Shoulder dystocia with 1st baby. Will it happen again?

[lsmama]

Hi all. I delivered my daughter (now 3) naturally in a midwife-attended hospital birth. She got stuck pretty badly but thanks to the dexterity of my fabulous midwife, she arrived safe and sound. Blue, a bit banged up, with low apgars, but fine. No NICU needed, we went home on time and that was that. She was born at 39 weeks and weighed 8.10.

Now I'm pg with #2 and using the same midwife who I really do like and trust. She offered me the option of scheduling a C-section b/c there seems to be a 25% recurrence rate for shoulder dystocia. I refused that up front and I think I am ok with our compromise plan - - ie. we make a determination once I hit 38 weeks based on u/s and fundal measurement. I have followed her advice of starting low (in terms of my weight) and staying low (in terms of weight gain). I started about 10 lbs lower than I did with DD and have only gained 8 lbs so far and I have just hit 20 weeks. That said, I stayed quite fit with DD and gained 30 lbs so it's not like my weight gain with her was insane.

Anyway, sorry for the novel, but I am looking to hear from anyone who had shoulder dystocia with #1 but went on to have a successful natural birth/healthy baby with #2. I would also love to hear from anyone who heard similar info to what I am hearing and ended up with a C. I am trying to stay open minded but clearly will do anything I can to fight hard for a natural birth without being foolhardy.

Thanks!
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[lovebeingamomma]

My initial reaction to your post is I think it's a very bad idea to be restricting calories so a baby will be smaller, no matter what the reason that just doesn't sound good. I've never heard of a midwife prescribing something like that. The c-section is completely up to you but with just a 25% chance that it will happen again for me personally I would go natural again, as I think with a good midwife and proper positioning during pushing it shouldn't be a problem. My two cents.

[shells_n_cheese]

I also had a SD with my 2nd baby (1st was delivered by cesarean), at home. My DD was stuck for a while, needed resuscitation, had low apgars, and had an injury to her shoulder (brachial plexus) but that thankfully resolved fully on its' own (she is now 17 months).

We plan to start TTC our third child next year... and I am already a little worried about the next birth. I do not want to go through that again, and I am sure the baby wouldn't either. I have not heard of the 25% rate of recurrence that your MW quoted though, I have always heard 10%-12%. That's much lower.

I think it's great that you are open-minded to how the birth may play out. I think I will also be touch-and-go too, and if I have an u/s that shows the baby is really, really big and/or my gut feelings about it at the time say a VB will not be best, I will go with a c-section with no regrets.

It sucks that we have to make these choices.

I'm sorry that I don't have advice to offer you... just wanted to say you aren't alone. Congrats on your pregnancy, BTW!

[shells_n_cheese]

Originally Posted by lovebeingamomma

The c-section is completely up to you but with just a 25% chance that it will happen again for me personally I would go natural again, as I think with a good midwife and proper positioning during pushing it shouldn't be a problem. My two cents.

I don't think 25% is the right number for a recurrence of SD, but for arguments' sake, I don't think a 25% chance of something possibly life-threatening happening is low at all. If that's the case, then there shouldn't be an issue with a 25% c/s rate, as it's "just" 25%.

And, again, I am tired of people brushing off true SD with the statement, "just a position change, and it shouldn't be an issue". I see that a lot here. SD is not only about what position the mother is in when pushing. True SD happens at home too, when a mother is upright and in all the "right" positions, with a "good midwife". It happened at home to me and my DD.

[mmaramba]

Now this is very much my personal opinion, but I... would feel uncomfortable with a MW who seriously offered me the option of an elective C, tried to get me not to gain "too much" weight and had a compromise plan that involves her assessment of how big she thinks your baby is (I'd bet you'll be "measuring big"). Note that I'm not sayiing she'd lie to you, just that weight assessments are very unreliable and when you're a hammer, everything looks like a nail.

