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Baddington CL, Parker GC, Wakelin KJ. "I felt like I had no options": Navigating an ultrasound prediction of a large baby in pregnancy. Women Birth 2023; 36:e556-e562. [PMID: 37142498 DOI: 10.1016/j.wombi.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Pregnancy ultrasound is deeply embedded in maternity care worldwide, undertaken routinely and in response to clinical indicators. Though ultrasound fetal size predictions can be inaccurate, they heavily influence clinical decision-making. As a result, women with a scan prediction of a 'large' baby may be more likely to have unnecessary interventions. AIM This study aimed to explore the implications of an ultrasound prediction of a 'large' baby on birthing women's experiences of their pregnancies and births. METHODS The study was underpinned by feminist poststructural theory. Semi-structured interviews were undertaken with women who had an ultrasound prediction of a 'large' baby. Transcripts were analysed using reflexive thematic analysis, with particular attention to discourse. FINDINGS Dominant medicalising discourses prioritised surveillance and risk-centric care, and problematised large babies. Engagement with these produced oppressive effects on women including loss of control as they were directed towards high intervention care, and the experience of fear and guilt. DISCUSSION A 'large' baby prediction has a negative impact on women's experiences. Women take up dominant discourses that frame predicted large babies as a medical problem to be managed, with little tangible improvement in outcomes. They struggle with fear and guilt as they experience their pregnancies as sites of risk and are constituted as failed mothers who are responsible for their large babies. CONCLUSION The prediction of a 'large' baby in pregnancy has undeniably negative impacts on women. We encourage midwives to scrutinise the dominant discourses of authoritative scans and problematic large babies, becoming vectors for critical thinking and resistance.
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Affiliation(s)
- Cara L Baddington
- School of Midwifery, Te Pūkenga Otago Polytechnic, Private Bag 1910, Dunedin 9054, New Zealand.
| | - George C Parker
- School of Health, Te Herenga Waka Victoria University of Wellington, PO Box 600, Wellington 6140, New Zealand
| | - Karen J Wakelin
- School of Midwifery, Te Pūkenga Otago Polytechnic, Private Bag 1910, Dunedin 9054, New Zealand
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O'Dwyer V, Russell NM, McDonnell B, Sharkey L, Mulcahy C, Higgins MF. Antenatal prediction of fetal macrosomia in pregnancies affected by maternal pre-gestational diabetes. J Matern Fetal Neonatal Med 2021; 35:7412-7416. [PMID: 34229553 DOI: 10.1080/14767058.2021.1949447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIMS Higher rates of fetal macrosomia may occur in infants of women with pre-gestational diabetes compared with non-diabetic controls. Antenatal predication of fetal macrosomia remains challenging. Ultrasound over-estimated fetal weight could result in over-classification of fetuses as macrosomic with corresponding inappropriate clinical interventions. Previously we had studied a measurement - the anterior abdominal wall measurement (AAW) - to predict fetal macrosomia in fetal estimation of weight. The purpose of the study was to study whether specific third trimester ultrasound measurements with measures of glycaemic control (HbA1c) predicted macrosomia in babies born to women with pre-gestational diabetes. In particular, a new variant of this measurement (fetal anterior abdominal wall thickness (AAW), abdominal circumference (AC) ratio: AAW:AC) was investigated. METHODS This was a prospective cohort study in a tertiary referral maternity hospital. Serial growth scans including measurement of AAW and AC: AAW ratio was performed at 30, 33- and 36-weeks' gestation. Birth-weight data was collected, and macrosomia was defined as >90th centile based on gestational age and gender of the baby. Serial HbA1c as measured at the first antenatal visit, 14, 20- and 36-weeks' gestation were reported for this