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agonizing over having a section - Page 3

post #41 of 60
Originally Posted by mommamiagal
My homebirth doctors are excellent , and very skilled with this type of thing and actually told me that they hadn't seen this in many many years.( Maybe I am not the Birthing Goddess that I thought I was. )
It just kills me that you would think any less of yourself for finding yourself in this situation-- of course you are a birthing goddess-- the fact that you had complications does not take that away. Like Heavenly I am surprised by the cavalierness of some comments to your post .

Regarding fistulas, not all women who develop them are undernourished teenaged girls (and really, are American women in such great health? Take a look around next time you're in the grocery store). Fistulas were not uncommon even in this country up through the 19th century.

post #42 of 60
I realized I did not respond to the specific situation. If I were in your position I would have the c-section. I discussed it with my DH (I hope that's alright) and he agrees that he would encourage you to go for the c-section. C-sections are overused, definately, but that is not a reason for us all to condemn ones that are truly necessary. Maybe you (general you) would choose to undergo another vaginal birth even knowing you could end up with severe problems for life but IMO unless YOU are the one who has suffered through what this lady has suffered I don't think you should condemn her for her choices or treat her as if she uneducated about birth.
post #43 of 60
I have been in this situation as the birth attendant believe it or not. I have only had 2 true shoulder dystocias since I started practice (I saw many more in training) and they have been with the same woman.
First birth was my 3rd on-my-own birth, so I will admit to probably needing more experience. The mom is a decent sized woman, with a generous seeming pelvis. She labored spontaneously, and pushed her baby out mostly side-lying, although did the dreaded semi sitting for the very end. She pushed the head out easily, but the shoulders wouldn't come. At that time, I was aware of only the more medical methods for managing shoulder dystocia. We did McRobert's maneuver, suprapubic pressure, then I used the corkscrew maneuver and finally freed the baby. Mom had a deep second degree laceration, baby was very slowly to start to breathe, blue and floppy, required bagging to start, and had a brachial plexus palsy (an injury to the nerves that supply the arm.) The palsy got completely better by 2 weeks of age. The baby was 9 lbs even, but had "linebacker" shoulders.
Three years later, I attended her second birth. After discussion of options, she preferred to try another vaginal birth. I felt more confident, having practiced the Gaskin maneuver, and having changed my practice to encourage moms to stay upright as much as possible. She again went into labor spontaneously, and pushed spontaneously. She mostly pushed in a true squat or on hand and knees, and stayed on her hands and knees for birth. I used every technique I've ever heard of to minimize sticky shoulders - hands off the head, no attempt to turn the head to line up the shoulders, no stopping to suction, encouraging mom to push as she felt the urge. The head was born very slowly, and then as the mouth emerged, it almost looked the head was sucked back in (called the turtle sign) I had not touched the baby at all to this point. Mom continued to push with all she had, but baby didn't budge. She was on her hands and knees already, and I tried to nudge the shoulders free, but couldn't. We had her move to upright kneeling (which is very like squatting) but baby still couldn't be freed. I finally managed to get a hand in and push the posterior shoulder free and the baby was born. His shoulder finally wiggled loose about 5 seconds before I gave up trying and tried to break his clavicle instead. It was over 5 minutes from delivery of head to shoulders. Baby was blue and floppy and required resuscitation again. He again had a brachial plexus palsy, but it again was better by 2 weeks of age. The mom had only a small second degree laceration from this birth. This baby was 9 lbs 8 oz, again with huge shoulders.
This mom and I have had a lot of discussion about what to do if she decides to have more children. We have agreed that unless we had good reason to suspect a smaller baby, she'd probably have an elective cesarean. We did have good outcomes both times in the end, but a minute or two more in each case and that may not have been the case. Babies do die occasionally from lack of oxygen due to shoulder dystocia. Watching her son be resuscitated last time was a significant source of stress and really ruined the lovely birthing environment we had going. Frankly, as her attendant, I don't want to be in that position again, watching a baby's heart rate go down and down and down and not being able to get him free.
And you cannot just wait until the head is out, see if the shoulders are stuck, and THEN do a cesarean. There is a technique called the Zhavenelli (I'm really not sure on spelling here) maneuver, in which the birth attendant attempts to flex the head and push the head back in for cesarean birth, but it is considered a last resort, and in many cases may not be possible. The head rotates and moves quite a bit coming through the pelvis and down, and it's really hard to repeat that in reverse. Even if the head could be pushed back into the abdomen, there is a high likelihood of significant damage the mom, and a high risk of lacerating the bladder or lower uterine segment trying to get the baby out abdominally. This procedure is considered last resort if the baby is going to die if you don't try something. I've never heard of it being performed successfully.
To the OP, it's hard to say what you should do. You'll have to follow your intuition, I think. I think in general, cesarean to prevent damage to the perineum doesn't have a lot of good research to support it. Cesarean to prevent shoulder dystocia doesn't either, though. I wish you the best in making a decision, and hope you'll find good support here no matter what you choose.
post #44 of 60
Thread Starter 
To doctorjen....With my first homebirth, 2nd child, I had a 2nd degree with shoulder dystocia . The baby crowned for 5 minutes and through many changes in position and possibly a little help the baby delivered. She was very blue , needed a little oxygen under the nose but was just fine, no transport needed for either of us.
My third baby, 2nd homebirth, turned out a little differently, I needed transport to the hospital for extensive repair for a bad 4th degree laceration. Having to leave my newborn at home was very traumatic, but she was brought to me after the surgery was completed and stayed with me until the next day when I was released. Luckily I had a great urogyn to repair me and things are OK, some gas incontinence but nothing really devastating. My perineum is a lot shorter than normal, so there is not much to work with if I should need repair again. My daughter were both 10 1/2 pounds, they both crowned for 5 minutes but the last one needed more help getting out and that's were the 4th degree came from I bet, the doctor went in up to his elbows basically.He did what he had to do, and I have two healthy girls.

