Questioning the registrar's opinion?

[Giddyup]

Hi, I am 35 weeks pregnant and went for a growth scan today as the baby is measuring 2 weeks ahead. The scan showed the baby to be on the 97th centile for length and abdomen circumference (but with a tiny pin head!).

The registar has said I need to be under registrar care at the hospital and I cannot have a water birth or go to the MLU. When I asked about my planned home birth she laughed in my face!

I have read lot's of threads regarding growth scans and the general consensus on here seems to be they are often wildly inaccurate. So, I am totally confused as to whether I should take what they say as gospel or not.

I am already a bit as the consultant at the hospital but me under high risk care for my weight with a BMI of 30, but in my area the guide lines are over 35 for a high risk! (my midwife checked)

Does anyone have any advice if they have been in a similar situation? It's my second child, my first was a complete breeze, in water and DS was 8lb 5.

Did the registrar explain why she felt you needed to be under consultant led care and have a hospital birth?

If it were me I would want to understand:

• what the scan measurements could indicate
• what the implications could be
• what the likelihood of those implications occurring is
• why those implications would indicate labouring in hospital would be advised and
• how your labour would be handled differently in hospital rather than at home.

I wouldn't take what they say as gospel, but I would respect their training and knowledge - then again I'd expect respect to be a two way street and, from my experience with registrars and consultants, that's not always a given :(.

So, after all that, I'd be on the phone to your MW asking for a referral with the consultant (NOT their registrar) to clarify the situation. I'd also memorise these phrases by Mary Cronk in preparation.

Ultimately, as I'm sure you know, its your right to have a HB regardless of what is advised - but before you go against medical advice make sure you understand the pros and cons of your choice. Its never easy in this situation and there's rarely a clear cut right/wrong answer - you just have to do the best you can given your personal circumstances.

(For what its worth, I learnt to be beligerent re. medical advice when DD1 decided to be persistently breech - I declined their offered ECV and/or CS and opted for a HB with IMs. It was a wonderful, calm birth and DD1 is now a lively 3 1/2 yr old)

Thanks Tangle, she didn't say why it would be a risk. She was hurried and a bit dismissive unfortunately and her English wasn't too hot.

I am a bit of a wimp and didn't ask too much at the time as I was a little surprised (sonographer just said the Baby was a good size).

I am going to sit tight and speak to my midwife when DP gets back from his business trip and use the questions and responses you have kindly outlined for me. I have very little faith in consultant already as her take on the BMI contradicts my midwife, her colleagues and the manual they have been issued with. Mid wife has promised to try and get that sorted in case it changes things.

Then I will think about tackling the Consultant again (but she made me cry the only time I have ever actually met her).

DP is now little spooked about HB unfortunately (he was only recently 100% comfortable with the idea) so I may concentrate on trying for a water birth in the MLU. We thought we would probably just got there when I am in Labour and they will hopefully let me stay as the midwives are also chilled about it all.

ok, I would recommend you change consultants to start with and find one who you like and feel respects you, I'm in my second cholesasis pregnancy and met with my consultant today, the best thing about him is I totally trust him and if he says something needs doing I believe he's doing whats best for me and my baby, takes so much of the worry away and I am so relaxed with this one, BMI has apparently changed, with my first I didn't need a GTT test (BMI of 33) this one I did and the midwife told me guildlines have changed recently and its now BMI of 30 or over they watch so it could just be two different sets of guidelines they're following.
Would definately recommend you sit down and find out why they feel the size is an issue, from what I've been told (and from scans on my DD) they are inacurate for weight but not things like head measurements so if it were a huge head and they felt your pelvis was too small they'd probably be more likely to be right but if your baby has a little head then this alone shouldn't cause an issue, if it was just sizze then you are within your rights to stick to a homebirth plan.
sounds like you need a better carer and some more information which you can discuss with your DP and agree on together

I would ask for a second opinion, either privately (lots of good consultants in Portland Hospital London, many also work in the NHS by the way) or from a NHS consultant.

I might be wrong in which case apologies for sacremongerong but I though head and abdomen circumference were meant to be the same, or at least close. Perhaps that is problem? I am big for dates (bigger than you) and growth scan confirmed likely to be big baby but have had no suggestion that it affects birth plan, although am not having a home birth.

Thanks for the responses everyone. SquallyRose, I think you have hit the nail on the head about wanting to trust the Consultant. Thats good to know about the BMI guidelines changing too,I felt singled out TBH and its never nice to called a fatty.
(good luck with your pregnancy and impending birth by the way).

Is it easy to just ask for 2nd opinion (NHS)?
Would I ring the hospital or my midwife?

EmmaKateWH You are not scaremongering, I thought the difference in measurements seemed a tiny bit extreme. Do you or anyone else know what that might be indicitive of? If not I may have to start Googling and that is never a good idea with medical stuff!

