with only an hour and a half pushing! But if you can, perhaps try to plan your next birth at home with a midwife who understands the benefits of the upright positions during labor and birth. Or hire a doula who can accompany you through a natural hospital birth.
    You may want to visit an osteopath to help with healing the damage done to your pelvic girdle.

    All the best!

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