study. RESULTS Of the 416 pregnancies analyzed, mean maternal age was 33.3 years. One in five women were primigravida's. The mean birthweight was 3548 g (+/- 581 g), of which 142 (34%) babies were classified as macrosomic. The median gestational age at delivery was 383 weeks (314 - 402 weeks). There were 37 (9%) babies born preterm at <37 weeks' gestation. Mean AC measurements in fetuses that would be born with macrosomia compared with those with a non-macrosomic birth weight were 282 mm vs. 266 mm at 30 weeks, 318.3 mm vs. 297 mm at 33 weeks and 350 mm vs. 325 mm at 36 weeks' gestation (all p < .001). Mean AAW measurements in macrosomic fetuses compared with normal size fetuses were 3.7 mm vs. 3.3 mm at 30 weeks, 4.9 mm vs 4.3 mm at 33 weeks and 5.9 mm vs. 5.3 mm at 36 weeks' gestation (all p < .001). The mean AC: AAW was 0.01 for both normal and macrosomic fetuses at 30 weeks. There was no clinical or statistical difference in AC:AAW ratios between non-macrosomic and macrosomic infants. Binary logistic regression showed that AC at 36 weeks was most predictive of macrosomia (76.5%), followed by AAW at 30 weeks (68.5%). Using a combination of HbA1c booking, 14, 20, 36 weeks and AAW 30, 33, 36 weeks and AC 30, 33, 36 weeks predicted macrosomia in 80.9%. The ratio of AC: AAW did not act as a useful antenatal clinical predictor of macrosomia at birth. CONCLUSIONS Abdominal circumference at 36 weeks was the single best predictor of fetal macrosomia. A combined model of HbA1c, AC and AAW was the best antenatal predictor of macrosomia, with intriguing clinical possibilities in the possible prevention of maternal and fetal complications of macrosomia.
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Affiliation(s)
- V O'Dwyer
- Obstetrics and Gynecology, National Maternity Hospital, Dublin, Ireland
| | - N M Russell
- Obstetrics and Gynecology, Cork University Maternity Hospital, Cork, Ireland
| | - B McDonnell
- UCD School of Medicine, University College Dublin, Dublin, Ireland
| | - L Sharkey
- UCD School of Medicine, University College Dublin, Dublin, Ireland
| | - C Mulcahy
- Midwifery, National Maternity Hospital, Dublin, Ireland
| | - M F Higgins
- Obstetrics and Gynecology, National Maternity Hospital, Dublin, Ireland.,UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
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Pénager C, Bardet P, Timsit J, Lepercq J. Determinants of the persistency of macrosomia and shoulder dystocia despite treatment of gestational diabetes mellitus. Heliyon 2020; 6:e03756. [PMID: 32346630 PMCID: PMC7182725 DOI: 10.1016/j.heliyon.2020.e03756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/03/2020] [Accepted: 04/03/2020] [Indexed: 01/03/2023] Open
Abstract
Aims to identify potentially modifiable risk factors associated with the persistency of macrosomia and/or shoulder dystocia in infants born to women treated for gestational diabetes mellitus (GDM). Methods this case-control retrospective study included 113 cases complicated by macrosomia (ponderal index ≥97th percentile) and/or shoulder dystocia, and 226 controls without these complications. Factors associated with macrosomia and/or shoulder dystocia and with failure of diabetes management were assessed by multivariable analyses. Results Macrosomia and/or shoulder dystocia were associated with previous delivery of a large for gestational age (LGA) infant (adjusted odds ratio, 2.34, 95% confidence interval [1.01–5.45]), three abnormal glucose values during oral glucose tolerance test (2.83 [1.19–6.72]), a higher gestational weight gain before treatment (1.08 [1.01–1.15]), and failure of diabetes management (2.68 [1.32–5.45]). A non-Euro Caucasian origin (3.08 [1.37–6.93]), previous delivery of a LGA infant (3.21 [1.31–7.87]), institution of treatment after 32 weeks of gestation (3.92 [1.86–8.25]), and insulin therapy (2.91 [1.20–7.03]) were associated with failure of diabetes management. Conclusions supportive care in at risk women, limitation of weight gain in early pregnancy, shortened delay between diagnosis and treatment of GDM, and intensive insulin dosage adjustments might be means to improve the neonatal prognosis of GDM.
