Academic staff , nasibeh faculty of nursing and midwifery , Sari,University Mazandran Iran

Abstract

In case of appearing macrosomia , the amount of death as well as maternal fetal and neonatal damages will be increased. As some researchers recommend cesarean for improving macrosomia periantal outcome , the aim of research is to evaluate the proportion of this proposal . In this case control research , 5440 child- birth files have been studied in 1997.

The case group was consisting of mothers having more than 4000 grs weight neonate and control group was consisting of those mothers having 2500-3999 grs weight neonate .

All imperfect files and those child birth having below 37 weeks pregnancy duration were liad aside . The amount of caesarian for 5000grs weight and upper was 100% , in 4500-5000grs 33.3% and for lower than 4500 grs was 20.2%.

The total caesarian in macrosomic group was 22.5% in comparison with 15.7% in control group . The most important reason for caesarian in macrosomic group was failure to progress and fetal distress and in control group failure to progress & C . P . D.

In 2.8% of vaginal child–birth of macrosomia group , shoulder dystocia has happened among which 0.9% ( two cases ) was brachial plexus paralysis .

Fetal distress was also observed in 26.9% of cesarian child–birth of macrosomia group . While studying the results , we can say that none of the maternal–neonatal complications in vaginal child- birth group of macrosomia will be increased to 4500 grs in comparing with caesarian group .

So vaginal child–birth in contrary with cesarian , for fetus having below 4500grs is considered an alternative and the chance of testing labour can be offered to the mothers .

Key words : macrosomia controlling child – birth , maternal- infant complications.

Introduction

Macrosomia is called to those neonates having 4000 grs weight or more . Several studies were carried out in order to determine method of delivery in fetals macrosomia . Some of the researchers had recommended freely use of caesarian for terminating pregnancy in removing macrosomia (1,2).

The main reason for selecting cesarian is to prevent shoulder dystocia as well as resulted complications (3 ,4 ).

But since shoulder dystocia and damaging brachial plexus is not generally predictable (4,5 ) , and in case of appearance is temporary in most cases and mendable (6,7 ) , so some other researchers recommend testing vaginal child - birth for mothers having fetal macrosomia (5,8) .

Specially , according to some reports , increase of cesarean in recent years , have not only improved perinatal outcome , but also it is not suitable as routine for these cases (9,4) . Therefore , more studies on method of child - birth and complications due to macrosomia should be carried out ( 3 ).

So , the aim of present study is to evaluating method of delivery in macrosomic neonates .

Method of study

This research is in form of case control method and retrospective . The studying society was consisting of 5440 files of those women referred to Imam khomeini Hospital for child – birth in 1997 . All files related to mother and fetal macrosomia were evaluated , then after laying aside those imperfect files , other cases were studied .

Among the files , 476 cases of control group were selected randomly among those women had 2500-3999 grs weight infant as well as perfect file.

All child–birthes having below 37 weeks age were laid aside . Repeated caesarian factors as well as presentation , age and parity was matched between two group. The studying factors were , method of child–birth and reason for cesarean and maternal-neonatal complications.

Groups data were separately analyzed . For statistical calculations , spss software , for quantity variables T test and for quality variables x test are used .

Results

The number of fetal macrosomia was 232 cases ( 4.3% ) among which 162 cases ( 70% ) were male infant . Studying method of child–birth shows that cesarian is carried out for 52 persons ( 22.5% ) from macrosomic group in contrary to 73 persons ( 15.7% ) from control group . The amount of delivery by instrument was 4 persons ( 0.8% ) in control group and no by instrument child–birth was carried out in macrosomic group. The amount of cesarian for 5000grs weight and upper was 100% , in 4500-5000grs 33.3% and for lower than 4500 grs was 20.2%.

Comparing the method of child – birth in both show meaningful difference ( P< 0.03 ) .The reason for cesarian is mentioned in table 1 . In macrosomia group 4 persons ( 12% ) had elective cesarian among unrepeated caesarian . Others are given the chance to test labour .

Table 1 : studying the reason for caesarian in macrosopmia and control group

The reason for caesarian Child – birth	Macrosomia		Control
	number	Percent	Number	Percent
Repeated cesarian	19	36.5	32	43.9
C P D	6	11.5	9	12.3
Fetal distress	12	26.9	18	24.1
*Lack of progress	9	17.3	5	6.8
Abnormal presentation	3	5.8	5	6.8
Thick meconium	1	2	4	5.5
Total	52	-	73	-

* There is a meaningful difference between two group ( P < 0.03 ) .

Studying the fetal complications show (table 2) that appearing shoulder dystocia as well as meconium defication in macrosomic group are those complications which have meaningful difference in control group . Among 6 cases ( 2.6% ) of shoulder dystocia , 2 cases ( 0.9% ) were accompanied by brachial plexus paralaysis and 1 case ( 0.05% ) with clavicle breaking .

Neonatal death was not observed in macrosomic group too .

Table 2 : comparing the fetal – infant complications in macrosomia and control group

Complications		Macrosomia		Control		pvalue
		number	Percent	number	percent
Fetal distress		19	8.3	25	5.5	NS
Meconium defication		28	12.1	35	7.4	P < 0.0538
Meconium aspiration		2	0.9	5	0.1	NS
Apgar score Below 7	Minute 1	8	3.4	15	3.2	NS
	Minute 5	1	0.4	8	1.7	NS

Studying maternal complications (table3) showed that there was no maternal death in macrosomic group .