I know you said that there is no current research on either c sections after 4th degree or s.d. babies. Would s.d. be considered a positioning situation that would go under cephalopelvic disproportion or is that just that the head is too large? Is my chance for developing a fistula great because of my current "anatomy"? Thanks. By any chance are you in the Chicagoland area?
post #45 of 60

I think any woman with a potential c-section in her future has some of the same feelings you are having. I'm planning to VBAC - my dd was born via c-section b/c she was breech and I had a rare lymphatic cyst that could have burst during pushing, so this time around, without the complications, I'm a good candidate for it.

I just wanted to let you know from my personal experience with a scheduled c-section, no labor, at 39 weeks that I had a wonderful delivery and recovery. I just wanted you to know that there are wonderful outcomes so that fear wouldn't be the only factor in your decision-making process. My OB let me try to nurse on the table, which was unsuccessful, but she sewed me up quickly so that I was able to make another successful! attempt within 45 minutes of dd's delivery. My milk came in 20 hours after delivery - dd "roomed" with me and I nursed every hour or so to make it happen quickly (once again I must mention that I never had a single labor pain and my cervix was totally closed and in the OB's words - "a mile long and hard"). I took nothing stronger than ibuprofen for pain. A long-acting (22 hr) morphine dose was placed in the spinal block, and I felt absolutely no affect from it other than a lack of pain because it targeted only that region. After that initial dose wore off I really had nothing more than discomfort. The baby was out within 20 minutes of my spinal and had none of the signs I was looking for in a baby exposed to epidurals/spinals - she was totally alert like babies are supposed to be for a while after delivery.

I really wish you the best of luck in your decision - I'm sorry I can't say what I'd do in your situation because I really don't know... I just wanted to share this so that it might help reduce the fear factor a bit...

post #46 of 60
I understand your situation better now.

It sounds like the c/s might really be the best option and it is possible to make a c-birth a positive experience too. You can plan w/ your OB to have the c-birth as comfortable for you as possible (bringing your own music, etc).

W/ my own c/s I was very worried about my nursing relationship w/ DD. The nurses brought DD to me as soon as I was finished being stitched and transfered to my room. I couldn't feel my legs yet, but they rolled me over and got DD latched on right away.

Also, it was very important for me that DD have one of us w/ her at ALL times. When DD had to leave the room, DH went w/ her. IF you feel strongly about that, I highly recommend having a support person just for you present or even hiring a doula. I have hired a doula this time and plan to keep her even if I do end up w/ a repeat c/s.

I still regret not waiting until I was in early labor for a c/s though. Then I would have been sure DD was ready to go. If I had to do it all over again and still end up w/ the c/s, I'd wait for labor to begin. A recent study showed that it's very beneficial for baby for mom to be in labor before beginning an "elective" c/s. Maybe it would possible for you to speak to your OB about that also.

