Birth decisions - age 40, large baby

[CCrowe]

Wondering if other people have any experience of weighing up whether to try for a vaginal birth or have an elective caesarean with a similar risk profile to me?

I'm 40, we are planning to go ahead with the recommended induction at 39 / 40 weeks if we try for vaginal birth, the baby's head circumference is measuring big, in 97th percentile (all of which increases risk of tears, emergency caesarean and other complications) and we have an anterior placenta. If we try for a vaginal birth I've planned to have an epidural for a number of reasons.

I'm just not sure what to do. I don't have an ideological view one way or another, I just want to weigh up what might be likely to be the best option Last time we saw the consultant she still believed it would be better to try for vaginal birth but that was before we got the latest head measurement.

If avoiding an emergency C-section is your aim (and rightly so) I would research the stats on how many inductions, epidurals etc end in emergency C-sections

Absolutely try for a vaginal birth. I’ve had 6 babies, all big and 5 of them especially big headed and had no major issues …. My last was a c section but not because of his size! Has the induction been recommended due to the estimated size?

Is this your first baby? If you have a prior (recent) vaginal birth already that will likely affect people's advice.

Is an anterior placenta relevant? I've had that twice and nobody ever mentioned additional risk to me. Unless yours is too low or something?

I was induced at 41 weeks with my boy, he was over 4kg and head circumference was 97th percentile. I was 37 at the time and he was my second baby. Took me a lot of pushing and I had to get into the stirrups but he was born vaginally. I'm size 8. Had some stitches and lost a bit of blood. I would do the same again. I didn't have the drip though, just waters broken and no epidural. Good luck to you

Tricky and a personal decision.

I was very keen to avoid a caesarean. Had a big headed baby, I was in the pushing stage for three hours which was dangerous for me and for baby. We’re both fine luckily but I had a 3rd (nearly 4th) degree tear, and since birth I wee when I cough so I’ve been wearing tena pads all winter. I’m really worried one day I’ll wet myself at work.

Looking back I think I was overconfident and trusted nature too much. I’m lucky baby was ok. I do wonder if a caesarean might have saved my bladder control!

I had induction booked at 40 weeks when I had baby measuring on the larger side and gestational diabetes. Didn't need the induction in the end, went into labour naturally at 39+6.
Had an epidural and bub came out with from help from a doctor with some forceps, very happy with my decision, I would follow the obstetrician advice in your situation I think.

Thanks for all the comments, much appreciated. Good to know people's personal experiences.

To answer a couple questions - no I'm not prioritising avoiding a caesarean, personally I think the benefits and risks are very difficult to weigh up as they are not easily comparable to each other, but my consultant said she always recommends to try for vaginal birth if it is possible.

It's my first baby.

They recommend induction because of my age, being 40 and the increasing risk of still birth after 39 weeks.

I'm not sure anterior placenta is directly linked to emergency c section but it is linked to prolonged labour.

From what I can work out the risk of an emergency c section is more than 50% based on my risk factors and a third degree tear is more than 12%.

My 2nd babies head was born on 97th centile (not picked up on any scans as he was only 7 lbs 10…just a big head which he has now grown into!) I delivered him with a minor graze that did not require stitches. This was on the induction drip after being admitted for high bp at 40+6.

Check out evidence based research. You can make an informed decision about what’s right for you - you don’t HAVE to have an induction if you don’t want to.
Sarah wickham

I had my big baby aged 37. I refused induction after seeing what the rest of my antenatal class went through and close friends. I found the hospital were very keen to tell me the risks for waiting and the risks for c section but couldn't think of any risks for induction. Hmmm...

I'd say at least half of my mum friends who were induced ended up with emergency c section after 24 hours plus in labour. The others all had interventions, including forceps. Induction can be tricky because baby and your body is being forced into something it's not ready for and this can cause baby distress.

Saying that, I had a spontaneous labour at 41 + 5 and also had epidural and ventouse so still interventions. I found the ventouse absolutely fine and unnoticeable really as I had the epidural.

I'm opting for an elective caesarean for DC2 though but can't comment yet on which is the least worst option!

Pelvises are less flexible with age. Personally I think this depends on whether you feel instrument assisted vaginal delivery would be better than an elective CS? Having stared down this particular barrel, I was, in that moment, relieved when initial talk of preparing myself for forceps, switched to an emergency section. A subsequent elective section was extremely civilised in comparison.

Do your research.
Look up induction on big babies.
There is a line of thought that big baby is more likely to get stuck.
And line of taught that they get stuck due to induction as things ramp up and it cannot adjust properly.
I would opt for vaginal without induction or go for elective.
Also check your hospitals targets for vaginal births. My hospital was shit and pushed for TOLAC untill I discovered I had uterine tear in previous pregnancy from paperwork.l they obviously did not read.

Anterior placenta isn’t in and of itself linked to prolonged labour - where have you got that from?

There is some evidence to suggest that babies are more likely to be back to back with an anterior placenta, and it’s that that can cause a longer labour. If your baby is in the right position then anterior placenta is totally irrelevant. I had an anterior placenta with my second and she was born within an hour of first contraction.