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Affiliation(s)
- Cécile Pénager
- Department of Obstetrics, Cochin-Port-Royal Hospital, AP-HP, Paris Descartes University, DHU Risks in Pregnancy, 123 boulevard de Port-Royal, 75014, Paris, France
| | - Pascal Bardet
- Department of Diabetology, Cochin-Port-Royal Hospital, AP-HP, Paris Descartes University, DHU Authors, 123 boulevard de Port-Royal, 75014, Paris, France
| | - José Timsit
- Department of Diabetology, Cochin-Port-Royal Hospital, AP-HP, Paris Descartes University, DHU Authors, 123 boulevard de Port-Royal, 75014, Paris, France
| | - Jacques Lepercq
- Department of Obstetrics, Cochin-Port-Royal Hospital, AP-HP, Paris Descartes University, DHU Risks in Pregnancy, 123 boulevard de Port-Royal, 75014, Paris, France
- Corresponding author.
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Abstract
OBJECTIVE To characterize the prevalence of and factors associated with clinicians' prenatal suspicion of a large baby; and to determine whether communicating fetal size concerns to patients was associated with labor and delivery interventions and outcomes. METHODS We examined data from women without a prior cesarean who responded to Listening to Mothers III, a nationally representative survey of women who had given birth between July 2011 and June 2012 (n = 1960). We estimated the effect of having a suspected large baby (SLB) on the odds of six labor and delivery outcomes. RESULTS Nearly one-third (31.2%) of women were told by their maternity care providers that their babies might be getting "quite large"; however, only 9.9% delivered a baby weighing ≥4000 g (19.7% among mothers with SLBs, 5.5% without). Women with SLBs had increased adjusted odds of medically-induced labor (AOR 1.9; 95% CI 1.4-2.6), attempted self-induced labor (AOR 1.9; 95% CI 1.4-2.7), and use of epidural analgesics (AOR 2.0; 95% CI 1.4-2.9). No differences were noted for overall cesarean rates, although women with SLBs were more likely to ask for (AOR 4.6; 95% CI 2.8-7.6) and have planned (AOR 1.8; 95% CI 1.0-4.5) cesarean deliveries. These associations were not affected by adjustment for gestational age and birthweight. CONCLUSIONS FOR PRACTICE Only one in five US women who were told that their babies might be getting quite large actually delivered infants weighing ≥4000 g. However, the suspicion of a large baby was associated with an increase in perinatal interventions, regardless of actual fetal size.
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Abstract
Estimation of fetal weight is an important component of antenatal and intrapartum management of pregnant women. While many clinicians use ultrasound estimates of fetal weight to assess fetal growth, there are inherent challenges in both the diagnosis and management of suspected fetal macrosomia. Given the inaccuracy in estimating fetal weight, and the risks that accompany cesarean birth or induction of labor, the management of suspected fetal macrosomia requires open communication and shared decision making between the woman and her health care providers. This case study and literature review highlight the current management and recommendations for suspected fetal macrosomia.
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O'Neill SM, Khashan AS, Kenny LC, Kearney PM, Mortensen PB, Greene RA, Agerbo E, Uldbjerg N, Henriksen TB. Time to subsequent live birth according to mode of delivery in the first birth. BJOG 2015; 122:1207-15. [PMID: 25825045 DOI: 10.1111/1471-0528.13359] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To estimate the rate and time to next live birth by mode of delivery. DESIGN Hospital-based cohort. SETTING Aarhus University Hospital (AUH), Denmark. POPULATION All pregnant women attending AUH were invited to enroll in the Aarhus Birth Cohort (ABC) study between 1989 and 2010 (n = 91,625). METHODS Women were followed from their first live birth until the subsequent live birth or until censoring due to study end using Cox regression models. MAIN OUTCOME MEASURES Rate and time to subsequent live birth according to mode of delivery. RESULTS 46,162 index live births were identified, of which 22,462 (49%) had a subsequent live birth. Women with any type of caesarean had a 6% reduction in the rate of subsequent live birth (HR 0.94, 95% CI 0.89, 0.98), which remained unchanged in the analysis by type (emergency, HR 0.95, 95% CI 0.89, 1.02; elective, HR 0.91, 95% CI 0.85, 0.98) compared with women who had a spontaneous vaginal delivery (SVD). Operative vaginal delivery was associated with an 8% reduction in subsequent live birth rates (HR 0.92, 95% CI 0.86, 0.98) and vaginal delivery complicated by shoulder dystocia with a 19% reduction compared with SVD. Median time to next birth in days was shortest in women with a first caesarean (994 days, 95% CI 973, 1026) and longest in women with a vaginal delivery complicated by shoulder dystocia (1065 days, 95% CI 994, 1191). In women with planned pregnancies, the shortest median time to second birth was in women with breech vaginal deliveries (859 days, 95% CI 737, 1089) and the longest in women with vaginal deliveries complicated by shoulder dystocia (1193 days, 95% CI 1028, 1430). CONCLUSION The impact of mode of delivery on subsequent rate and time to next birth was minimal in this study. The greatest reduction was among women with assisted vaginal delivery complicated by shoulder dystocia. This study is strengthened by data on pregnancy planning as well as information on complications of pregnancy, delivery and neonatal morbidities, all of which may influence a woman's decision on subsequent birth.