HUGS and good luck w/ your decision. I can only imagine how tough it is for you.
post #47 of 60
Originally Posted by mommamiagal
I know you said that there is no current research on either c sections after 4th degree or s.d. babies. Would s.d. be considered a positioning situation that would go under cephalopelvic disproportion or is that just that the head is too large? Is my chance for developing a fistula great because of my current "anatomy"? Thanks. By any chance are you in the Chicagoland area?
I didn't really understand what doctorjen meant about no research to support c-section for 4th degree laceration or shoulder dystocia. Presumably your risk for either would be zero with an elective c-section, no? I think what she must have meant is that there's no research for increased risk for 4th deg lac or SD in subsequent births. I do know that my doctor feels that I am at increased risk for a severe tear and accompanying issues and in my quest for info I found this study which concluded that those with prior 3rd and 4th deg lacerations have a 3.4x higher risk with subsequent birth.


One other thing to consider: some have advised going into labor first if you do go with a c-section. You should consult with your doctor about this. I think there may be an increased risk of prolapse and incontinence going that route.
post #48 of 60
Originally Posted by scoobers
One other thing to consider: some have advised going into labor first if you do go with a c-section. You should consult with your doctor about this. I think there may be an increased risk of prolapse and incontinence going that route.
Why would there be an increased risk for these things if the c/s is delayed until ctx begin? Are there studies on this?
post #49 of 60
Thread Starter 
I think that I pretty much made up my mind and decided that it is best for both my baby and me to do the section. I have thought long and hard and talked to professionals, and non professionals and I just can't come up with a better decision, although it's not my ideal birth. Hopefully it will be an uncomplicated birth and I will be happy that I made the right decision. Any advise on losing the fear factor?
I am scheduled for Sept 6th so please keep me in your thoughts and prayers! I may ask my doctor to move it to 40 weeks instead of 39, just to be be closer to my actual due date. I do not know if I want to wait for labor to begin though because my last labor was quite short, only 4 hours. I would not want this turning into some emergency rush job, also I want the OB that I am seeing to do it, not someone on call at the time. I talked to a LC today and she said as soon as the placenta is delivered the body kicked in the appropriate hormones to get milk production in gear, and I will be having baby rom in aand nurse on the hour. I jus weaned my 2 year old a few months back, I wonder if that will have anything to do with my milk production kicking in faster as well.

Thank you for all the advice, it has really helped me. I welcome any other advice to get me through this journey.
post #50 of 60

Good luck! It sounds like you've researched your choices well. I wish you a speedy and uncomplicated birth- you birth goddess you!

post #51 of 60
Good luck! You can pm me anytime about how to make a section a beautiful relaxed experience. I think your milk will definitely come in quickly with rooming in too.
post #52 of 60
everything will turn out fine, I'm sure!
post #53 of 60

congratulations on making a decision - sometimes that can be the hardest part!

now, focus on embracing your decision, loving your decision, and learn as much as you can about the process so you won't have any surprises. I'm sure your provider will be more than happy to go through the process step-by-step with you.

And I'm certain you'll have no problem with nursing - the LC was right; hormones produced by the presence of the placenta repress lactation (as anyone who has had some placenta left in the womb will tell you) and during your c-section they are sure to get all of it out. Nursing frequently will also get you going!

best of luck to you!
post #54 of 60
For the record, I didn't mean there was no research, only that the research available doesn't provide a clear cut answer. When you are looking at rare circumstances, you often have to treat a lot of folks to prevent 1 problem. For example, you have to treat over 200 women who are GBS positive with antibiotics to prevent transmission to one baby, and even more women to prevent one serious long term problem (like 2000.) That's helpful data to know. Even with babies suspected to be very large, you'd have to do cesareans on many, many women to prevent one case of a permanent injury to a baby. One estimate is that 2,345 cesarean deliveries would have to be performed to prevent 1 permanent brachial plexus injury in an infant if you performed cesarean deliveries for all women with fetuses estimated to be 4000 grams or more (8 lbs 13 oz)
link - http://www.aafp.org/afp/20040401/1707.html
Yes, the risk of 3rd or 4th degree laceration is zero with a cesarean birth, but the risks of cesarean are there, and you definitely have an abdominal incision to deal with. No way of course ahead of time to know if you are one of the unlucky folks to have a bad complication either way. Under usual circumstances, if I'd had a bad tear the first time, I personally wouldn't have a cesarean to avoid perineal damage or pelvic relaxation because I think there are other ways to manage that risk (especially keeping all sharp objects away from the perineum, and pushing spontaneously and in a mother-chosen position.) I've never had a client have a repeat bad tear - and have had many have very minor tears or intact perineums on their repeat birth.
The situation here is much trickier though, because the perineal damage seems to have been caused by shoulder dystocia and the need for intervention to prevent serious harm to the baby. If you could be guaranteed that you wouldn't have that issue again, great, but of course you can't.
I hope you'll have a wonderful birth and can't wait to hear about your new baby!
(And no, I'm not in the Chicago area - but I trained there and know the practice you birthed with before.)
post #55 of 60
i admit to not reading all of this thread, but just wanted you to know that i am in the same situation. we are having a cs in dec. with my 3d, after 2cs's. i guess i just never was intended to give birth naturally. and after 36 hours of labor the first one, its a big bummer for me to know that i probaby wont feel any labor with this one. i hope to keep in touch with your threads as you go through this and the questions you have. this is my first planning cs and im a bit weirded out about it. dont know why...just am.
post #56 of 60
Congratulations on your pregnancy!

