shoulder dystocia - Page 2

[wombatclay]

We investigated whether differences in anthropometric measurements still exist between infants of nondiabetic and diabetic mothers following strict glycemic control.

Anthropometric measurements of infants of mothers with well-controlled gestational diabetes do not differ from infants of nondiabetic mothers

(all bolding mine)

I have a lot of doubts about gd as a diagnosis in general, but the study actually seems to suggest that a diabetic mother following a strict diet has the same sized infant as a non-diabetic mother...it doesn't provide a comparison to women with GD/Diabetes who are not controlling their diet. So really the only conclusion here is that women who control their diet have babes the same size as non-diabetic women who don't control diet. Which would actually support the idea that dietary control makes a positive difference in the diabetic community in terms of infant birth size.

Of course, it also doesn't suggest that dietary control would be helpful for a nonGD/Diabetic mother, and it doesn't suggest that smaller babes are less likely to present with SD. But if a mama has GD and/or diabetes and was worried about a macrosomic babe... this study might reassure her (and her care provider) that a controlled diet could be a safe/effective option to something like early induction.

[liseux]

Since true SD is a bone issue it really doesn't matter if the baby is that chubby, GD or not. I think looking at the dad's shoulders might tell more. I also think that it is a good idea to find out how your mw work in any extreme situation, not just SD. As long as a mw doesn't panic and goes through the motions, starting with Gaskin, most cases that can resolve will resolve.

[wombatclay]

Since true SD is a bone issue it really doesn't matter if the baby is that chubby

Very true! And in true GD/Diabetic mamas the concern shouldn't be a "light" baby, the concern should be to control the size of those bones...in true macrosomia it's not the weight, it's the "size" of the bits that causes problems. But the studies into SD don't support weight as being a good predictor of SD anyway...


ETA- I'm surprised that there aren't studies looking at positioning. I realize that would be tough using existing data, but perhaps an analysis of home/bc versus hospital birth levels of SD? I know the website mentioned earlier reviewed the impact of epidurals on SD and didn't find much, and later the authors discuss the fact that the gaskin manuever may have limited use in a population that uses a lot of epidurals/meds that inhibit rapid maternal movement. Hmmm...any med pros out there looking for another publication?

[naturegirl7]

I didnt do a strict GD diet - I already eat a modified version of a diabetic diet cuz of family history. Just based upon the types/amounts/combos of food and 3 small meals plsu 2-3 healthy snacks - not a calorie count.... Just a healthier way to eat in general - and I was more faithful while pregnant just becuase I was told I was in a higher risk group for getting GD - not because I was afraid of a small baby. My nieces all ranged from 8.8 to 11lbs so I knew I was in for big babies. Plus I know that fat squishes. I was never worried about a chubby baby cuz I knew he/she would just squish those beautiful fat rolls right on thru.

Big shoulders run on both sides of the family - Me and DH both have wide shoulders. So does DS, and I am figuring so will our other kids whenthe time comes. It isn't a big fat baby that worries me - it is another set of wide shoulders and not knowing for a fact that my new MW can handle it....Before I wasn't expecting SD, so there was no worry that the baby may not just slid right out. But now I know about SD and have that terrifying experience of thinking my baby was dead/dying.....it makes SD suddenly a concern for me and any future births.....I am so scared that I will pick a MW that says she can handle Sd or has experience with it, but when the time comes it isn't the case....I am terrified that without my old MW we won't have such a good outcome....that maybe there will be permanent nerve damage the next time around, or worse.....


So how can you tell the difference between "sticky" shoulders and SD?? I mean, DS did end up with nerve damage in his neck and arm, so I am figuring he was a "true" case of SD - but how do you define "true" or "severe" SD??

I guess the bottom line for me is how to I pick a good MW? Is there something specific I need to ask her? How do I know if the MW I chose has experience with "true" or "severe" SD and will really be able to handle it if it comes up again? How do I trust that she really can handle it and my baby will be safe?

[mwherbs]

true I have been looking at so many GD reports that I just blew past this one except that even the big babies--We did a secondary analysis on neonates who weighed 4,000 g or more at birth. Anthropometric measurements again did not differ significantly between the groups. the study says are the same

