The Biggest Baby I’ve ever caught

Here’s a lovely birth story to share, my 99th delivery:

We were all expecting a big baby. Her estimated fetal weight from Leopold’s palpation was judged to be approximately 4500 gms. The baby felt huge: fat and happy, and we were all duly nervous, because her first baby was only 7.5 pounds. She wasn’t a large woman, either, but her pelvis felt incredibly roomy, so we were proceeding very carefully, watching closely, wondering if things would progress.

She had an epidural, but even with the epidural, everything was hurting her: her back, her legs, her vagina. With the assistance of her partner, we kept turning her side to side, sitting her up and lying her back down, trying to alleviate some of the pain through what limited position change is available when someone has an epidural. She had cold packs on her forehead and sacral massage. Even so, it wasn’t helping much. She began to feel a lot of rectal pressure and wanted to start to push, but she still had a small lip of cervix in front of the baby’s head, so we breathed with her through her contractions and tried to keep her from pushing. She was really unhappy with us at this point; who wants to breathe when they feel like pushing?? It’s the hardest thing in the world, and she really struggled with it.

The thing is, even though her cervix felt nice and soft, and we could possibly reduce the small lip of cervix in front of the baby’s head, we didn’t want to. With large babies, there’s a lot of danger involved in reducing an anterior lip and bringing someone to fully dilated when maybe they’re not supposed to be. Sometimes there’s a reason for a woman with a large baby not making it to fully dilated. Sometimes it’s a message to you that the baby is actually too large, and it’s a warning that should be heeded. So we let her body work on its own, without forcing it, and eventually, after over an hour of being at anterior lip, the last remaining, stubborn piece of her cervix finally disappeared.

Our concern, of course, was shoulder dystocia, which is without a doubt one of the most dangerous of all obstetric emergencies. With shoulder dystocia the head is delivered but the shoulders get stuck, and you have only minutes to get the baby out before he or she begins to rapidly decompensate on account of the severe cord compression that occurs. There’s a whole list of maneuvers that you’re supposed to work your way through: first you pull the legs back, which helps to widen the pelvic outlet, and then you apply suprapubic pressure, which helps to pop the baby’s shoulder under the pubic arch and get the baby out. If that doesn’t work, you move on to other maneuvers, like Wood’s Screw or the Gaskin Maneuver (named after our favorite midwife, Ina May). You reach your hand in and try to delivery the posterior arm. Even though it’s not the perineum that’s the problem, but actually the bones of the pelvis, an episiotomy is often cut in order to ensure that there’s enough room to get your hands in to maneuver (and in our sick society, if a lawsuit is ever being brought to court on account of a shoulder dystocia, apparently if you haven’t cut an episiotmy, it’s a huge strike against you, since cutting is part of the “standard of care”. I’m not sure that I agree with that, but on the other hand, in such emergencies, you do what you have to do). You empty the woman’s bladder. You pray. You try the maneuvers again if they didn’t work the first time. The clock ticks so slowly, so that miliseconds seem like eons and all you can do is stare at this stuck baby with a face that’s slowly turning more and more purple. Sometimes nothing works. Sometimes you need to break the baby’s collarbone or humerus in order to get the shoulder out. I’ve never had a true shoulder dystocia yet in my short career as a midiwife, but I’ve seen a terrible shoulder dystocia in my work as a nurse, and I’ve heard the stories. It’s no joke. It’s one of the scariest things you’ll ever have to deal with in this profession.

So we were nervous, and rightly so. But she was making slow progress, on her own. She began to push once she was fully dilated, but she was tired, and her effort wasn’t great. She lost her fighting spirit, and began to cry, asking for a cesarean, telling us that she couldn’t push any more, telling us she wanted to die. This is all pretty normal stuff for the pushing phase, at least among the women we take care of at our hospital, but it only served to make us even more nervous. The four P’s of labor are the Powers (contractions), the Pelvis, the Passenger (baby) and the Psyche. If any one of those P’s are missing, you’re in trouble, and staring at this huge baby waiting to be born with a mother who’s psyche wasn’t in the best place was very, very worry-making. There comes a point in the labor as the baby’s head is just beginning to peek into view when you can really get a sense of just how big the baby is. You can put a finger on the baby’s crown and then palpate the baby’s rump through the woman’s uterus, and get a true measure with your hands for the first time, and let me tell you….this baby was HUGE.

But she was making progress. Slow progress, but progress. The baby’s head began to come into view during pushes, then would tuck back in again in between contractions. This is called Turtling, and it’s a sign of impending shoulder dystocia, and when we saw this, we really began to wonder what in the world we were doing by encouraging this woman to push. Slowly, though, it became clear that the baby was moving down, and was starting to stay down, even in between contractions. We could still get our fingers in, and could still feel lots of room in the sides and the back of her pelvis, and little by little, she kept pushing the baby down. Soon enough (well, after over an hour of pushing), she began to crown.

I was catching the baby, and was gowned and gloved and ready, running through the shoulder dystocia maneuvers in my mind. The doctor was standing next to me, also gowned and gloved. We had the pediatricians in the room, waiting. The back up doctor was also in the room, plus another midwife and 3 nurses. We had a stool ready, in case someone needed to stand on it to apply suprapubic pressure. We had broken the bed so there was plenty of room to get in close to her perineum, if need be (of all my births so far, I’ve broken the bed on only two deliveries, just to give you an idea). And there we all were, waiting, sweating, watching and waiting.