I have two sites with interesting information to help you make your decision. http://www.ubpn.org and http://www.birthlove.org (maybe it is birthlove.com) I used the birthlove site first to strengthen my resolve to have natural births, and later, when I decided to have a cesarean birth, to help me create as good a cesarean birth as possible. The first site is the United Brachial Plexus Network's discussion boards, which have tons of information on shoulder dystocia and the increased risk of SD for for babies who had siblings with SD. They know it inside out because they had children who had birth injuries from SD, but they are not just knee jerk pro cesarean. Instead, they have information about the factors to consider, etc.

Good luck.
post #57 of 60
Thread Starter 
Thank you for the additional info, I found the UBPN very resourceful, one which I will show my Dr. I do remember that for a lot of the pushing, up until the shoulders were stuck, I was in the typical pushing position out of my own comfort level. It is what felt best for me, but maybe it didn'y allow for maximum pelvic outlet?
I am going to see my Urogynecologist, the one who repaired me 2 years ago, to talk with him on Friday. I just need his opinion, it has been 2 years since he saw me and I am going to have him take a look.

Although, I said I made my decision, I don't know If I truly have in my heart.
Thank you!
post #58 of 60
Sorry for the late reply to this thread. I don't have any advice, but wanted to let you know you are not alone. I know how you feel. My son was born 14 1/2 months ago (my first) and I had a 4th degree tear. It didn't heal well (although I did not get a fistula) and 7 month later I had to have it repaired. The recovery from the repair was worse than recovery from birth.

I am not pregnant, but hope to be soon. The doctor who did the repair (a colorectal specialist) said I should have a C-section next time because they cut out a lot of scar tissue and part of my muscle. Of course I want to try vaginally again, but everything I went through makes me very scared. I feel so conflicted as I can tell you do too. I really think I will have a C-section, but I am not sure. I had some fecal incontinence before the surgery and that that was pretty bad.

Good luck to you with whatever you decide and please keep us posted.
post #59 of 60
i've only had a c-birth, so i can't compare, but one thing i never read about before the birth (and i was on bedrest so i was reading *everything* i could get my eyes on!) was ADHESIONS. apparently it's the least talked about long-term side-effect of a cesarean, but the most prevalent and painful. i'm 9 months PP and still bent over in shock sometimes from sharp, tearing pains during menstrual cramps or after lifting something the wrong way.

if you search the web about "c-section adhesions" and study, then IMO you can make an informed decision about which kind of tearing/scarring would be easier for you to recover from in the short-term and the long-term. sort of a "lesser of two evils" kind of thing.

post #60 of 60
well, to make you feel better about a section if i can...

i took the easy (for me) route. we had an "accidental" (long story) ultrasound at 35 weeks, that seemed to predict a very large baby with a truly enormous head circumference. my doctor said i could elect a c-section, and after a lot of agonizing i went for it. I'm 5' 2" and we were worried that the little guy was going to be 11 + pounds.

Delivered of a 10lb, 1oz baby boy via section at 38.5 weeks. Head circumference was 15.4 inches! I've got to say I'm pretty comfortable with my delivery method. No problems breastfeeding, and my recovery was rapid. PM me if you want to chat.

Please don't flame; I'm a huge fan of natural childbirth! I'm just also a wuss. :LOL
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