It should be easy to ask for a second opinion, I'm NHS too (York) I was lucky this time as I met my consultant when going through it with my first so this time I just refused to deal with anyone else and politely said I didn't want a registrar near me, I've therefore had one opinion and one care plan from someone I trust, I'm totally relaxed, last time I was a hysterical bundle of nerves who was convinced I'd have a stillborn baby so it makes all the difference.
I'd probably say speak to your midwife first and explain that you don't gel with your consultant and see what she advises, she'll probably know what to suggest, you don't have to give reasons or explain yourself, its your baby, your care and is a known fact that you'll have a better birth if you trust your care and the people around you. You'll find it easier to be objective if you trust your consultant and you aren't a mushroom, its your baby and your body so they have no right to decide things for you and expect them to take you at face value.
This time I have been very polite and apologetic but very firm, I don't want to cause you problems and I'm happy to wait a bit longer to get what I want but I will only deal with ...., I don't want anything else from anyone else except blood results and I'll discuss the implcations at clinic etc

The guidelines for BMI actually state if over bmi 35 you should birth in a consultant led unit.

here
"12. Care during childbirth
12.1. Where should women with obesity give birth?
Women with a BMI 35 should give birth in a consultant-led obstetric unit with
appropriate neonatal services, as recommended by the NICE Clinical Guideline No.
55 (Intrapartum Care, Sept 2007).56
Women with obesity are at significantly higher risk of shoulder dystocia15,20 and postpartum
haemorrhage10,20 and immediate obstetric intervention is vital in these situations. In
addition, babies born to mothers with obesity are up to 1.5 times more likely to be admitted
to a neonatal intensive care unit than babies born to mothers with a healthy weight.10,20,46
The odds of admission have been shown to increase with each increasing BMI category,
similar to those defined by WHO.23 Please see the table in Appendix 3 for the specific risks
associated with maternal obesity.

• Evidence level 2++ The NICE Clinical Guideline No. 55 recommends that women with BMI 35 should be advised to give birth in an obstetric unit to reduce the increased risk of maternal and fetal adverse outcomes. It recommends an individual risk assessment regarding planned place of birth for women with a booking BMI of 30 ? 34."

here for the full RCOG GUIDELINES on obesity on pregnancy.
www.rcog.org.uk/files/rcog-corp/CMACERCOGJointGuidelineManagementWomenObesityPregnancya.pdf

I had a booking bmi of 30 and am planning a homebirth if all remains well, I see no reason why I cannot give birth at home and I know a lot about pregnancy am am in final year of midwifery training.

no one can refuse you a homebirth it is your right to give birth whereevr you want.

you are entitled to 2nd opinion I would personally ask for a consultant midwife. As for her laughing at your birthplan that would infuriate me.

giddy i wonder if its because they are worried about a risk of shoulder dystocia? if baby's head is showing to be average and the body larger, there may be a slight increased risk, regardless of the weight of the baby. if this is the case i would strongly advise against homebirth as this needs the urgent care of health professionals to deliver the baby safely, and every minute counts.

also regarding the scans, they might not be accurate regarding weight of the baby, but if they are worried about proportion of baby's head to body in regard to shoulder dystocia, they are often quite accurate.

however i might be barking up the wrong path here, you really need your consultant to explain why she feels a hb/wb is not considered safe.

My GP told me at the time that I had the right to request a second opinion. However, I wanted immediately as I had a number of major concerns and that is why I went private, because it enabled me to get an appointment the same day (from memory cost me about £100 including a scan, I saw Donald Gibb based in Harley Street, Goodbirth company or something like that, I can look it up if you want).

Re. HB vs MLU vs Consultant Unit, I have seen some women press for a HB as a way to get HCP's to agree to the MLU, usually in circumstances where access is being refused due to policy rather than actual increased risk. Depending on what you find out and how you feel you its a strategy that could be worth considering.

Re. SD, I completely agree that this is true obstetric emergency. However, a very experienced MW said to me when we were planning a HB (before we knew DD would stay breech) that there is very little that can be done in hospital that can't be done at home to resolve SD (and that those procedures are performed extremely rarely) - and that the safety of you and your baby lies in the competence of the MWs you have with you wherever you're giving birth. Every second does count - and better to have 2 skilled MWs there, ready and acting than to have a MW ringing a bell and waiting for someone more confident to arrive and take over...

When's your next MW appointment and when does your DH return? It could be worth getting the ball rolling asking for a 2nd opinion/different consultant so that you have the appointment there and ready when your DH gets back (why are they always away when you need them most?)

Fingers crossed you can find a consultant you can put your trust in :)

I wondered if it might be a shoulder dystocia issue too. I will ask midwife for an explanation, then seek a 2nd opinion. I am not really near London, but if all else fails I will bear a private consultation in mind. Thanks for the advice everybody

I am about to call midwife and ask for second opinion, just "manning up" (am a real wimp!) as next midwife apt is not until 38 weeks.

I have just been chatting to a mum at the school gate who's baby was measuring bigger than mine for head and abdomen circs and length and nobody batted an eyelid about her having a midwife led waterbirth. She had a similar sized first child too and this baby ended up being only 8lb 4 anyway!

My lovely midwife is trying to squeeze me in for an apt tomorrow with head midwife of MLU who can apparently accept me even if consultant recommends otherwise. Hoping she can as clinic only runs on the 1st of the month and the !st Nov is my due date & DS was a couple of days early!