A lot of true SD occurs in non-macrosomic babies (like your first)... It sounds like she is genuinely nervous about dealing with another SD with you, and I do understand that. But her POV seems on the whole big baby/SD thing seems... "off" to me. Ensuring better positioning cannot GUARANTEE no SD (as shells said above), but it's a better bet than trying to make your baby smaller (I can't see how even half a pound is likely to make a huge difference).

I'm concerned that even if you continue to push for a NCB, she'll want to induce before baby "gets too big," etc., and that in and of itself is more likely to lead to poor positioning, or "FTP," etc.

You know your MW and your gut better than I do, but from what you described, she's not someone I'd feel comfortable with, though I think it's wonderful that she was so dextrous and helpful for you in your first birth. Best of luck!

[lsmama]

Thanks everyone. I know, it's just a really tough call. I am in no way "restricting calories" just trying to make sure all of my calories are coming from high quality sources and avoiding processed foods and sugars. I'm also continuing with running during my pregnancy which I wasn't doing with DD. I would hate to suggest that I'm somehow starving my baby. I am a healthy weight and all of my scans suggest that my baby is thriving.

It's so tricky, and I really don't know what to do. I assume I could try a 2nd opinion with another OB or M/W, though with my history I do wonder how their approach would differ from my current m/w's. I guess it can't hurt to check. On a purely practical level, I do love the practice and have had great experiences with the OB who would be the one doing the c/s if it came to that. There's something to be said, I think, for feeling comfortable and trusting the team.

Ugh. I hate the murkiness of the situation. I totally feel like it's going to be a gut-based judgement call in the end and, my luck, I will totally be that woman who they say is going to have a 10 lb baby and will end up with a c/s and a 7lb kid. However, like a pp said, I feel like 25% is nothing to scoff at. If anyone has access to different stats or more recent studies on recurrence, please pass them on.

Thanks again!

[lovebeingamomma]

Originally Posted by shells_n_cheese

I don't think 25% is the right number for a recurrence of SD, but for arguments' sake, I don't think a 25% chance of something possibly life-threatening happening is low at all. If that's the case, then there shouldn't be an issue with a 25% c/s rate, as it's "just" 25%.

And, again, I am tired of people brushing off true SD with the statement, "just a position change, and it shouldn't be an issue". I see that a lot here. SD is not only about what position the mother is in when pushing. True SD happens at home too, when a mother is upright and in all the "right" positions, with a "good midwife". It happened at home to me and my DD.

Shoulder Dystocia rarely causes death, just like c-sections rarely do. Most cases are resolved by better positioning, and yes, a good midwife can make a difference. I weigh the risks on either side and I said what I would do personally. I said it shouldn't be an issue, just like I confirm people who are having c-sections that it should be fine, even though I know there's a chance it might not be. 25% chance of it happening does not mean a 25% chance of it being a big problem. I never say 100% everything will be fine, just like I don't tell people what to do, as I was clear in my post "it's completely up to you".

And to OP: I've read up a lot on pregnancy diet and the importance of gaining enough in the first 2/3 of a pregnancy so that's the only reason I mentioned it sounding like an odd suggestion, I know no one would try to starve their baby on purpose.

[Carlyle]

It's such a scary position to be in, isn't it? My first was stuck for a while too, with "turtling" after her head was born and quite a wait before we were able to deliver her body (at the hospital) and I was definitely worried about it happening with my second. My first was 10 pounds 7 ounces, and my second (just born!) was 11 pounds 2 ounces despite the fact that I am fairly small and I didn't gain excessive weight with either pregnancy. My second was a tiny bit sticky on the way out, but nothing like my first (to me it felt like my second just slid right on out, but my mw said she felt a little sticky). With your first birth, what maneuvers/positions did they try in order to get your baby out?

I did a bunch of research after my first was born and realized that although the doctor who was there did a bunch of stuff, it was really quite rough and there may have been other techniques that would have worked better without requiring such a rough start.

