Question about "Too narrow of bones" with giving birth

Higgs · Oct 21, 2009

I think what the doc really meant was the pelvic outlet is too narrow, but perhaps she should have said what she meant, instead of trying to dumb it down and just confusing people.

As for the other issues you raised...dunno...but the doc shouldn't have related her own horror stories. Imagine if you needed surgery and your surgeon goes, 'Oh yeah, i had this op years ago and boy, what a hard time I had: pain, blood, infection - sheesh, I'm lucky to be alive...'

Not very professional really.

Coffee Nurse, BSN, RN · Oct 21, 2009

It's called cephalopelvic disproportion, and yes, it can result in failure to progress during labor (and subsequent c-section). However, from what I understand, it's difficult to diagnose with much certainty prenatally, since both the mother's pelvis and the baby's head undergo a considerable degree of shape/size change during birth.

If your friend hadn't been induced today, it might have behooved her to seek a second opinion, especially if she's felt in the past that this particular OB isn't really listening to her wishes. I don't know if MDs directly make more money for each section versus lady partsl birth, but it's certainly a bigger money-maker for the hospital, which may indirectly benefit the doctor.

Either way, best of luck to your friend! Keep us posted on how it goes.

SNLou84 · Oct 21, 2009

Thank you for the responses! Yes, I agree...the dumbing it down didn't help matters and it wasn't in a way that even made much sense either. I told my friend that once she starts to dilate that everything will change in that region (just like you said) and hopefully she will be able to give birth naturally over a c-section. I am still waiting to hear on what happened but I really don't believe that her "bones are too narrow". I just think the doctor is a strange one.

My soon to be sister-in-law, when she had her baby, her doctor was very unprofessional. He would feed her all these stories/facts to which we would then have to argue with her that she shouldn't listen to him because she would believe everything he told her. He prescribed her pain medicine after her c-section and told her that she could take them for 2 weeks before they would enter into the breast milk. I told her I always heard that if you take a medication, etc.., it can enter the breast milk then....not two weeks later. That is correct right? This same doctor told her she shouldn't take the baby out of the house for a month.

Coffee Nurse, BSN, RN · Oct 21, 2009

It depends on the medication. Some don't enter breastmilk at all; most do, but to varying degrees. I think the doctor might have meant that the drug level could take two weeks to build up to a level that would be concerning? I have no idea. At any rate, a lot of the moms in my NICU are on pain meds, and I've only ever heard from the more experienced nurses that they don't need to worry about the meds adversely affecting the babies through breastmilk, especially since during the first few days to week, when newborns are most susceptible to any effects of the medications, they aren't getting that much anyway, since they're only getting small amounts of colostrum instead of ounces and ounces of milk.

This is a link to LactMed, a searchable database from the National Institutes of Health on the effects of drugs on lactation, breastfeeding infants, etc. It is targeted more towards HCWs as opposed to laypeople.

jonesecho, RN · Oct 21, 2009

:twocents:I will explain some things and hope it clears up and does not confuse you more. I worked in OB quite a while. It is amazing how confused people get but not surprising. There are so many variables and things to understand that I can see why so many people get confused or the wrong info.

First of all women who are going to give birth should really filter out most of what other women tell them. Many are their own war stories and let me tell you the best info that someone can give you is that there are no rules when it comes to labor and anyone that thinks they can predict everything accurately is a fool. Even a woman who has several children can have very different birth experiences.

what your friend needs to read about is the pelvic outlet and their different shapes. Please believe me that you can't look at someone and say they are big boned, etc. and will have no problems. A persons pelvic outlet shape cannot be seen. there are ways the dr. can measure them and predict -although they are not all good at this.There are many big looking women that cannot progress and many small looking women that have no problems.

Ultrasounds can be off as much as a pound. I have seen so many where they say CS because of big baby and then the baby is not big and some where the baby was big.

