VBAC after shoulder dystocia

[Juggling3]

Hi there mamas. Can anyone share experience or thoughts about this topic? I'm due in September with my 4th baby. I've had 2 vaginal births and the second was the shoulder dystocia. Ds was 10lbs 8 oz with a shoulder dystocia that required a fair amount of manipulation according to my OBs. It was also an unmedicated birth and really was a positive experience for me-neither ds nor I suffered any permanent damage from it. I was advised to have a cesarean birth with ds #3 because he was measuring large by US at 38 weeks. Sure enough, he was 10 lbs at 39 weeks. The cesarean recovery was awful. Not so much the pain, but I resented the lifestyle limitations that came with it.

Anyway, my OBs are very open minded and told me that I can have a vbac if this baby does not measure LGA at 38 weeks.I  do believe that is what I want, but I'm a little nervous about it. It seems like shoulder dystocias are so rare that I have trouble finding anyone who has been through it. Mine really didn't seem that bad to me, other than some pain, and bladder trauma that resolved after 2 weeks. But I'm told that it can be really serious and do get the feeling that my OB group is very cautious about wanting to avoid another shoulder dystocia.

I'm not diabetic and am being super careful about exercising and eating lightly in hopes of not growing a big boy again. 

[kitkat5505]

I think each baby and birth are so different that there's no way to predict if you'd have shoulder dystocia, even with a large baby. I had mild SD with one of my twins who was 7lb9oz but had no problems with DS#2 who was 8lb14oz. Lithotomy pushing position greatly increases the chances of SD too.

[Lineymom]

I saw this on the new posts.  I don't have any experience with VBAC, but I do with SD.  My first was 10lb4.  He did not get stuck.  The second was 11lb1oz.  His shoulder was "hung" for a moment, but I was already doing some major pushing because his heartrate had dipped into the 60's due to cord compression.  I was in a typical hospital bed position.  When pregnant with my third, I decided to have a homebirth.  SD was my primary concern.  I was relieved that I was having a girl, because I thought that would decrease the chance of a bigger baby.  My labor was different with her.  She was still rather high and I was 2cm at 2:30 and she was born at 3:37.  I say that because maybe that could be related.... like my bones didn't have as much time to make room?? I was kinda shocked at feeling the need to push, and never really gave it my all, after all I wanted to have more of a relaxed birth.  I pushed her head out in the birth pool.  Then pushed and pushed and pushed...  I had to stand with her head still out, step out of the pool and get on my hands and knees (supposed to be the best position for SD- we had discussed this as the plan) on the floor, still had to push probably 2-3 more times.  She was pink and perfect, with perfect apgars.  The midwife was amazed that she was fine!  She was only 9lb10oz! 

When reading things about SD and deciding about homebirth, I decided that if we did have a SD, I would be more comfortable with the way the HB midwife would handle it (hands and knees) than the way the hospital midwife or OB would (turning the bed upside down, breaking a shoulder.)

[ablepearl]

WHat did the OBs have to do to get him out when you had the dystocia?

[Juggling3]

Well, I'm not positive the names of all the maneuvers they had to do, but according to the doctor it required 'several maneuvers'-the McRoberts and the suprapubic pressure. Then, I think they ended up having to rotate and pull one of his shoulders out and that caused some injury/paralysis to my bladder, which fortunately resolved gradually after two weeks. I did not try the all fours attempt because I had tried that position to push out his head and it didn't work so well. I had to be upright and squatting to push out the head, then I remember having to be on my back with my legs pushed up, which I think is called the McRoberts. It wasn't a really long time for his body to be born, certainly less than 5 minutes.

[wombatclay]

(hugs)

My first birth ended in a c/s.  My second birth was a successful vbac BUT dd2 developed shoulder dystocia and it was a bit "dramatic" there at the end... she was stuck for several minutes and required resuscitation.  I was squatting (unmedicated) when she got stuck, the Gaskin (all fours) didn't work, McRoberts didn't work, and eventually my care provider reached in, twisted, and pulled... leaving me with a 4th degree tear.  Thankfully dd2 recovered quickly (she has a few neurological quirks that may be due to the oxygen deprivation or may not, we'll never know) and I recovered as well as possible (no fistula, no fecal or gas incontinence, but I do have minor bladder and uterine prolapse as a result, recovery was hell, and the scar tissue and nerve damage still causes some discomfort 4 years later).

DS was born two years after dd2 and his birth was another VBAC.  More than the vbac, the chance of another SD (and to be honest, another tear) was what freaked me out.  I spent a lot of time processing dd2's birth, researching SD, and talking with care providers/dh/doulas/btdt mamas.  I finally figured out my comfort level, switched from a home birth to a midwife supported hospital birth, explained to everyone that while I wanted another VBAC I would prefer a c/s to another sd/tear and wanted to know if my labor started following a wonky pattern (I pushed for nearly 4 hours in many positions with dd2 before she got stuck and I told people that if I wasn't making CLEAR steady progress then we were going to the OR), focused on spinning babies and hypnobabies, drilled my dh and my doula on all the different SD solutions (duck walking, gaskin, etc), bought a copy of the Labor Dystocia Handbook (by Simkin), and tried to relax.

DS had "sticky" shoulders but nothing like a true dystocia, and he was born after only about 45 minutes of pushing.  I labored in the tub for a while and then on my side... ds was born while I was side lying actually.  I'm expecting my fourth child in early Sept and I'm trying to keep my balance once again.  I'll be with the same midwives and hospital and hope for another VBAC... but I'm leaving my birth plan as it was for ds.  If things seem to be going "wrong" then I want to know and I want the option to move to the OR (even though I dread another c/s and recovery).