Also, the risks associated with big babies are with big babies, specifically abdominal circumference, not big heads. Is your baby measuring large all over or just the head? The fear often with big babies is shoulder dystocia, which is when the shoulders get stuck after the head is out.

I had two fast and smooth labours with babies whose heads were off the scale big (literally over 100th centile) and the midwives said the head size probably helped as there was such pressure on my cervix 😬.

It sounds like you’re factoring some slightly irrelevant points into your decision. The relevant things are your age and the fact it’s your first baby. A planned c section will be more certain and probably middle ground in terms of outcome - question is whether you want to gamble for a smooth vaginal birth (better) or vaginal birth with complications/emcs (worse).

Have you considered asking for a water birth? It hadn't really occurred to me until my lovely midwife suggested it. I was over 40 and was advised to have the induction but went into labour early hours of the booked induction day. With the best laid plans, stay open to things taking an unexpected turn. Good luck!!

I would consider including the risk of 2nd degree tearing in your calculation too. I had very deep 2nd degree tearing which took so much longer to recover from than my 2 subsequent planned c-sections.

My sister and SIL both had first babies aged over 40. Both induced, neither baby with especially large heads. Both had to have emergency c-sections after several days of labour.

My last baby was big with a big head, and was the easiest of my three labours. Their weight does help labour progress if you can stand up etc

For me a big part of the decision would be whether you plan to have more babies or at least think you might. Once you have had 1 c-section there is pressure to have another.

I am 42 and my third baby is due today and also measuring big. I am waiting for a spontaneous vaginal birth because the baby’s estimated weight is 4Kg and I have previously had vaginal births with 3.8 and 3.9Kg babies so I don’t think this baby is particularly big for me. There are two kinds of growth charts, one is universal and one is adjusted for maternal height and weight and race and weight of previous babies. My 95th centile baby on the universal chart is only 75th percentile on the chart based on my personal stats.

I had a big baby at 42. Gas and air only vaginal birth which was far easier than my first much smaller baby. I did stay mobile and upright though and that helped a lot. Personally I'd want to avoid a section but you have to do whatever you feel most comfortable with. A large baby doesn't necessarily mean you'll be mangled. I had a small graze and was absolutely fine.

I was induced with a drip twice (dc2 and dc3) after my waters broke but had no contractions both times. I had an epidural and lovely births both times. The epidural meant I could wait for my babies to full descend and I only did 2 to 3 pushes for each of them. I was very relaxed and calm.

DC 1 was spontaneous labour and no epidural but was a shorter labour but felt more stressful as I didn't get my pain relief right.

Mine measured big but were not in reality so I'm personally a bit sceptical about the ability to measure with accuracy!

Can you send the evidence regarding anterior placenta increasing chance of prolonged labour because I’ve never heard of that

Thanks again for all the replies and personal stories, very helpful!

Yes sorry I wasn't clear - wasn't meaning to say anterior placenta causes longer labour, just that it can be a risk for back to back, which can in turn be a risk for longer labour - it's not a main factor I'm considering.

Head circumference is independently linked to greater emergency caesarean risk and greater risk of third and fourth degree tears (especially combined with shorter perineum which, um, applies as well). There's some evidence head circumference is a bigger factor than high birth weight overall.

https://www.sciencedirect.com/science/article/pii/S2589933323001891

https://pubmed.ncbi.nlm.nih.gov/26254515/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8460378/

To clarify I've been offered induction because of being aged 40 and the risk of stillbirth increasing, not because of the baby's size. I appreciate the risk of stillbirth is small and induction brings other risks so we're taking our time with that decision.

I am planning to have an epidural if we have a vaginal birth for reasons around mental health and uncontrolled pain, it's something we've had on my birth plan from the start and my consultant has supported.

I realise there's no options without pain or risks but we're just weighing the negatives and positives between elective caesarean and opting for a vaginal birth that might go fairly well but also has a significant chance of ending in a severe tear (worst outcome from my point of view) or an unplanned c section which they estimate is more likely than not for me with a vaginal birth. I'm not against an elective section by any means, in some ways I view it quite hopefully, but it's something we'd need to push for if we did decide on it.

Obviously there's not an easy option and you can't know what will happen but it is helpful to make sure we're going in as informed as possible.

The stats you mentioned 50% risk of emergency c-section sound scary. Personally only had elective sections & seemed very easy and super relaxed/quick. Don’t get me wrong the first week sucked but after 10 days honestly never felt like I’d had children since. Can’t say that for anyone else I know but maybe I was lucky.

First baby, 40, massive head, your odds of a smooth vaginal delivery are very low. Take the c section and avoid putting yourself through a long induction/labour only to probably end with CS anyway

I would avoid induction unless the obstetrician was strongly advising it for safety reasons. If they said “it’s up to you, it could improve xyz” I would say no thank you.
This is because the majority of people I know have been induced and every time it has ended in multiple interventions esp emergency c section.
also even more uncomfortable than standard birth

I would choose an elective c section over induction.
I've had two vaginal births so can’t speak from experience but just from what I’ve heard.
however I do recommend a vaginal birth as an amazing life experience! I’m glad I did that over c sections