C section vs. vag birth with 4th degree -shoulder dystocia

[mommamiagal]

Hi. I have posted before. I am still agonizing over a c section, because the more threads and ifo that I read, the more scared I get.

I put a list together of some cons for both. Please offer advice-suggestions.


C section cons- major ab surgery, longer recovery: possible bleeding, infections, adhesions, cut bladder, longer hospital stay, IV's , catheter, newborn problems, meconium, breastfeeding issues

vaginal birth with prior 4th degree and shoulder dystocia x 2 cons-
possible repeat tear, repair and recontruction, possible fistula, fecal-urinary incontinence, sexual dysfunction, infection
problem with baby with shoulder dystocia..prolonged crowning possibly resulting in damaged baby or death.

What would you do looking at all risks? Now of course, none of this could happen and each birth scenerio could be totally uncomplicated, but how do you predict and feel comfortable with your decision.

[WriterMama]

I would go for a vag birth for sure because the outcome could very well be different than your first birth, whereas major surgery will be a given in the c-section scenario.

Have you researched birthing positions that help you avoid sd? My ds had mild dystocia and I was sitting semi-reclined in a birthing tub. If I had feared he was going to be a big baby (he was my first and I had no idea I'd have a 9lb 4 ozer!), I would have labored on hands and knees. And clearly, if we hadn't resolved the shoulder issue as quickly as we did, I'd definitely have changed positions (as it was, we put pressure on my pubic bone which tipped it up and freed ds's shoulder).

With my second baby, I didn't labor in water (she came too fast to fill the tub), but because she was a "land birth" my attendant was able to put hot compresses and olive oil on my perineum, and also guide me to push slowly, so I didn't have any tears at all. (With my sd baby, I had a 2nd degree.)

Now it looks like you are having a hospital birth. Have you discussed your anxieties with your doc? How does he/she respond? Is she willing to accomodate your desires (to deliver on hands and knees, for example, or to support your perineum)? Do you feel that the hospital will be a safe environment for your birth?

I highly recommend the book Birthing From Within to help you work through your fears. It was so helpful to me in working through my fears about sd for my second baby.

Best of luck!

[pamamidwife]

it sounds like you're getting the "let's save your pelvic floor" talk from your doc.

I had a third degree tear with a reconstruction at a year and a half postpartum. My perineum, therefore, is very thin. I would never hesitate to have a vaginal birth - at home. Even if I had a shoulder dystocia previously - I know that my risk of having it again, especially if I was upright and pushing when I wanted, would be very, very low.

It sounds like you're not sure about the cesarean. Nobody can make up your mind for you, but I will say that your OB, just by training and being a surgeon, feels more control with a cesarean. I would not trust an OBs opinion on this issue at all, I'm sorry to say. Most OBs are still touting that cesareans help prevent pelvic floor problems later in life, which is BS. Truth is, they are surgeons. Not experts in natural, normal birth.

[doctorjen]

But what if you had had 2 previous shoulder dystocia births - both at home, pushing on hands and knees? And the last one caused a spontaneous 4th degree tear, necessitating transport after birth? But, both babies actually did fine once they were out? However, while the births were both homebirths, they were attended by physicians, not a midwife that is experienced with shoulder dystocia - so maybe that makes a difference? That is the situation the OP is in. Her previous birth attendants apparently felt they were unwilling to attend her at home after the previous 2 births, so have referred her to an OB.
I don't know what exactly I'd do in this situation, but I might first have a long talk with a homebirth midwife before I decided what to do. Of course, this is complicated by the fact that we are in IL, where it's darn hard to find such a midwife.

