Doesn't "everyone know" that lithotomy is narrow?

[Youngfrankenstein]

I have a huge flag in my OB folder shouting "Shoulder Dystocia" from the birth of my second son. I am on baby #4 now. My homebirth midwife (I'm doing parallel care) said from what I described during labor and how they just "moved my legs" I really didn't have a true dystocia.

Considering I was induced, had an epidural, and was in the lithotomy position during pushing and he came out in 20 mins or so and was 9# 14 oz, I agree with my mw about it not really being a big deal.

Yesterday, my CNM was saying "they'd" do an ultrasound at 39 weeks and offer me a prophlactic C-Section because I have big babies and it's their policy to do so.

I asked her to look at the birth notes and she read what the other CNM wrote back then and it was as I described. I also said "Well, I was on my back."

She didn't say anything or change her opinion at all. From all of the birth literature I've read, "everyone knows" that lithotomy is the narrowest position of the pelvis. So why can't she see that this "shoulder dystocia" really was not a big deal.

If you didn't read my rant yesterday, she said, "Well if the baby's head comes out and the body can't, it's horrible."

What gives?

[nashvillemidwife]

Are you talking about true lithotomy position (feet in stirrups) or McRoberts (legs flexed back)? McRoberts actually produces the widest diameter of the pelvis, and is easily facilitated by lithotomy since it only requires someone to lift your legs out of the stirrups and push them back.

[Youngfrankenstein]

Feet were held in a stirrups position. I've read the the hands and knees or squatting were much wider. Obviously you know more than I do about it. I guess I'm just saying it doesn't seem like a panic situation and he came out fine.

[nashvillemidwife]

But you said they moved your legs to get the baby out? All positions will provide adequate room in the pelvis to birth most babies; the thing about lithotomy (in this case) is that even though the feet in stirrups may not be widest, it is very quick and easy to change you to McRoberts, which is the widest. If you have a dystocia in hands and knees, for example, it would be slower and awkward to flip you into a squat or McRoberts.

I'm not saying it's best to birth on your back - far from it! But the CNM is right about it providing more room to birth a big baby. Squatting is also effective but requires more effort on the part of the mom and her supporters and is very awkward on a hospital bed.

[AlDente]

I'm not an expert, but I agree with you. It sounds like if you were in a different position, the baby would have come out much easier. I didn't read your previous post, but it sounds like your midwife is not very supportive of normal childbirth.

Of course, if you stay with that practice, you can always refuse the "offer" of a c-section and even the 39 week ultrasound.

But if I were you, I'd be looking into other options. I wish you the best!!!!

Hugs!

[Astraia]

Well, you started in lithotamy = narrow passage
Then when it became apparent that baby's shoulders were a bit sticky, they pushed your legs back to help open your pelvis more (mcroberts) and the stickiness was relieved.

Chances are in another position the shoulders never would have stuck at all.

So yes, I would say that that wouldn't count as a "true" distocia (although there is some debate in medical circles as to how many procedures you need to do in order to count it as a TRUE discotica). I'm not a professional... I just read a lot :P


Your midwife seems pretty hard-headed. Yes, if the head comes out but the body can't it is horrible. Your last baby was not a situation where the body *couldn't* come out, so really she's jumping to conclusions and throwing the worst-case stuff at you.

[Youngfrankenstein]

Originally Posted by Astraia

Your midwife seems pretty hard-headed. Yes, if the head comes out but the body can't it is horrible. Your last baby was not a situation where the body *couldn't* come out, so really she's jumping to conclusions and throwing the worst-case stuff at you.

He was 2 babies ago. My last one was 1# less and there were no problems whatsoever. I don't think she personally thinks I should have a section, I think she's just going with the party line and I get annoyed when I'm treated like a cow in a feed lot.

If she truly felt I was in "danger" (or any hcp)-tell me the stats...what are the chances? What are the risks of Section, etc. They never go there, they just play the emotional cards.

[mysticmomma]

Just because it's widest doesn't mean its the best for that baby and that mom at that time.