"We did a secondary analysis on neonates who weighed 4,000 g or more at birth. Anthropometric measurements again did not differ significantly between the groups."
-----which matches up with other older studies in that strict control compared to normal they have similar size babies.... the Japanese and others are really looking at the genetic of this and say -size has a genetic base--
and even though technically we can call this a "bone" issue it really is a combo of position, (powers) how the baby is being pushed or pulled through the pelvis, Pelvic shape, if there are drugs present that would change the tension in the pelvic floor or in the baby's state of consiousness(because the baby has to navagate), timing and sometimes size-- in a true shoulder dystocia I would disagree with the pictures I have seen on the net- the shoulder does not get under the pubic bone and then stop- what I have felt is the shoulder that is toward the front over rides the sympathis pubis-- now at a point it can certainly get pulled and wedged under but really we want to avoid that tug-o-war between where the shoulder is and where the head wants to go-- now usually the shoulders are cross from each other so if there is a high sacral promenence or one that sticks out more then a baby can get pinned against it too-- or if mom is on her bottom or semi-reclining it is pressing the tail bone and the sacrum upward instead of letting it flex outward with the pressure of the baby's head and the baby's head is shifted forward changes the travel path of the baby and traps the shoulders-also changes the cues for twisting and turning at a timely place sort of like making a left hand turn too soon- while pulling a trailer- the trailer can end up hitting a car sitting at the stop sign(head goes where you want it to but shoulder hits the pubic bone) this is why size does not always matter-- it is travel path..
--------------
here is the another abstract about size being the same diet control or not.

Am. J. Obstet. Gynecol. 1997 Jul;177(1):190-5.

A randomized controlled trial of strict glycemic control and tertiary level
obstetric care versus routine obstetric care in the management of gestational
diabetes: a pilot study.

Garner P, Okun N, Keely E, Wells G, Perkins S, Sylvain J, Belcher J.

Department of Obstetrics and Gynecology, University of Ottawa, Ottawa Civic
Hospital, Ontario, Canada.

OBJECTIVES: The purpose of this study was to determine whether strict maternal glycemic control for the treatment of gestational diabetes lessened the risk of fetal macrosomia, birth trauma, neonatal hypoglycemia, and operative delivery. The aim of the pilot study was to prepare for a multicenter trial by assessing patient acceptance of the study, by determining realistic accrual rates, and by detecting any major adverse outcomes in the control group that received routine obstetric care. STUDY DESIGN: The study was a prospective randomized controlled trial comparing fetal-neonatal and maternal outcomes in 300 women with gestational diabetes. Women randomized to the treatment arm were managed by strict glycemic control and tertiary level obstetric care, and women in the control arm received routine obstetric care. RESULTS: Three hundred women with gestational diabetes mellitus were studied. There was no difference in maternal
age, weight, or length of gestation between groups. The treatment mean birth weight was 3437 +/- 575 gm compared with 3544 +/- 601 gm in the control group, a difference of 107 gm (not significant). Macrosomia rates were similar. There was no birth trauma in either group. The frequency of neonatal hypoglycemia and other metabolic complications was the same. The mode of delivery also showed similar patterns. The treatment group had significantly lower preprandial and postprandial glucose levels by 32 weeks' gestation, which continued to term. CONCLUSION: This pilot study suggests that intensive treatment of gestational diabetes mellitus may have little effect on birth weight, birth trauma, operative delivery, or neonatal metabolic disorders. It has demonstrated the safety of proceeding to a multicenter trial of sufficient sample size to confirm these findings.

Publication Types:
Clinical Trial
Comparative Study
Multicenter Study
Randomized Controlled Trial

PMID: 9240606 [PubMed - indexed for MEDLINE]

[wombatclay]

naturegirl- I think the "right" care provider is going to be very understanding once you explain your history and your concerns. They want you to have a wonderful birth experience, and they should be willing to work with you to make you as comfortable as possible. If that means answering a million questions until YOU feel confident in their abilities, then they should be fine with that!

Just explain your birth experience, your worries/concerns, and ask them point blank if they have had experience with SD or other potential birth emergencies. Ask them what they did, what the outcome was, how they felt at the time, what they might do differently now, etc. Interview doulas and find out which of them have attended mamas who have had scary/traumatic births in the past...perhaps a doula who has experience assisting VBAC mamas? Just someone who will be able to empathize with your concerns about a birth not going as expected.

I had a really bad experience with my first doula and when the time came to interview doulas for my second birth I wasn't sure I even wanted one (and I'm a doula myself ). Anyway, when I interviewed doulas this time I was very up front about my past experience and explained that I had some trust issues and it wasn't personal...but that I needed to ask them A LOT of questions, sometimes the same question a few times, and were they going to be okay with that? The doulas who didn't want to spend the time helping me connect with them before the birth were obviously not the ones I needed with me so...it's the same thing with your new midwife. Be up front about your fear/concerns and see who reaches back to you.

You might also want to consider therapy, journaling, self hypnosis or hypnotherapy, or some other path to help you process and find peace with the trauma of your first birth. Birthing from Within has some wonderful exercises for this sort of processing as well. Emotional healing can take time too...and birth is so emotional/hormonal anyway that a moment of fear can just last and last if you don't take the time to address it in a productive manner.