[mwherbs]

so give me more information-- tell me the stories of the births-- things I want to know size of babies at birth, lenght of labor, positions you were in during labor, and position you were in during pushing anything novel done? was a vacume or fundal pressure involved.
spontanious 4th degree is rare did someone have their hands in at the time of the tear? how were the babies gotten out and condition. length of time from head -complete birth

[mommamiagal]

To give you my history. I have 3 children, One born in the hospital with epsiotomy, 2 born at home with shoulder dystocia , each weighing 10 1/2 pounds. The first homebirth(physician and nurse attended) was about 8 hours, everything went as expected, until the head crowned for 5 minutes, I changed into many positions and finally got her out. 2nd degree tear, just a few stitches, no transport, baby needed a little oxygen , but everything was fine.
The second homebirth was fast, 4 hours from when my water broke to the end. THis one was a little different, I labored in a birth tub for most of my labor, it was great, but it was very painful with lots of rectal pressure. Apparently when the baby was crowning you could see her head through the rectal opening. I changed into many positions again. She also crowned for 5 minutes, and then the doctor had to deliver her by using a manuer with his hands up me to get her shoulders out. I was all one hole , no perineum left and also 1 inch into the rectum torn. I really didn't feel anything down there, lost a lot of blood, needed transport to the hospital for extensive repair. A urogynecologist repaired it, but said that I was so swollen from the transport(took 2 hours) that if it would have been 5 minutes more I would have had to wait for repair. They gave me a spinal and the repair took about 45 minutes. I had to leave my newborn at home, until I was in recovery and then my husband brought her to me and she stayed with me overnight. It was a big ordeal, and the recovery was a few weeks on ice.Going to the bathroom was hard and I had to make sure it was very clean to prevent infection. I guess it all healed well, except my perineum is very thin and short. I do not have fecal incontinence, but sometmes gas is hard to control. I have to watch what I eat. Although I dread having a c section,I would like to preserve the functions that I have dealing with my pelvic floor . That recovery was not a piece of cake either, and I was seperated from my newborn for awhile for surgery. My homebirth doctor recommended a c section this time because of my history, so that is why I changed to another OB, that was also her recommendation.Not only to protect my pelvic floor, but the baby who will probably be a big one agian with the same situation, and to protect him from consequences of shoulder dystocia. So, it's not that easy of a decision, believe me I have hypnobirthed, read Birthing From Within, Homebirthed, I did not fear childbirth aand always trusted my body, but now........I think I may need some help with this whether it's a vag birth or c section..I am so torn , and it's all I think about. IT han't been the most joyful pregnancy, having this decision weighing on me.Thanks for all of your words.I appreciate your advice.

[amanda2b2]

I can't really offer any real advice just what I would do. C-sections are my biggest fear Iwould do almost anything to avoid one but I have to honestly say after reading your story, if it were me I would most likely have the section. How far along are you? Can they tell you how big they guess the baby is?
OT- Waht is a homebirth physician? I have never heard of that before.

[meowee]

I would have a c-section, without a doubt. I have had a homebirth and unmedicated hospital births, all with midwives, just so you know where I'm coming from.

Let me suggest that you not let the internet (whether MDC or other sites) sway your opinion in this matter. This is a decision for you, your family, and the care providers you trust. I know you are agonizing about this... but there is so much "stuff" online and such extreme opinions (both "natural" and "medicalized" opinions) without moderation that it is not the best tool to use in decision-making.

[anonymommy]

OK lemme get some clarification.

What is the problem with "crowned for 5 minutes?" I am sure both my babies crowned for much longer. Do you mean the head was born for five minutes before the shoulders? Do you mean the head was born all the way and a subsequent contraction failed to birth the head?

What positions were you in for your shoulder dystocia births?

Was pushing influenced by someone pronouncing you complete? Or did you wait until it was involuntary or nearly so?

I tore to the rectum with my first baby (MANAGED against my will and birth plan birth with a midwife, 9#3 baby, supine against my will, etc). My second was 11#, totally spontaneous UC involuntary second stage, and I was leaning forward and h/k during second stage. No real tearing, no anal effects whatsoever, although I did get a skin split when I asked my mom to give him a little pull under the armpit when his head was out and I was trying to get him out before the next contraction. There was no pain and no swelling, not even any stinging on urination. I looked like a cracked/chapped lip down my scar -- well articulated.

[alegna]

It's a hard decision to make.

