I know I often write about the risks of risk management and our constant focus on measuring women and their babies, but I really feel that papers like the one that I spotted this week need to be shared. That’s because it describes an analysis of the outcomes of over 64,000 women and their babies which shows that the practice of estimating the baby’s weight before it is born is associated with a higher chance of the woman having a caesarean section.
Here are the actual figures:
18.5% of women who had their baby’s weight estimated by ultrasound and documented in their notes had a caesarean section.
13.4% of women who had their baby’s weight estimated clinically and documented in their notes had a caesarean section. (In other words, a midwife or doctor estimated the baby’s weight by feeling the baby with their hands).
11.7% of women whose baby’s weight was not estimated/documented had a caesarean section.
All of the women were had reached 37 or more weeks of gestation, were planning a vaginal birth with a single, live, healthy, vertex (head-down) baby and had not had previous caesarean sections. Even after the researchers adjusted to take other variables into account, the differences between the groups remained significant.
As with all research, there are things that might have affected the results and we always have to interpret the findings with caution. For instance, we might ask ourselves why clinicians are more likely to estimate the weight of some babies, and whether that is because of another factor which might also increase the likelihood of an operative birth. But researchers do try to control for such variables, and we must not underestimate the effect that our human perceptions have on decisions. If clinicians think that a baby might be larger than average, for instance because a sonographer has recorded an estimated weight that is above the norm, then they might be quicker to suggest a caesarean section than if the fetal weight hasn’t been discussed, measured or documented.
This isn’t simple or clear-cut, but if fetal weight estimation carries a risk, then the one thing that concerns me most is this: women usually aren’t asked whether they want to have someone estimate their baby’s weight, and they certainly aren’t told about the possible risks and benefits of this screening test before it is performed on them and then document in their medical records. And, given the ramifications of this screening test, not to mention the fact that our estimation of fetal weight is often not that accurate (for who doesn’t have a friend whose baby was thought to be tiny when it was inside but turned out to look like a mini All Black upon arrival), I think we need to give some serious thought to whether it is justifiable to continue such a practice or whether it might be something that women and their families should be informed and asked about before it is performed.
Froehlich, RRJ, Sandoval, G, Bailit, JL et al, for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network (2016). Association of Recorded Estimated Fetal Weight and Cesarean Delivery in Attempted Vaginal Delivery at Term. Obstetrics & Gynecology 128(3): 487-94. doi: 10.1097/AOG.0000000000001571
OBJECTIVE: To evaluate the association between documentation of estimated fetal weight, and its value, with cesarean delivery.
METHODS: This was a secondary analysis of a multicenter observational cohort of 115,502 deliveries from 2008 to 2011. Data were abstracted by trained and certified study personnel. We included women at 37 weeks of gestation or greater attempting vaginal delivery with live, nonanomalous, singleton, vertex fetuses and no history of cesarean delivery. Rates and odds ratios (ORs) were calculated for women with ultrasonography or clinical estimated fetal weight compared with women without documentation of estimated fetal weight. Further subgroup analyses were performed for estimated fetal weight categories (less than 3,500, 3,500–3,999, and 4,000 g or greater) stratified by diabetic status. Multivariable analyses were performed to adjust for important potential confounding variables.
RESULTS: We included 64,030 women. Cesarean delivery rates were 18.5% in the ultrasound estimated fetal weight group, 13.4% in the clinical estimated fetal weight group, and 11.7% in the no documented estimated fetal weight group (P<.001). After adjustment (including for birth weight), the adjusted OR of cesarean delivery was 1.44 (95% confidence interval [CI] 1.31–1.58, P<.001) for women with ultrasound estimated fetal weight and 1.08 for clinical estimated fetal weight (95% CI 1.01–1.15, P=.017) compared with women with no documented estimated fetal weight (referent). The highest estimates of fetal weight conveyed the greatest odds of cesarean delivery. When ultrasound estimated fetal weight was 4,000 g or greater, the adjusted OR was 2.15 (95% CI 1.55–2.98, P<.001) in women without diabetes and 9.00 (95% CI 3.65–22.17, P<.001) in women with diabetes compared to those with estimated fetal weight less than 3,500 g.
CONCLUSION: In this contemporary cohort of women attempting vaginal delivery at term, documentation of estimated fetal weight (obtained clinically or, particularly, by ultrasonography) was associated with increased odds of cesarean delivery. This relationship was strongest at higher fetal weight estimates, even after controlling for the effects of birth weight and other factors associated with increased cesarean delivery risk.