Birth after Shoulder Dystocia

[chocolatefish]

Hello all

I hope you don't lind me asking for your opinions / experiences. I am TTC while living in France with my DH and DS. I don't speak French well enough to ask any local midwives their opinions on this and am fretting a lot about it!

DS was born December 08 in NEw Zealand where, as you probably know, birthing is largely midwife led and normal birth is encouraged. Birth was 14 days overdue, the night before I due due for an induction. I laboured at home then in a pool at the hospital. I had my waters broken at around 7 cm after 'not progressing' for a while. I went back in the pool until I was about 9 cm. I got out (largely because I had used up the hosps supplies of portable G&A and needed to get to the piped supply in the delivery suite!). I continued to move around, use the shower, etc until fully dilated and told to push. By this point I was up on the bed. Well I pushed and pushed. After a short time DH and the MW were telling me that they could see DS head and it was virtually delivered... but then I just couldn't sustain the pushing and he slipped back in. I could feel this happening (boy could I feel it!), hand on his hair and everything but just couldn't get him out. After (I think) quite some time of this, an obs came and examined me and warned me that if he wasn't delivered in the next 15 mins or so, they would look at using ventouse to get him out. Everything is a bit hazy by this point as I was fairly knackered and disheartened. However I remember looking at my MW face and realising just how serious things were getting... so I gave it my all in when the next contraction came along. Next thing I knew the room filled with people, 2 MWs threw my legs back in the air while another pushed right down on my pubis (McRoberts and suprapublic pressure I am guessing?), MW cut a 2nd degree epis and performed Woods screw (?) manouver. At which point DS finally was born. He was slightly blue, but recovered very fast, and sustained no other damage. After his birth, I had a debrief with the MW. She's a seasoned professional, and has been in the business a long time but she looked truly shaken by his birth. And once she heard we were leaving NZ she made me promise that if I got pregnant again I absolutely had to tell the medics / MW that DS had been a SD.

So fast forward 2 years and we are living in France. Birth here is highly medicalised, epidurals are standard, monitors fitted on arrival, no pools, no moving freely and - unsurprisingly a high rate of CS. And a lot of weight is placed on maternal and baby size / weight measurements for 'allowing' a normal labour to proceed. ECS is readily recommended for large babies / small mums. DS was a lot larger than my NZ MW was expecting - 9lb 4oz. But there they don't even measure you or weight you through the pregnancy. I just hid it well I guess as I am tall.

What I am looking for your opinion on is whether to fight my corner for a natural birth after a SD, or whether I should go for an ECS? IF there had been no SD then no question, I would do whatever it took to have a normal birth. But the possible recurrence of the SD is really shaking me.

Seems crazy to be asking when not even PG but I like to tick boxes in advance! thank you so much for reading this far.

[shells_n_cheese]

I'm sorry, as I don't have any advice to offer, but I just wanted to say I totally understand. We had a SD during our homebirth. SCARY. DD needed resuscitation. I NEVER want to go through that again (and I am sure my DH would agree--as well as any future babies).

I am also planning on another child soon... I am also not sure if I would try another homebirth, go to the hospital, or just sign up for a c/s.

I am very interested in reading the responses as well!

[*EarthMama*]

I had shoulder dystocia with my first birth and found this reassuring in regards to repeat shoulder dystocia. It is actually not as likely as you would think...

"The rate of repeat shoulder dystocia in a subsequent vaginal delivery has been reviewed in six series and the risk of recurrence ranges from 1.1% to 16.7%. The average recurrence rate was relatively low at 10.1%."

I would personally go for the natural vaginal delivery.

[moonshoes]

I had this exact scenario with DS, age 6, complete with a post-partum hemmorhage (in a hospital with a midwife). I am due with baby #3 in 4 weeks and we are going for a homebirth this time. I feel the risk of this happening again is quite low, and I am confident my midwife will be able to handle it if it does happen. I am personally horrified by the idea that I should elect a C-section because of what "might" happen.

I am so sorry your midwife was so shaken (mine was too) and I am sure she is quite competent, but try not to let her reactions color you decisions.

I wish you the best of luck.

~Catherine

[sharr610]

I would try to track down a large ex pat group...maybe check with the embassy, the universities, or even churches. Find some other mamas that speak your language who have maybe given birth in country. SD or not, sounds like you will need someone familiar with the system, language and culture to help you make the best decision where you are.

Good luck, mama!!

[milansmommy]

My first DS had SD so I was very scared that it would happen with DS2 but it didn't. The big difference for me was with the first one I had an epi and was pushing laying down and with DS2 I had a natural drug free birth and birthed him on a birthing stool. DS1 was 10lbs 1oz and DS2 was 12lbs 6.5 oz. I really think being in the right position for my pelvis to open as wide as possible was extremely important. It's such a scary thing and that was my biggest worry throughout my pregnancy.

[clovergirl33]

It sounds like your SD may have been influenced by your position. Most SD can be prevented/resolved by upright/hands + knees position.

[shells_n_cheese]

Originally Posted by clovergirl33

It sounds like your SD may have been influenced by your position. Most SD can be prevented/resolved by upright/hands + knees position.

You tell this from her post? What position was she in that could have caused it?

[AlexisT]

All-fours does have a high success rate, but I'd be cautious about second-guessing an experienced midwife from a secondhand report. The OP didn't even say what position she was pushing in.