My take on the situation- I've read all the background and some of this is gut, not any specific information given- I think part of the problem was that he was a Dr. Doctors DO things. It's what they're paid the big bucks for. It was clearly his action that caused your tear. I know that he did it for the baby. I think a good hands-off midwife could have handled the situation with significantly less trauma to you. I don't know all the specifics of what one might have done, but most homebirth midwives I've known (even more medical ones that I didn't like) have a certain amount of intuition about them. (hope that makes sense and doesn't sound too woo-woo ) I really think you would not have had the 4th degree tear with a midwife. I think that if you can find a midwife this time around you can have a peaceful homebirth (I don't think I would set foot in a hospital in your shoes- asking for trouble even if they don't feel grumpy with you for not obeying their rules) If you can't find a good experienced homebirth midwife, I don't think that a section is an awful choice in your shoes. BUT I would make it my lifes work to find a good midwife. (FWIW even if I decided on a section I wouldn't schedule it- I'd go into labor first for the baby)

Hope that helps. I'm sorry that you haven't been able to find peace on this decision yet.


-Angela

[pamamidwife]

ah, doctorjen, I didn't know about the pushing on hands & Knees part both times with two previous SDs.

It's tricky, for sure. I would say listen to your heart, pray or meditate on it and then go with what your gut is telling you.

[OnTheFence]

Originally Posted by mommamiagal

Hi. I have posted before. I am still agonizing over a c section, because the more threads and ifo that I read, the more scared I get.

I put a list together of some cons for both. Please offer advice-suggestions.


C section cons- major ab surgery, longer recovery: possible bleeding, infections, adhesions, cut bladder, longer hospital stay, IV's , catheter, newborn problems, meconium, breastfeeding issues

vaginal birth with prior 4th degree and shoulder dystocia x 2 cons-
possible repeat tear, repair and recontruction, possible fistula, fecal-urinary incontinence, sexual dysfunction, infection
problem with baby with shoulder dystocia..prolonged crowning possibly resulting in damaged baby or death.

What would you do looking at all risks? Now of course, none of this could happen and each birth scenerio could be totally uncomplicated, but how do you predict and feel comfortable with your decision.

The csection, mainly because of two family members. Both had 4th degree tears, one opted for a csection for second birth, other family member had three more vaginal births and has had more complications from it and she is now pushing 60.

Also, I want to say that my recovery from my past two csections was far easier than many vaginal births I know of that had complications, this includes homebirthing mothers too. I listed in another thread that your bladder being cut during a csection is very very low. The key is to know your on OBs statistics, have the bladder completely drained -- however if you have a tilted uterus this increases the risk of your bladder being cut. Meconium, newborn problems and breastfeeding problems can also occur with a vaginal birth, especially one with problems. I've been fortunate that I have had no newborn problems or breastfeeding issues, even with my emergency csection. (I've had 3)

I know I am the voice of dissent here on mothering, but hands down I would go with an elective csection, and it would be planned. However my sex life is pretty much on my high priority list, as is a live baby.

Goodluck with whatever you decide, you have a tough decision ahead of you.

Kim

[chapulina]

mommamiagal,

I am amazed at what you and your body have gone through; how very courageous of you to have another baby!

Just my opinion, but if I were in your place, I believe I'd consider the c-section for this time. I understand the benefits of natural childbirth and think it is almost always the best route for women, but sometimes there are extenuating cirmcumstances that are beyond our control. Every body is different, as is every baby, and sometimes it creates nearly impossible situations.

Its likely, though not for sure, that this baby will be another good size; and that your perineum is a bit weaker than most. Thus, a good chance for a repeat, or even worse, experience.

I'm 38 weeks into this pregnancy, and my first was a 9'6 with shoulder dystocia; the ob wants me to have a c/s. I'm following with the midwife who delivered my first, so tomorrow I'll get her thoughts on this. I do understand about being fearful of the surgery - I really don't want it either. But, on the other hand, I'm glad it is an option when truly needed. In the good old days, there were women who died in childbirth because there were no other options.

best of luck to you and I hope this birth is safe and smooth for you.

[eleven]

As a c/s mama and VBAC hopeful, I would choose the section.