Table 3 : comparing maternal complications in macrosomia and control group

Complication	Macrosomia		Control		pvalue
	number	Percent	number	percent
Labour acceleration	68	38.2	121	30.4	P < 0.001
Labour induction	2	1.1	39	9.8	P < 0.05
Vaginal tearing	26	11.3	45	9.5	P < 0.05
(P.P.H) postpartum hemorrhage	7	3.1	5	1	P < 0.05

Comparing maternal-neonatal complications between vaginal child–birth and cesarian in macrosomic fetus shows that there is postnatal bleeding (3.8% ) , shoulder dystocia 3.4% (6 cases ) , clavicle breaking 1 case ( 0.6% ) , brachial plexus paralysis 2 cases ( 1% ) just in vaginal child – birth . At the same time , there is no meaningful difference between vaginal and cesarian child - birth from the complications view . Moreover vaginal tearing has happened in 26 persons (14%) of macrosomic group by vaginal child-birth. Prenatal asphyxia was found just in one person of macrosomic group had vaginal child-birth other complications are mentioned in table 4 .

Table 4 : comparing maternal – infant complications between vaginal and cesarian child–birth in macrosomic neonates

Complication		Vaginal Delivery		C/s Delivery		pvalue
		Number	Percent	number	Percent
Fetal distress		5	2.8	14	26.9	P < 0.05
Meconiumi defication		20	11.1	8	15.4	NS
Apgar score Below 7	Minute 1	8	4.4	-	-	NS
	Minute 5	1	0.6	-	-	NS

Discussion

One of the propose of this research is making decision about the method of macrosomia infants child - birth . Main reason for selecting cesarian is to prevent shoulder dystosia and resulted complications ( 10 , 11 ).

But since shoulder dystocia and damage to bracial plexus is not precisely predictable ( 4 , 11 ) and if it happens will be temporary and amendable ( 12 , 15 ) , So most of the researchers recommend to test vaginal child-birth for mothers having fetal macrosomia ( 13, 4 ) . In this research , the amount of cesarian in macrosomic group was almost 1.5 times more than control group ( 22.6% ) in contrary to 15.6%. Klimberly (1998 ) , in his study reported cesarian 26.4% (10 ).

Ziel and Parks mentioned the amount of cesarian 22.5% and 9% through instrument child-birth ( 8% low forceps and 1% mid forceps ) (6) .

In the contrary spellacy and Berard have mentioned the amount of cesarian 33.8% and delivery by instrument 36% (14,15) . In recent studies , the reason for high amount of cesarian are as follows :

1 ) the studied infants weighed more than 4500 grams were selected .

2 ) The amount of diabetics or fat mothers are high in the research . On the other hand , Mikulandra and Nixon ( 1998 , 1996 ) have mentioned the amount of cesarian 7.2% and 11.2% .

The reason for lower amount of cesarian in both researches is that first they have used by instrument child-birth ( forceps and vantose ) more , and second less complication mothers have refered to these centers (9). In this research unfortunately for controling macrosomia child-birth no by instrument vaginal method was used . In most researches the amount of by instrument vaginal child-birth was reported from 3% to 11% . (14 , 9 )

In some studies , the amount of using vantose was two times more than forceps ( 17 , 9 ) . Some of them never used vantose ( 3, 14 , 6 ) .

In the research , 100% of mothers had 5 kg or more infant had cesarian section for the delivery of fetuses . An elective cesarian section was recommended by Kimberly , Berard and Oleary (15,10 ) . Berard believs that since we may have 10% fault for estimating fetal weight , it is logical to operate cesarian those fetals estimated to have more than 5 kg weight . This causes reduction of perinatal damage then may not increase the amount of cesarian ( 10 ) .

Another problem is comparing the complications of cesarian and vaginal child-birth in macrosomia group . The complication which showed meaningful difference between both groups was fetal distress . It was 9.6 times more than vaginal child - birth . If making decission for cesarian is too late , the amount of aspiration meconium and severe asphyxia will increase in cesarian in comparison with vaginal child-birth ( 3 ) .

Since the obove mentioned complications have not increased in cesarian group , so it seems that fetal distress is the reason for cesarian rather than its complication .

In the contrary , concerning vaginal tearing in vaginal child- birth , it should be mentioned that 1 case of cervical tearing and 25 cases of perineal and vaginal tearing were observed which easily amended and no special clinical problem left for the patients. Berard and Rodriguez have mentioned vaginal tearing 11% and 9% in vaginal child - birth of macrosomia in which all cases were amended without any complication (18,15 ).

In present study , the total shoulder dystocia was 2.6%. Rodrigues ( 1996 ) mentioned it 2% (18 ) and Gonen ( 1996 ) 2% (7 ) as well . In this research , none of fetal distress , meconium aspiration and asphyxia increased in macrosomia group in contrary to control group .

According to Meshari’s report ( 1990 ) , the amount of asphyxia was 0.7% and had no difference with control group ( 16 ) . Berard ( 1998 ) had emphasized on this finding .

Concerning the maternal complications , the results of studies showed that , like other studies despite less increase of some complications , no death or serious complication observed in this group (11 , 9) . postnatal bleeding in macrosomia group of present study is 3 times more in contrary to control group .

While studying the results , we can say that none of the maternal–neonatal complications in vaginal child- birth group of macrosomia will be increased to 4500 grs in comparing with cesarian group .

So vaginal child–birth in contrary with cesarian , for fetus having below 4500grs is considered an alternative and the chance of testing labour can be offered to the mothers .

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