What helped with my VBAC was remembering that every birth is a new birth, every babe is a new babe. Just because something happened in one birth and with one babe, it doesn't mean it will happen that way in another birth and with another babe. Obviously it's easy to go the "negative path" there and say "well things were okay last time but next time it may be worse"...but try to go the positive path and say "last time something happened that we didn't expect but things are going to be fine this time". I found the hypnobabies home study course to be a big help in releasing my fears and finding peace with my new birth...well, that, and bugging the heck out of my care providers and support people to make sure I was 100% comfortable with them and confident in their skills/attitude/support.

Good luck...I hope you find the perfect provider who will have the experience, attitude, and caring nature that will support you in your next birth! And I hope neither of us experience SD (or other birth trauma) again!

[liseux]

NatureGirl, there really is no way to be sure that your baby will be safe. I do think that having a mw who is calm and has dealt with severe SD in the past can help. It is hard to know because a true case is going to be a true test.

The difference between sticky and severe IMO: sticky shoulders get hung up but when mom flips over to hands and knees they come out pretty quickly with the next contraction or maybe the next one. The true cases are when the Gaskin doesn't work and the baby is stuck for at least 5 full minutes after delivery of the head.

It might just help to talk to midwives about your fears and hear what they think and the order they might go in if faced with a real SD. There are some midwives who just brush it off like, "oh, SD, piece of cake, its so easy to deal with at home where you have an unmedicated mom who can just flip over." Those mw's may have never seen a real SD, which thankfully is still rare. A mw who has a healthy fear and respect of SD would be a better bet.

[wombatclay]

liseux- So, my dd's head was out for a few seconds shy of 4 minutes (3 minutes 56 seconds by the clock) but the Gaskin manuever didn't work. My mind is pretty fuzzy in terms of details (ah, birth brain!), but her head came out while I was squatting, they tried the gaskin first, then side lying and then on my back with knees pulled waaaay back, then gaskin again I think...I know the knees up position wasn't the last we tried, but I also know I was on my back as dd was handed up to me since they started me on oxygen (to breath for dd via the cord) and had me massage dd while she was on my chest.

But she wasn't stuck for 5 minutes, she didn't have a brachial plexus injury, and she has no broken bones or dislocations. She was just stuck. I'm content with the diagnosis of SD, but I'm curious how you would label this case...

[mwherbs]

It sounds like shoulder dystocia to me-- one thing about shoulder dystocia is that there is room to put your hand in because there is nothing in the lower birth canal except the baby's neck-- because there is nothing there is why you can get a hand in to move a baby-- a shoulder dystocia that is like this gives me a bit of pause- differently than say a hospital dx of sd without many moves done

[naturegirl7]

Originally Posted by mwherbs

It sounds like shoulder dystocia to me-- one thing about shoulder dystocia is that there is room to put your hand in because there is nothing in the lower birth canal except the baby's neck-- because there is nothing there is why you can get a hand in to move a baby-- a shoulder dystocia that is like this gives me a bit of pause- differently than say a hospital dx of sd without many moves done

Well that explains why reaching in and "unhooking" DS worked! I swear that was the worst part of my entire labor/birth in terms of pain - the MW reaching in a doing whatever she did to unhook him. That was when I tore - not when he crowned (repeatedly LOL).

[naturegirl7]

wombatclay - thank you so much for the support and the suggestions. I think you are right - I thought I was okay with our birth experience as a whole until now. Moving and just thinking about replacing my MW is making me reprocess the whole experience and alot of my fears are coming to the surface. Atleast it is happening now, and not while I am pregnant though, right? And I can try to come to terms before I get pregnant again....Thanks for the interviewing suggestions - I was afraid that the potential MW may think I was a bit paranoid or negative for obsessing over this. But it is a real fear, and you are right that I need someone willing to listen to and support me emotionally in addition to being able to handle the SD itself. I was so focused on the impact on birth, that I lost sight of the emotional toll it is taking on me....

Maybe I will start interviewing now, even though it isn't until next year that we plan to TTC....I already told DH that I will NOT get pregnant until I find someone I trust to catch the baby. He doesn't quite get it.


Lisuex - I know there is no guarantee with anything in life - especially during childbirth - but I woud like a reasonable degree of certainity that my baby is safe, rather than spend the majority of labor scared and creating a negative birth environment for myself and my baby. I want a degree of certainity of safety to the point that I can trust the MW fully and surrender to the birth process rather than be plagued by fear.