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Affiliation(s)
- S M O'Neill
- National Perinatal Epidemiology Centre, Cork University Maternity Hospital, Cork, Ireland.,The Irish Centre for Fetal and Neonatal Translational Research, Cork University Maternity Hospital, Cork, Ireland
| | - A S Khashan
- The Irish Centre for Fetal and Neonatal Translational Research, Cork University Maternity Hospital, Cork, Ireland.,Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
| | - L C Kenny
- The Irish Centre for Fetal and Neonatal Translational Research, Cork University Maternity Hospital, Cork, Ireland
| | - P M Kearney
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
| | - P B Mortensen
- National Centre for Register-based Research, Aarhus University, Aarhus, Denmark
| | - R A Greene
- National Perinatal Epidemiology Centre, Cork University Maternity Hospital, Cork, Ireland
| | - E Agerbo
- National Centre for Register-based Research, Aarhus University, Aarhus, Denmark.,Centre for Integrated Register-based Research, Aarhus University, Aarhus, Denmark
| | - N Uldbjerg
- Perinatal Epidemiology Research Unit, Department of Paediatrics, Aarhus University Hospital, Skejby, Aarhus N, Denmark
| | - T B Henriksen
- Perinatal Epidemiology Research Unit, Department of Paediatrics, Aarhus University Hospital, Skejby, Aarhus N, Denmark
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Physical activity, sedentary behaviour and fetal macrosomia in uncomplicated pregnancies: a prospective cohort study. Midwifery 2014; 30:1202-9. [PMID: 24861673 DOI: 10.1016/j.midw.2014.04.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 04/04/2014] [Accepted: 04/25/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVE to explore maternal energy balance, incorporating free living physical activity and sedentary behaviour, in uncomplicated pregnancies at risk of macrosomia. METHODS a parallel-group cross-sectional analysis was conducted in healthy pregnant women predicted to deliver infants weighing ≥ 4000 g (study group) or < 4000 g (control group). Women were recruited in a 1:1 ratio from antenatal clinics in Northern Ireland. Women wore a SenseWear(®) Body Media Pro3 physical activity armband and completed a food diary for four consecutive days in the third trimester. Physical activity was measured in Metabolic Equivalent of Tasks (METs) where 1 MET = 1 kcal per kilogram of body weight per hour. Analysis of covariance (ANCOVA) was employed using the General Linear Model to adjust for potential confounders. FINDINGS of the 112 women recruited, 100 complete datasets were available for analysis. There was no significant difference in energy balance between the two groups. Intensity of free living physical activity (average METs) of women predicted to deliver macrosomic infants (n = 50) was significantly lower than that of women in the control group (n = 50) (1.3 (0.2) METs (mean, standard deviation) versus 1.2 (0.2) METs; difference in means -0.1 METs (95% confidence interval: -0.19, -0.01); p = 0.021). Women predicted to deliver macrosomic infants also spent significantly more time in sedentary behaviour (≤ 1 MET) than the control group (16.1 (2.8) hours versus 13.8 (4.3) hours; 2.0 hours (0.3, 3.7), p = 0.020). KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE although there was no association between predicted fetal macrosomia and energy balance, those women predicted to deliver a macrosomic infant exhibited increased sedentary behaviour and reduced physical activity in the third trimester of pregnancy. Professionals caring for women during pregnancy have an important role in promoting and supporting more active lifestyles amongst women who are predicted to deliver a macrosomic infant given the known associated risks.
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