Should I have an induction to prevent a big baby?

From time to time, readers write to me at birthsenseblog@gmail.com, telling me their birth stories and asking for advice for the next time around.  I’d like to share this reader’s story with you, because her situation is fairly common and one that we can all learn from:

My first baby was born at 42w 2d (refused induction) after a very long labor. I got stuck for hours at 5.5, finally agreed to them breaking my waters and got an epidural because I wasn’t managing. Then it went very quickly, I was completely dilated ~2 hrs later, waited another hr or so before pushing and then the fun started. I ended up pushing for 3.5 hrs, mainly lying down, though I did try other positions as well. The baby somehow didn’t turn all the way, they reached in to turn him and couldn’t, tried to vacuum twice and couldn’t, and as they basically gave up on anything besides for a C-Section he miraculously turned. Turned out the baby was 10 pounds 2 ounces, and must have been stuck in a bad position for most of the labor (they said that’s why it stalled and I had terrible back labor all along also.)

I’m now at the beginning of the second trimester with my next pregnancy. Since I had such a big baby, a complicated delivery, and was late (no GD, no family history of big babies either, and both my husband and I are avg-small), does it make sense to induce at term to try to make things easier? What else could I do to make this birth go easier than last time?

(I’m torn about the epidural – did it make me feel less and harder to push, but on the other hand, I don’t think that I would have had the strength to push for so long without that break in between (I was completely wiped out).

First of all, let’s list the factors that we need to consider when thinking about this birth:

• Big baby, concern that this baby could be as big or bigger
• Long, painful back labor
• Worry about need for epidural with next labor vs. whether it affected ability to push
• Considering induction for next baby

All of these factors are important things to think about as our reader plans for her next birth.  We do know that inductions for mothers who have given birth before usually are not more likely to end in cesarean sections, compared to the 50% c-section risk for a first-time mother being induced.  The Bishop’s score is a chart that allows a provider to estimate the likelihood of a successful induction, based on softening/position/thinning/dilation of the cervix, as well as how low the baby is in the pelvis.  But while the Bishop’s score correlates well with whether or not a baby can be born vaginally following an induction, it does not tell us anything about likelihood of causing fetal distress to the baby, or a difficult labor.  I have cared for women being induced, whose cervixes were very “favorable” (the medical slang for a cervix that is soft, thinned out, and already dilated a few centimaters), yet who had long, painful labors due to the baby’s position or some other unknown factor.  So it’s difficult to predict that an induction will be easy, based on the Bishop’s score alone.

If I were this reader’s midwife, these are the things I would advise her to focus on for this pregnancy:

• With a history of a very large baby, and no gestational diabetes, I would be working very closely with my client on her nutritional intake during pregnancy.  Some very good diets, such as the Brewer diet, are full of healthy foods but very high in calories, and tend to result in very large babies.  Just as pregnancy and birth care should be individualized for each woman, so should dietary recommendations.  The Brewer diet is excellent nutrition, but too much nutrition for some women.  The saying that “your body will only grow as big a baby as you can handle” is true only to an extent.  That’s akin to telling a non-pregnant woman that she can eat as many calories as she wants, and her body will only assimilate those calories which her metabolism will burn.  We all know that this is not the case–you and your baby can gain significant weight if you are eating more calories than your body is burning.  This is not to say that every woman who has a big baby has had a calorie imbalance during pregnancy, but it is a factor which should be considered.  Exercise should play an important part in your pregnancy.  Beginning with your non-pregnant weight, you can calculate how many calories a woman of your size needs per day to maintain your weight.  In this calculator, enter ’0′ for the number of pounds you wish to lose, and leave the box for days to lose weight blank.  Consider your activity level in making this calculation.  Most women overestimate their activity levels, and it’s important to understand the difference between being active and actually exercising to a level that will increase fitness and maintain good blood sugar control.  This past Birth Sense post discusses exercise in pregnancy.   Once you determine how many calories you need to maintain your own body weight, add to this figure no additional calories for the first trimester, 150 calories per day for the second, and 300 for the third.  All calories should be obtained from high-quality proteins, whole grain foods, fruits, and vegetables.  “Empty” calories such as sweetened drinks, chips, desserts, etc., should be only an occasional treat. 
• Consider whether you might have borderline gestational diabetes.  Some women who have large babies developed gestational diabetes after the testing at 28 weeks showed them to be normal.  Did you fail your 1-hour test, but pass the 3-hour test?  In this case, you should repeat the 1-hour test in four weeks (at 32 weeks) or do some random finger-stick blood sugars at home to see how our body is handling the foods you are eating.
• Have regular visits with a chiropractor experienced in prenatal chiropractic, beginning in the 2nd trimester at the latest.  There is increasing evidence that subtle pelvic misalignments can contribute to back labor and misaligned babies.
• I would not recommend induction unless there are medical reasons to do so.  You had a 10 pound baby!  You have a great pelvis!  Most likely the position of the baby was the biggest factor in slowing your labor and pushing.
• I would recommend avoiding an epidural if possible.  In your case, it sounds as if it was a good choice for your first labor.  However, if I were your midwife, I would have encouraged you to wait longer than one hour to “labor down” (allow the baby to descend in the birth canal passively, without mom pushing).  This is usually not difficult for a woman with an epidural, as she typically will not have a strong urge to push early in the second stage.  Three or four hours of passive descent is not unreasonable.  This allows the baby’s head to mold gradually, and helps the baby to be able to turn into a favorable position.  Once the head is visible at the opening of the vagina, the mother will generally have a good sensation of pressure, and be able to push her baby out in a short time.  This avoids exhausting mom, and helps birth to occur normally.
• I would use an upright position for birth.  If you do not have an epidural, this is easy to do, and being able to move into many different positions is beneficial to the baby being able to mold and move through the birth canal.  If you do have an epidural, the key is to get off of your tailbone, allowing more room for baby.  You can be helped onto a birthing stool right by the bed, or on top of the bed, with the foot lowered all the way and the head raised all the way.  You will need one support person on each side of you to make sure you are securely seated on the birth stool.  This opens the pelvis and allows the tailbone to flex, creating more room for baby.
• The temptation to induce is quite logical.  Intuition tells us that if the big baby caused a difficult labor, inducing so the baby is smaller will result in an easier labor.  This is usually not the case.  Studies have not shown an improvement in birth outcomes with induction for suspected big babies.  However, if the baby does seem to be getting very large, if you are overdue, if your cervix is very favorable, and if the baby is in a good position, it is not an unreasonable consideration.  If I agreed to help you induce labor in this situation, I would recommend sweeping the membranes first, to see if labor would start on its own. My next choice would be what is called a mechanical induction, which is done with a foley catheter or a special catheter designed for induction.  This allows your body to progress into labor on its own.  Patience is key–if you are willing to work on getting into labor over the course of a few days, rather than trying to force your body into labor in a few hours, you will likely have a better result.

The decision to induce because of a history of a big baby is complex, as you can see, but the positives in your case are that you have a terrific, roomy pelvis, and it will be your second baby, which typically is faster and easier regardless of baby’s size.  With consideration and planning, I believe you will have a much easier, satisfying second birth.