The chances of the above complications during a non-emergency (or better yet, planned) cesarean are very low. While I was profoundly disappointed by my surgery, my physical healing has been very good.

It sounds like the vaginal birth complications are more likely in your situation. The fact is, you already did everything *right* to have peaceful homebirths. For me, the possibility of something going wrong again would be too much.

(I have read your other thread here and was pretty sure I'd choose a cesarean based on that. The fact that your babies head was visible through the rectal opening while crowning sealed the deal, so to speak.)

Cesareans can be beautiful, peaceful, loving experiences - just ask Kim (OnTheFence).

I wish you peace and wisdom as you plan for your birth.

[WriterMama]

Wow. Well, after learning more about your situation, I would have to say that I might very well consider a C-section if I could not find an experienced mw who was willing to be very hands-off. However, the only person who can know is you. Listen to your heart. HUGS to you!

[mommamiagal]

OK lemme get some clarification.

What is the problem with "crowned for 5 minutes?" I am sure both my babies crowned for much longer. Do you mean the head was born for five minutes before the shoulders? Do you mean the head was born all the way and a subsequent contraction failed to birth the head?

What positions were you in for your shoulder dystocia births?

Was pushing influenced by someone pronouncing you complete? Or did you wait until it was involuntary or nearly so?

Sorry, I should clarify. Yes, the baby's head was out for 5 minutes, while trying to deliver the rest of the body, the shoulders. The baby was making faces, etc, my husband said it was so weird seeing the head just sticking out of me while I was switching positions. It does become a little worrisome hostile in the environment because you know that time is critical, baby could be in jeopardy and you know you have to push it out. Yes, I do mean that the head was born all the way, and the contractions, as hard as I pushed with them, was not doing a thing to push the baby out.
I was never told when to start pushing, it was all up to me, and I had a huge urge to push, probably starting at 8-9 cm. It was the most incredible urge to push that ever had with my last one, lots of rectal pressure too. It literally felt like she was coming out of my behind, and I remember thinking that..and guess what ..she did, sort of.
I used the birth tub for all of my labor , and then they wanted me on the bed for deliver, to see what was going on. I think that they expected another dystocia, and wanted to watch the cord maybe? I used hands and knees for pushing and also the usual sitting position but it was all I could do because of the pain.

[liseux]

Alegna, sometimes fatal shoulder dystocias still happen even with hands off midwives and the Gaskin maneuver. There have been babies who had cardiac arrest and severe brain damage after only 5 minutes of being stuck, others have survived as long as 15 minutes and just needed oxygen. S. D. is still one of the top unexpected train wrecks in birth, the other biggies can usually be predicted, like pre E and pp hemmorrhage. The only thing that has yet to be an indicator for a SD birth is a previous SD. And it could get worse each time.

[alegna]

True. They do happen. Women and babies die from C-sections too. It's a hard decision, but she asked opinions. In her previous post where she said she'd decided on a section I supported her. She asked opinions again and I gave mine.

to the OP- no matter what you decide.

-Angela

[Heavenly]

I would go for the c-section. I think the risk of a problem in a vaginal delivery is too great. IMO you have done everything humanly possible to have a normal, vaginal birth. I know others on here will tell you you should do this or that but really they weren't at your births and don't know all that they entailed. You are the only one living your life and you are the only one who will deal with the consequences. I am going against the Mothering grain as well, planning a repeat c-section after two c-sections instead of going for a VBAC. I am doing what I know is right in my situation, listen to your heart and do the same.

[WinterBaby]

You've probably read as much as is ever going to be helpful. Certainly there is a very real reason to plan a c-section, although I think most people would understand your desire for having a vaginal birth again too. It seems like you're at the point where you need to turn off this outside speculation and debate and turn inward to listen to your own voice to make this decision and find your peace with it. I feel comfortable with decisions I make when I've gone with my gut feeling and listened to my inner voice regardless of the voices around me. (As I contribute to some of this outside noise and distraction - and that's what it really is - noise distracting you from hearing the one voice you need to be paying attention to - trust yourself. I'd take time away and stop reading, you're as well informed as you need to be, lol.)