The reason they call a CS when the baby is breach is because the infants head is the largest part of the body and if the rest of the body were to deliver but then the head would not fit through the pelvic outlet- you can see the problem there.

there are multiple reasons for CS's to be called. It can be a non-reassuring fetal heart rate that cannot be corrected through what we call neonatal resuscitation,/ it can be failure to progress for reasons that possibly the cervix does not keep dilating, or because the baby does not come down low enough either due to size of the pelvic outlet or presentation of the babies head. Again, there are so many variables. Everything is not textbook. There can be an arm coming down along side of the head, there can be a head that is not looking down like it is supposed to. the proper presentation is occiput anterior.

the woman's hormones to deliver are all triggered by the body. This is why it is nicest when she is able to go into labor naturally. This is not to say that someone who is induced with either a prostaglandin gel, or with pitocin which is the same hormone the body has to make the uterus contract. the other name for it is oxytocin.

i worked for 11 years in this field and felt as though i understood it well. I was not the typical cute little nurse that many doctors like to look at and just make everything seem more wonderful, but i attained the doctors confidence when they could see i understood the processes and had good judgement. if you have further questions i would be glad to answer them.

i will tell you that i think it is unprofessional for the dr. to tell her about personal experiences in case that happens to your friend. we all tend to want to do this because we lived it,/ but we need to realize that there are so many scenarios. If she is really convinced the pelvic outlet is too small or shaped in a way that would make delivery impossible along with the ultrasound showing a large baby- well then she could say to the patient there needs to be a cs. there is nothing wrong with your friend asking to try lady partsl birth and going to cs if not possible, or if she isn't shown the reasons why she needs a cs. she could also get another opinion. i have seen other ob nurse who did not do as well at considering all the anatomy and physiology involved with birth. labor and delivery nursed truly have to keep assessing and reporting what they see to the dr. and to the pt. there are many signs of progression and many signs of problems and it takes not only knowledge but experience to know how to sort them out. it is also good to know how many classes the labor nurse had in fetal monitoring. i know of some hospitals that don't put an emphasis on them and just have their nurses learn from experience. i believe they are good to have every couple of years at least. most labor nurses have way more fetal monitor classes then the ob dr. a good ob dr. knows to value their nurse. i had 2 basic fetal monitor classes and then i went to an advances class. the labor nurse has to know how to monitor the mother in labor and the infant's response to the stress of it and the whole time be aware of pathophysiogical problems that can arise in labor, such as; pre-eclampsia, mothers with gestational diabetes or with type 1 diabetes. They need to know problems that can occur with teen mothers, older mothers, etc. the mother in labor does need to have confidence in her dr. and a good nurse will keep her informed while listening to her. a labor nurse's assessment includes listening to the mother's cues on how she feels, etc. they should never think they know so much as not to listen to her. the mother in labor should only have well controlled visitors that she wants in the room. it is very hard for the nurse if they are out of control visitors.i don't have a lot of time to explain what i consider out of control visitors but if there is anyone hard to handle in labor it is not usually the mother to be. i suggest any mom that will deliver in the hospital to go to childbirth ed .classes that will review the room , equipment and what will happen. the reason why is there is so much to teach that she will be better prepared. good luck to her and let me know if i can answer anything else. when i was young and had my first child i was not a nurse yet and did not have good experience with the childbirth. it was quite a long time ago and things have changed ,thank God. this made me all the more eager to change the experience that my pts. had when about to deliver their baby. :twocents: :specs:

Conejita, BSN · Oct 21, 2009

As others have said here, the measurement tools used to screen for CPD and macrosomia (a big baby) are often fairly inaccurate and most women should at least be given the chance to labor and try for a lady partsl birth.

:twocents: Being induced complicates the matter even more.

Inductions often fail when the body is not ready to let the baby out (or baby has not moved into a favorable position). Is your friend being induced for a specific medical reason? It is still within the normal range for pregnancy to go to 42 weeks gestation and often primips naturally go over 40 weeks. Most of our providers won't induce for "post-dates" until the completion of the 41st week (evidence based practice), unless there are other medical complications present (preeclampsia, for example). Hopefully your friend's dates are accurate!

Sometimes, we have patients who are just sick and tired of being pregnant and beg for an elective induction before 41 completed weeks....in my experience, these tend to be the inductions that have the highest failure rate, especially with primips. If there is no fetal distress or other complications going on during the induction, sometimes our patients who end up with failed inductions are sent home to try and wait for labor to start on its own for a few days....and if labor does not start on its own, they come back in for another try at induction later in the week before going to a c/section. But not all hospitals have providers that truly try to avoid a c/section like where I work.

If your friend does not dilate according to plan, her MD may then diagnose CPD and want to section her. If she does have a c-section due to "failure to progress" or CPD, it will be hard to know if her pelvic outlet was truly inadequate. It is always possible that if labor would have started on its own, without induction, she might have been able to have a successful lady partsl delivery. We see this all the time in OB. The best evidence of this occurrence are successful VBACs (lady partsl birth after cesarean) that had had a c-section for CPD for the first baby. Often these women are able to deliver a larger baby lady partslly than their first baby that came by c-section. Of course, there are many other factors at work here affecting the outcome of each delivery, with fetal malposition being yet another common cause of "failure to progress".