[nashvillemidwife]

Originally Posted by Astraia

So yes, I would say that that wouldn't count as a "true" distocia (although there is some debate in medical circles as to how many procedures you need to do in order to count it as a TRUE discotica).

Quality, not quantity. It's the manner in which the maneuvers were performed. A true shoulder dystocia requires the practitioners to physically unhinge the shoulder from behind the pubic bone. If the baby is birthed without that manual assistance then it wasn't really stuck.

Originally Posted by mysticmomma

Just because it's widest doesn't mean its the best for that baby and that mom at that time.

True, which is why I never said that.

[mysticmomma]

No, you didn't!

[Youngfrankenstein]

Originally Posted by nashvillemidwife

Quality, not quantity. It's the manner in which the maneuvers were performed. A true shoulder dystocia requires the practitioners to physically unhinge the shoulder from behind the pubic bone. If the baby is birthed without that manual assistance then it wasn't really stuck.


.

Do you mean they would put a hand in and do it?

[nashvillemidwife]

Not necessarily reach a hand inside, but moving a truly impacted shoulder is going to require more effort than moving your leg.

[Astraia]

Originally Posted by nashvillemidwife

Quality, not quantity. It's the manner in which the maneuvers were performed. A true shoulder dystocia requires the practitioners to physically unhinge the shoulder from behind the pubic bone. If the baby is birthed without that manual assistance then it wasn't really stuck.

Now I'm confused. I can't tell if you're disagreeing with me (which I'm totally OK with!) or just expanding on what I said/ clarifying what I wasn't sure about.

[frontierpsych]

Originally Posted by Youngfrankenstein

Do you mean they would put a hand in and do it?

Both my first baby (stillborn due to SD and cord compression) and my second baby (required my midwife to reach in both hands and dislodge his shoulder) were born this way.

ETA: My first was delivered by paramedics in McRoberts position after failing to budge in any other position (standing, squatting, reclined, hands and knees, etc), my second was born in water with me on hands and knees, after my midwife moved the shoulder)

[nashvillemidwife]

Astria, I'm not agreeing or disagreeing with you, just stating facts.

[Astraia]

Originally Posted by nashvillemidwife

Astria, I'm not agreeing or disagreeing with you, just stating facts.

Just to clarify your earlier statement- would this be things like moving mom into more than one position? Because there seems to be a lot of position possibilities that you can try before going in with your hands to help disimpact the shoulders.

I just don't really understand where the line is drawn for sticky VS. SD

I'm not trying to come off as confrontational, but I feel like it reads that way...I just don't know how to fix it!

(this is not for any real reason, just to firm things up in my mind)

[nashvillemidwife]

Originally Posted by Astraia

Just to clarify your earlier statement- would this be things like moving mom into more than one position? Because there seems to be a lot of position possibilities that you can try before going in with your hands to help disimpact the shoulders.

I said that resolving a true should dystocia does not necessarily require putting your hands inside. In a shoulder dystocia, the baby's shoulder is impacted against the mom's pubic bone. Visualize is in your head. Large movements of the mother's pelvis, such as flipping her from front to back, could cause the pelvic bone to shift enough to release the shoulder. Simply moving her leg is not likely to have that effect; if it does, the shoulder was not impacted, it was just impeded. Some argue that if the problems resolves with position changes at all, it was not a true dystocia. I don't think that's necessarily true, but it's going to need to be a drastic position change.

[Astraia]

Originally Posted by nashvillemidwife

I said that resolving a true should dystocia does not necessarily require putting your hands inside. In a shoulder dystocia, the baby's shoulder is impacted against the mom's pubic bone. Visualize is in your head. Large movements of the mother's pelvis, such as flipping her from front to back, could cause the pelvic bone to shift enough to release the shoulder. Simply moving her leg is not likely to have that effect; if it does, the shoulder was not impacted, it was just impeded. Some argue that if the problems resolves with position changes at all, it was not a true dystocia. I don't think that's necessarily true, but it's going to need to be a drastic position change.

Ok, I get what you're saying now. I don't know why that had so much trouble getting into my head.

Thanks for the clarification!

[Youngfrankenstein]

That makes sense. And it makes me feel better.

[nashvillemidwife]

Glad I could help.