[Sweetiemommy]

Shoulder dystocia is more likely to happen again after it has happened once. It can be life threatening to the baby if the midwife isn't aware of how to deliver it properly. I can understand why the midwife would be shaken up, it is a do or die moment. Anyway, I had SD with my first two, they both had shoulders that measured larger than their heads! (My husband is a college athlete, 6'5 and big boned/muscular, I am 5'4 and 125 lbs, so it was kind of a mismatch, all three boys were between 9-10lbs). Anyway, the third baby came out fine, I pushed on my hands and knees, and the midwife did the Gaskin manuever (Ina May Gaskin learned it from midwives in South America). That's a good position for babies with big shoulders. And you have to push crazy HARD, which is easier if your birth isn't long and exhausting. My first two labors were ridiculously long, but the third was short and I had plenty of energy for pushing. So despite the fact that his shoulders measured just a big as my first, I guess there was more room down there by number 3. LOL. Anyway, you'll be fine, just find a good midwife who knows what she's doing before you have the next one!

[Lisalee2]

Originally Posted by chocolatefish

Next thing I knew the room filled with people, 2 MWs threw my legs back in the air while another pushed right down on my pubis (McRoberts and suprapublic pressure I am guessing?), MW cut a 2nd degree epis and performed Woods screw (?) manouver. At which point DS finally was born.

Just read through this thread, and noticed that the OP did state basically what position she was in. I'm assuming with this statement that she was lying down with her legs back in the air, right? From what I've read and heard, all fours or squatting is beneficial in this situation. If it were me, I'd try a natural birth again.

[shells_n_cheese]

Originally Posted by Lisalee2

Just read through this thread, and noticed that the OP did state basically what position she was in. I'm assuming with this statement that she was lying down with her legs back in the air, right? From what I've read and heard, all fours or squatting is beneficial in this situation. If it were me, I'd try a natural birth again.

I really don't want to nitpick this woman's story, but I have to respond.

Based on her story, I don't know if she was laying flat on back while pushing before SD happened, but I do know the maneuver she was describing (legs/knees up towards chest) is called McRoberts. It is used to resolve SD. During our SD, we actually tried the Gaskin (all fours) but it didn't work. We tried it numerous times--it just didn't work. What DID work was McRoberts. That's when she finally came out after 4 minutes.

[loveneverfails]

Originally Posted by shells_n_cheese

I really don't want to nitpick this woman's story, but I have to respond.

Based on her story, I don't know if she was laying flat on back while pushing before SD happened, but I do know the maneuver she was describing (legs/knees up towards chest) is called McRoberts. It is used to resolve SD. During our SD, we actually tried the Gaskin (all fours) but it didn't work. We tried it numerous times--it just didn't work. What DID work was McRoberts. That's when she finally came out after 4 minutes.

THANK YOU. All fours doesn't work for everybody! It's not the magic bullet that always fixes SD, and I'm extremely wary about how the danger of SD can sometimes get blown off with a simple "just get on all fours, and it'll fix itself!" Standing and then down to a full squat worked for me with one dystocia, McRoberts worked with a different one. In neither situation did the all fours position work for me. You're talking about a bony impaction, and there isn't going to be one remedy.

To the OP, I would absolutely raise the past dystocia issue with future care providers, but I would still plan for a natural birth. Things that I have found helpful include physical therapy to stabilize the pelvis (a sacrum that keeps rotating can't swing back properly) and see if dietary changes may reduce your baby's size. For some women, this would mean reducing sugars. For me, I actually minimized protein in the 1st trimester and my fundal height measurements for this pregnancy are right on track instead of 4-6cm ahead like they were with my 10 and 11 lbers.

[Lisalee2]

Y'all obviously know more about SD than I do.

[wombatclay]

I had SD with my second babe (first vaginal birth). The SD "hit" while I was in a squatting position, the Gaskin and McRoberts didn't work (I was med free, my OB actually trained with Ina... she's in Ina's book as a "midwife in disguise"). Eventually my OB reached in, twisted/pulled, and dd2 was born. She needed massage and air, and they left the cord intact while putting me on oxygen too to get as much oxygen rich blood as possible into dd2. She recovered, and there was no nerve damage, but she has some special needs that may have been caused or worsened by the oxygen deprivation. We'll never know if the SD played a role.

I did a LOT of research into SD... a vbac following SD and a 4th degree tear makes most care providers a bit nervous! I eventually decided that I wanted to try for another vbac, but I wanted to be in a hospital with all the bells and whistles. I had a midwife, I used the birth ball and pool, I delivered side lying... and while he was sticky and needed a little wiggling to get out there was no repeat SD. But it was just about my biggest fear during the whole pregnancy.

Although it's a "commercial" site (they're working on SD diagnostic software), there is a ton of information, including relevant studies, here. I'd suggest reading as much as you can, making sure your partner and any birth support you might have is familiar with as many SD resolution techniques as possible, and then deciding where your comfort zone is. I felt ok with a trial of labor with the assumption that if my birth started to follow the pattern of my SD birth then we'd move to a c/s. So, for example, I told everyone that if I'd been pushing for 2 hours and there wasn't much happening then I wanted to move to the c/s (I pushed with urge for roughly 4 hours before the SD).

Since you're not yet pregnant you have the time to do the research and find that comfort zone... in my case I felt like I was juggling the known risks of a c/s with the possible risks of an SD. And I felt ok taking things slowly, planning on a vbac but having limits in place for moving to a more medical birth. Other mamas make very different decisions. But given that a previous SD is the ONLY positive indicator of future SD risk, it's a good thing to think about and make peace with.

I'm sorry you're facing this future stress, and hope you can find a supportive care provider!