[wombatclay]

Interesting...my ob did "reach in" and do the woods screw maneuver after the position changes didn't work. During the attempt to resolve the SD my care provider told me to push as smoothly as I could during contractions, and then (after a few minutes had passed) they asked me to push/bear down very consistantly even without a contraction. Do you know if that is a standard thing, or just their own way of addressing SD? It was the only time during the 4 hours of pushing that my OB told me how or when to push....

I have my 6 week visit tomorrow and hope to find out how the birth seemed from "their" perspective...one reason I've been researching the heck out of SD so I can discuss this on a medical as well as personal level.

[naturegirl7]

I wasn't pushing very long - maybe a half hour tops before he crowned and we knew there was some sort of problem.
My MW told me that she needed me not to push, that the baby was stuck on my pubic bone and that it was going to hurt but she needed to help getting him unhooked - then I felt ungodly pain. Then she said she needed me to push, to really give her a good hard push and get that baby born. Nada - then she said she needed me to get on my hands and knees cuz we really needed to get the baby out - that was all I needed to hear - like lightning I was on hands and knees - DH laughed and said it was the fastest he has ever seen me move let alone move while pregnant. Two pushes later, he slid right out. Everything was burning from tearing so I didn't even really feel him actually coming out - I sorta felt it as his legs came out and all the pressure disappeared....

I also wonder if his determination and impatience to be born played a role in the SD. He was pushing so hard that he actually had a bull's eye pattern bruise on his head - you could see different rings based upon how far I was dilated at the time. LOL So weird looking. Plus my contrax after getting to the hospital were hellish - like what I would imagine Pit contrax to be like, but I didn't have Pit (did use RLL and cohosh tea until labor started though) - I don't know if it was just anxiety of being in the hospital (I did NOT want to go there - it broke my rhythm something awful) - the contrax came so right on top of each other that I could not tell when one ended and the next began. The MW woudl ask me are you having a contrax? And I would pitifully answer "I don't know - it never stops!"
And with all the pressure from his descending so hard - I felt like I was being ripped apart - giving birth to a freight train not a baby - as I endured a 2 hour long contrax that just didn't stop for me to breath - all the while puking my guts up....Yeah, transition kicked my butt something awful. At one point I began begging DH to take me home - that I changed my mind and I wanted to go home - not about having the baby, just about having him in the hospital. That is when the MW got me out of the tub, started the IV and gave me a small dose of Stadol to relax/stop puking/get a break. I napped a bit on my side in the bed and woke up with the need to push - I would not allow Dh to leave the room to get the MW cuz I needed to push and this baby was coming. Of course she was right outside and heard my vocalizing with each push and came running in While I do have some regrets about the Stadol, I do think it worked well - if the contrax and pressure continued like that and I continued to puke - I don't know if I would have been able to remain calm or have the energy to push and reposition when needed.....but now I wonder if it played a role in him getting stuck.

[wombatclay]

Hmmmm... sounds like back labor. You babe might have been posterior or not totally "lined up" so perhaps for your next pregnancy you might want to do all the spinning babies/optimal fetal positioning stuff? My first birth ended in a c/s (after 32 hours of those never ending/no breaks between them monster tsunami contractions, 19 of those hours stuck at 7cm) and dd1 was posterior and her head was tilted all the way to the side (her molding was all over one ear and really funny looking...not a "round c/s baby" head at all ).

This birth I was really obsessive about positioning and dd2 was lined up well. You can read the whole birth story in my signature, but basically I got to 10cm really fast, then pushed for 4 hours. I used hypnobabies and can honestly say the birth was uncomfortable but not painful. Her head was visible between contractions for over an hour and she wasn't coming down further (her head got stuck first, she had a "divet" across her head from banging on the bone) despite everything. I didn't actually feel anything "extra" during the SD resolution, didn't even feel the 4th degree tear when she came loose. I DID feel the repair though since the local they used left "windows". So after my med free birth I wound up getting an IV and fentanyl to help during the repair.

Since I'm a total pain wussie I can only assume the birth hormones combined with the hypnobabies were doing their thing!

[liseux]

Naturegirl, I wasn't trying to imply that you should be living in fear during your next pregnancy, not at all. I agree that finding the right provider will help you have the comfort and trust that we all need when birthing. I definitely agree that it can't hurt to openly discuss all of this with midwives that you interview. I also think there is a point of peace that you will feel when you find the right mw. This subject is close to home for me so I may not put things into words that well. In a conversation it would sound nicer I think.

Wombatclay, it sounds like you had a true case of SD. I agree with mwherbs, it definitely wasn't a case of being stuck in a bad birthing position. In my case I also delivered my ds' head squatting & then had the shoulders stuck. I went through the same drill to start with and also was told to never stop pushing, even without a contraction.

Hugs to you both, i know how scary it can be to think about future births.