Best wishes to your friend :up:

SNLou84 · Oct 21, 2009

Thank you again! I honestly feel inducing her now is too soon (she said she just turned 40 weeks yesterday) but I don't know if the 40 week estimate is completely accurate. I think they are more of going by the fact the baby is 7lbs 9 oz. and they feel that is a full-term baby n therefore time to give birth. But thank you all for clearing up the "narrow bone" statement made by the doctor. I now completely understand what is meant by that and I think it is likely the doctor didn't know 100% if that was the case or not.

Thanks again!!

honeymist · Oct 21, 2009

Is this a common issue in people with small/narrow hips? My Mom and Aunts used to always tease me that I have such narrow hips, I was going to have a he** of a time when I had a baby. This is seriously one of my secret fears! Does this really happen a lot???? (Clearly I'm a pre-nursing student here!! :) )

Conejita, BSN · Oct 21, 2009

Is this a common issue in people with small/narrow hips? My Mom and Aunts used to always tease me that I have such narrow hips, I was going to have a he** of a time when I had a baby. This is seriously one of my secret fears! Does this really happen a lot???? (Clearly I'm a pre-nursing student here!! :) )

As I understand it, true CPD is quite rare these days whereas it was more common during times of poor nutrition which caused rickets and other pelvic anomalies. CPD is difficult to diagnose but is often implied when the baby's head does not engage or with "failure to progress" during labor. There are so many other factors that could cause "failure to progress" that have little to do with the adequacy of the pelvis, that I believe that CPD is over-diagnosed. Some of these other factors include: fear, inadequate labor/emotional support, positioning during labor (or lack-there-of), and fetal malposition.

Just because you have "narrow hips" does not mean that you will necessarily have trouble birthing a baby. I have seen tiny women (5 feet tall, 100lbs) birth 9 1/2lb babies without problems. You just really can't tell by looking at someone from the outside. Things to know about your pelvis:

1.) it is not a fixed structure. During pregnancy and labor your body produces hormones that allow the ligaments that join your pelvic bones to stretch.

2.) the baby's head (the largest diameter to get through your pelvis) is also not a fixed structure. The baby's head is made up of bones that are separate and able to move in relation to each other - which allows the head to "mould" and reduce it's diameter = better fit through the birth canal.

3.) a squatting position during labor and delivery can increase pelvic measurements considerably.

4.) one of the most important factors of whether a labor and birth with be easy or impossible is the baby's position. If the head is flexed (chin tucked) and baby is OA, you may have an easy time. If the baby has a brow presentation or face presentation, it may be rather difficult/impossible to get the baby out in that position.

:twocents: I think it is really important for women to trust in their body's ability to birth babies. Our thoughts, fears, doubts, and desire for control during labor can really have an effect on progress and outcome . The best advice I can give is to trust that your body has its own innate knowledge on how best to birth a baby, and to just let go of all the other stuff :)

rbytsdy · Oct 21, 2009

My first baby was a c-section because she never descended into my pelvis. After 17 hours of good, strong contractions (and 12 hours of early labor before that), I only reached about 5cm. The doctor said the baby couldn't fit through my pelvis and therefore couldn't descend in order to help my cervix dilate. The doctor "checked" my pelvis during the surgery and said the baby never would have fit through b/c my pelvis is an oval shape rather than round. He advised planning c-sections for future babies.

I really didn't want to go through a c-section again so I decided I was going to try again. :) I had 41 hours of largely non-productive labor. For whatever reason, it took me a really, really long time to dilate. My midwife finally got me to labor in a squatting position and that forced baby #2 down (and out!). She had a perfectly round head - someone even asked if she was a c-section. I was mentally preparing for a cone-headed baby since my pelvis was supposed to be so narrow.

You really can't "diagnose" CPD until a mom has had the chance to push her baby out. Even then, positioning of the baby, epidurals, etc can interfere with a mom's ability to push her baby out. So having "CPD" in 1 labor doesn't mean you will have it in all labors. I have a friend who had an unmedicated birth the first time and pushed for 3 hours before she consented to a c-section. Her 2nd baby came lady partslly... and was over 1 lb bigger!!!

Elvish, BSN, DNP, RN, NP · Oct 21, 2009

I have little to no faith in third trimester ultrasounds to estimate fetal weight, and it rankles me when docs try to use them to scare women into having c/sections.

Other than that, I can't add anything to what other wise folks have already said.