Oh, my posterior asynclitic c/s born DD1 was 9lbs6oz.  DD2 was my vbac with sd and tear and she was 9lbs even.  DS was a little sticky but otherwise straightforward vbac at 9lbs8oz.  Size can be a factor, but it's not a major factor.  One good source for info is:

http://www.shoulderdystociainfo.com/index.htm

It's a commercial site (they're working on creating a SD predictive tool) but they have a wonderful bibliography of scholarly papers and "easy to read" info on known or suspected causes of SD along with any actual evidence to back up or debunk those theories.

Good luck!

[ablepearl]

I researched this for a friend a while ago and now I can't find the info.  There was a maneuver similar to the Gaskin maneuver, but it had mom bring one leg up, like a half McRoberts in all fours.  Of course I can't find it...lol

[ablepearl]

I should have known it was a spinningbabies thing! http://spinningbabies.com/spinning-babies-and/resolving-shoulder-dystocia  They call it 'running start'

[cinderella08]

Keep in mind dystocia, is not ALWAYS related to size!

I've seen shoulder dystocia in an 11lb baby, and I've seen it in a 7lb baby!  Sometimes it's size, sometimes it's presentation, and sometimes it just happens!

[Juggling3]

Thanks for all the input. I've looked at the shoulderdystociainfo.com website. Actually, my OB group is at a research hospital and one of my doctors is one of the primary authors of the research cited on there. Previous shoulder dystocia seems to be a pretty big risk factor. I do have to face and pray through my fears about damage to the baby and damage to my own body if it happens again. As much as I don't like the c section recovery and limitation, I think I would have a really hard time if I ended up with permanent bladder problems or prolapse because of injury because I am a runner and don't want to give that up. I was curious about hearing other's stories who had been through it because it is so unusual that it's hard to find personal stories about SD.

[wombatclay]

A little off topic (but not much)... if you're concerned about prolapse, you should keep in mind that c/s can play a role in causing prolapse.  One school of thought is that c/s will protect against prolapse in cases where the pelvic floor has already been traumatized (because the c/s prevents the bearing down and stretching of a vaginal delivery, and avoids the possible damage from a repeat SD or tear).  The other school of thought is that by removing/replacing/rearranging the pelvic organs (which is a necessary part of a c/s, for example, the bladder needs to be retracted from the uterus and bladder damage is a not uncommon c/s complication) a woman is at greater risk for eventual prolapse since the pelvic organs are no longer "to spec", so to speak.

There is little good data one way or the other as yet, but I think it's telling that rates of pelvic organ prolapse in young/active/healthy women have gone through the roof in recent years and so have the cesarean rates.  POP used to be thought of as an end-of-life concern but now it's one of the fastest growing conditions in the 30-something set.  And what raelly stinks is that many of the treatments for POP assume "end of life" and so haven't been studied in women who will use these treatments for decades of active life.  For example, a popular bladder sling product (surgically implanted "mesh" that holds an otherwise droopy bladder in place) is now known to "migrate" over the years causing pain and complications and hysterectomy (a common "first suggestion" for uterine prolapse) isn't really appropriate for a young woman and is now known to increase risk of other organs prolapsing within a few years of the surgery assuming a normal, active, lifestyle (oh say, chasing kiddos or engaging in impact sports).

I know it's kind of a catch-22... it's one of my personal demons actually.  I'm a vbac mother, I have a history of significant shoulder dystocia, I have a history of 4th degree tear, and I have minor pelvic organ prolapse.  I know that the only clear predictor of a future SD is having had one in the past and that most SD do not resolve with as little damage to the baby as mine did.  I know that women who have a second 4th degree tear have a better than 50% chance of developing permanent fecal incontinance, that another complicated delivery could turn my mild prolapse into a serious quality-of-life issue, and that there isn't a care provider or hospital in the country that wouldn't smile and nod if I requested a repeat c/s.  I also believe personally and know from studies that vaginal birth is the better option for both mom and babe, and that extended breastfeeding (for at least a year or two) is the best choice.  Put all those medical facts and personal philosophies together and I'm in a sorry state.  LOL

Anyway, I know I'm rambling, but I think it's important to let women know that while c/s might reduce the risks of one complication it can increase the risk of developing a similar compliaction.  For me it eventually came down to a "100% chance" of having my bladder fiddled with in the event of a rc/s vs the 10-15% chance of having my bladder fiddled with in a repeat SD.  But it was a sort of middle-of-the-road position since I wasn't committed to a vbac "at all costs" and in fact was probably more willing to move from a vbac to a rc/s than my midwife was... I was adamantly against anything like a wait and see attitude.  Thankfully it wasn't an issue, but it's sort of growing in my thoughts again as my own delivery month gets closer.  I'm re-playing arguements for and against, and looking up statistics, and trying to find that balance point this time round.

Ok, I really really am rambling now!  LOL  Good luck with your own decisions and balance finding.  I hope you have a wonderful birth and smooth recovery, no matter what you choose!  :)

[Juggling3]

I appreciate the 'rambling' Wombatclay! That's what a thread is all about  I had NO idea that fecal incontinence was a possible complication...not likin' that thought one bit! It's funny, I never thought about the bladder issues post c section, but now that you mention it, I remember having (and still do have) some occasional mild bladder incontinence after the surgery. I thought to myself, 'what the heck-how could that have happened?' because I assumed that wouldn't be an issue. I never could figure out why I had it, other than age or just carrying 3 babies, 2 who were VLGA. I'll have to ask the doctor about that one. I'm going to take it from here with prayer and not too much worry because there isn't a whole lot I can do to affect the outcome.