The head emerged, and it was huge and fat, with these chubby cheeks and tons of hair. I didn’t cut, but instead gave perineal support and pulled the perineum down around the baby’s face as he crowned. And there he was, in all his glory. It looked like she had the head of a young toddler between her legs, that’s how big he was. I don’t know about the rest of the staff, but my heart dropped into my feet when I saw that head. Surely this was going to be a shoulder dystocia. Surely we were all in a lot of trouble.

I let the head restitute on its own without rushing it. The baby slowly turned into ROT, and I thought: well, might at least try to deliver the shoulders, just to see what happens. So I gently applied downward traction, little more, little more…and then, all of a sudden, there was the anterior shoulder!! Just like that. Just like a totally normal delivery. As soon as I saw the top of the anterior shoulder, I applied upward traction to delivery the posterior shoulder, and the shoulders were out. Getting the actual baby out required hooking a finger under each armpit and actually gently tugging the baby free, because this definitely wasn’t one of those births where the baby was just going to slide out. But the baby came quickly and easily, with hardly a pause between the delivery of the head and the delivery of the rest of the baby. He began to howl, wiggling both his arms and fingers (a good sign, indicating that there was no erb’s palsy going on), and we put the baby onto the mother’s stomach, and everyone just sort of stared in amazement.

He was enormous!! Guess how big….just guess. Much bigger than 4500 gms. He was actually 5150 gms. 11 pounds 5 ounces. The biggest baby I have ever delivered, and one of the biggest babies I have ever seen.

Delivered in a hospital, by a midwife, without the slightest whiff of shoulder dystocia. Oh, and one of the best parts: she didn’t tear, at all. Her perineum was intact. There was one nick which was bleeding, which required one stitch, and that was it. That was it!! Such a miraculous, miraculous birth.

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7 Comments

  1. Posted June 9, 2008 at 7:34 pm | Permalink

    makes me so glad to do homebirths! :) (especially with unmedicated moms having big babies!)

    the largest in my practice has been 13.6 – my first breech was 11.6. I’ve had a number of 11 and 12 pound babies in my practice, too. I had one true shoulder dystocia that was a 13lb baby. It’s the only time I felt completely scared of losing a baby.

  2. lovingpecola
    Posted June 9, 2008 at 9:18 pm | Permalink

    99…how magical! The first baby I was intending to catch had an increased shoulder dystocia risk (BMI was nearly 50) and I remember all the discussions about all the people who would be present, etc and my preceptor reviewed all the stuff with me (HELPER) etc. It was so…intense…and I just kept thinking, but maybe it isn’t going to be a shoulder dystocia! But of course they/we prepare for the worst when we suspect it. She ended up going to section despite all our efforts (and the docs of course did not want her to go to the OR because of her BMI)

    Thank you for this story, it was so good to read.

    But I did want to clarify what you said about the turtle sign…I have always learned that it happens *after* the head is out…that it is the head being sucked back tight against the perineum as if it’s going to go back inside after crowning and the birth of the head has occurred…you know it differently?

    Good to read a new post from you!
    LP

  3. Posted June 9, 2008 at 9:31 pm | Permalink

    Oooooohhhh, thank you for that.

    I love living vicariously through you!

  4. The Midwife
    Posted June 10, 2008 at 10:11 pm | Permalink

    Hmm, LP, I think you’re right. Officially, “turtling” is after the head is out. But then, I still feel like you’d see signs of turlting much sooner than actual crowning, if you’re looking for them. I guess, to my way of thinking, if the shoulders are stuck, each push will bring the head down, but in between the contractions, it’s still going to want to move back up to where the shoulders are, because a neck will only stretch so far, and you’d see this during pushing as well as crowning. But yeah, I think my use of the word may have been slightly incorrect.

  5. hannah banana
    Posted June 11, 2008 at 8:51 pm | Permalink

    What a lovely story! Thanks for sharing!

    AND…I’ve meaning to write you – I’m headed to nurse midwifery school in just 3 short weeks! Your email (from eons ago) was so lovely and encouraging and I just wanted to let you know.

  6. Ritsumei
    Posted October 26, 2008 at 10:58 pm | Permalink

    What a great story! Yay Mom! And yay you!

    Interesting too. I had no idea that shoulder dystocia was so serious. One of these days I’m gonna splurge and get me a nice fat midwifery textbook. Birth is so interesting.

  7. hlp4ever
    Posted December 29, 2008 at 4:38 am | Permalink

    Found your article while surfing for big baby info. I’m pregnant with our fifth baby. My second baby was born 11lb, 6oz, in a hospital with shoulder distocia. It was a horrible experience. (He is fine now)

    My fourth baby was two weeks overdue, and the ultrasounds predicted a large baby. I was really scared to go through another shoulder distocia, but on the other hand, trusted my midwives so much more than the hospital staff of previous births.

    It ended up being my easiest birth, with only one stitch. She was born under water, weighing 11 lbs, 11 and one half ounces!

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