Here is a great website that helped me both in coming to terms with birthing vaginally again and in evaluating my mw's qualifications in dealing with dystocia: http://shoulderdystociainfo.com/shoulder_dystocia.htm I especially found bullet #10, where they detail the techniques, very useful. I felt that knowing these techniques and their effectiveness helped me feel much better about dealing with a dystocia even if it did happen again. I also really quizzed my mw about her dystocia procedures during our interview. She mentioned each one of these techniques listed and told stories about her multiple, multiple experiences in dealing with dystocia. She seemed very comfortable and relaxed about dealing with it while at the same time treating it with the seriousness that it deserves.

BAH--they've changed the article since I read it 4 years ago! It used to list the Gaskin maneuver (which they now call "the all fours") as one of the main techniques, but are now presenting it as a fringe midwifery thing that is isn't practical (since most women will have an epidural and won't be mobile enough to get on all fours) DESPITE the fact that it was the most effective of ALL the maneuvers that they listed (82% effective!). Idiots.

Also, here is what the article says about recurrence of shoulder dystocia: "It appears from the literature that the risk of recurrent shoulder dystocia is substantial: 10 to 15%. Moreover, women who have had a shoulder dystocia delivery that resulted in injury to the fetus have an even greater risk of having a recurrent shoulder dystocia and subsequent fetal injury." So not as high as the 25% chance your mw listed, but not as low as the general population, which this article lists as .5% risk.

However, they also say "The bottom line is this: In the past, nowhere in the literature were there studies that showed that the sensitivity or positive predictive value for predicting shoulder dystocia was high enough to justify obstetrical interventions in hopes of avoiding it." So scheduling a cesarean (which has its own risks) to avoid sd wasn't recommended as far as I can tell.

But there's apparently some brand new technology that can help predict it??? That's new stuff that's up there since I read this article back in 2006. Here's what they write: "As mentioned above, there is new research that has linked maternal size and fetal weight to the risk of shoulder dystocia. In addition, Dr. Emily Hamilton and her team of researchers in Montreal have developed a tool, based on sophisticated statistical and mathematical analysis of large numbers of shoulder dystocia cases, that can identify the majority of those mothers and fetuses destined to experience a shoulder dystocia.

The factors involved in this analysis of risk are maternal height, maternal weight, parity, gestational age, baby’s estimated weight, and maternal history of gestational diabetes or previous shoulder dystocia. Dr. Hamilton’s formula has been tested against several large independent samples of patients who had experienced shoulder dystocia with permanent injury. The data—some already published, some in the process of submission—shows that it is possible to consistently identify 50-70% of patients destined to have a shoulder dystocia with a false positive rate (rate of additional cesarean sections) of only 2.7%. (Dyachenko, Hamilton 2006)

Dr. Hamilton’s shoulder dystocia risk prediction tool has been commercialized into a web-based application by LMS Medical Systems and labeled CALM Shoulder ScreenTM (patent pending -- see www.lmsmedical.com)."

Anyway, sorry for the novel. Good luck with your decision.

[Carlyle]

I agree with pp that 25% is a scary # (even though the article I posted lists it as 10-15%, that's still pretty scary to me). But I also agree with the research I posted which says that in many cases, sd can be resolved without injury.

One thing that my mw suggested trying in order to keep the baby from becoming large was cutting out milk and ice cream in the last 2 months of pregnancy (although it doesn't sound like your baby was excessively large?). She said that in her experience, if the mom doesn't have gestational diabetes, a hidden milk allergy can contribute to making the baby larger. Wasn't the case in my situation (I tried cutting out milk and ice cream and still ended up with a larger baby!), but my friend who also had a 10 1/2 pound baby first time around did try this and ended up with an 8 pounder the second time (she also cut down on cheese and other dairy products though and I did not). I agree that cutting out sugar and processed foods is a great idea (for all moms, but especially ones concerned about larger babies).

I think a second opinion might help set your mind at ease. My mw was definitely comfortable with having a home birth with me depite the previous dystocia, so there are surely other approaches/opinions out there. You'll just have to decide what you're comfortable with and be willing to forgive yourself for any unintended consequences of that decision (vaginal birth OR cesarean). Ultimately, we can only do the best we can--there are no guarantees--and your decision will be made from love.

[77sugaree]

I had SD with my 2nd and I asked the nurse if there was a chance it would happen again (I am currently pregnant with my 3rd) she said that just because it happens once does not mean it will happen again. She didn't give me any stats or anything though.

[loveneverfails]

No advice for the OP, but I did want to let you know that while regular ultrasound is wildly inaccurate for weight at term, 3d ultrasound is evidently NOT having the accuracy problems with regards to weight. What I've heard is that it's generally accurate within 5% in either direction, so that might be a really good option for you once you're at 38 weeks and talking weight estimates.

Would you mind sharing a little bit more about how your overall labor and pushing phase was? Do you know how your baby was positioned?

[lsmama]

Carlyle - Thanks so much for that wealth of information. I think I will pursue a 2nd opinion, just to have some more context and to have a framework for evaluating my current mw's stance. . I will also look into that prediction tool which sounds fascinating. I will share it with my mw at my next appt. as well.

Thanks!

[lsmama]

Originally Posted by loveneverfails

No advice for the OP, but I did want to let you know that while regular ultrasound is wildly inaccurate for weight at term, 3d ultrasound is evidently NOT having the accuracy problems with regards to weight. What I've heard is that it's generally accurate within 5% in either direction, so that might be a really good option for you once you're at 38 weeks and talking weight estimates.

Would you mind sharing a little bit more about how your overall labor and pushing phase was? Do you know how your baby was positioned?

Thanks for the info on 3D u/s. I will be sure to have one of those at 38 weeks. My labor with my 1st began when my water broke at 2 am. I did not feel a single contraction for the rest of the night or well into the next day. I went in for an appt with my m/w at 4pm and I was 6 cm. She sent us home, told us to have dinner, and that she expected to see us soon. By the time I got home, I was having contractions 2 - 3 min. apart and moved quickly into transition within about 40 mins. . We got to the hospital and I was 9cm. It was back labor the entire time - never felt anything in my uterus. I labored on hands & knees over a birth ball at home, on the way into the hospital. I labored on the toilet at the hospital, on hands and knees, and ultimately (I think) on my side with my doula and DH holding my leg. DD was posterior and I pushed for 2 hours. I believe DD was turtling and shoulders would not deliver. mw went in and rotated her. I don't know all of the technical terms for all of this stuff, sorry!

[~Heidi~]

Thank you for sharing, sounds like a tough labor.

Ismama, my first birth was a traumatic shoulder dystocia. My baby's collarbone broke in the efforts to deliver her. Today, she is a happy, healthy 17-yr-old.

I have gone on to deliver vaginally 5 more times (the last being my first homebirth), and I have not had another case of shoulder dystocia. All of my babies are big, the last was 10lbs4oz. Almost all of my babies have been posterior.

I think you are making a wise decision in getting a 2nd opinion.

[Fly Girl]

I had a true shoulder dystocia with my first DD at home. Changing positions didn't resolve it and my midwife had to reach in and was able to pull her arm up and out which released her shoulders. She was 8lbs even. Not a huge baby but bigger than we expected. She was stuck for about 4 minutes but actually came out just fine with apgars of 7 and 9.

DD2 was born 4 months ago at home with my same awesome birth team. My labor was super fast and my body pushed her out in 3 contractions. No shoulder dystocia this time!!!!! She was 8lbs 3oz and the same length as DD1, so practically the same size.

So no, if you have a shoulder dystocia the your first baby it does not mean that you will have it again. I believe that it is around a 1% risk (regardless of the size of the baby) that you will have a shoulder dystocia and that rises to about a 10% risk if you have had a previous dystocia. Personally, I would never choose an elective section for the perceived risk by a care provider of possibility have a shoulder dystocia. Little babies get stuck too, not just big babies. And your baby was not that big. And restricting calories will not guarantee a smaller baby. I am pretty small and I gained 25 lbs with my first and 20 lbs with my second (didn't try to restrict, it just turned out that way). First babies tend to be harder to birth anyway and second babies tend to slide out much easier!!

Good luck! Btw I agree with the pp, get a second opinion from another midwife.