Homebirth - shoulder dystocia

[TerrysNo2]

Hi all

I am 38 weeks with number 2 and have been planning a HB throughout, we did try with DS but due to complications (back to back, expected long labour) I was transferred in.

The CMW has just been to deliver my pack and go through the checklist and she said that whilst "risk of infection" and "pain relief requirements" are a benefit of homebirth the main risk is shoulder dystocia which is when baby's shoulders get stuck on the way out.

She said that would mean baby was deprived of oxygen and an ambulance probably wouldn't get here in time to help the baby but I should be ok and that I need to understand this risk. No one has put things in such terms before and I am now petrified.

She also said its more common these days as babies are bigger and she said quote "we just don't know which baby its going to happen to" which makes me feel like I am playing russian roulette with my baby's life if I decide to go ahead with a homebirth.

I am really really upset and would love some other opinions / thoughts on this.

Thanks!

Firstly HUGs Terrys. It is a risk and one that my MW actually added to the list of risks that she discussed when she did my homebirth booking appt.

My MW stated that although it is a risk that has the worst outcome it isn't said to put people off of HB. My MW was great and stated that as I had no issues with that at 1st birth it less of a risk; she also stated that she feels my baby should be of similar size to DS (not accurate I know but an experienced guess). My MW was also very reassuring that MWs are trained to manovere babies with shoulder distocia although this isn't always successful.

I am definitely going for HB still, but am glad to be aware of the risks. It may be worth discussing your worries more with your MW & ask re: actual risks for you.

I hope that you manage to come to a decision re: HB that is right for you xx

Don't see how shoulder dystocia would deprive baby of oxygen if cord still attached? Very surprised a MW would say this so bluntly - yes, you need to make an informed decision but it sounds like blatant scaremongering to me, esp with your 2nd. I've had 3 HBs and never had this said to me so graphically. ALso I understood that it may be uncomfy (!) for you but like bumpand I thought MWs were trained in baby manipulation, and if necessary to cut you to help baby out

My understanding is that they would perform EXACTLY the same manoeuvre that they would in hospital - the McRoberts I think it is called.

There will be two midwives there at that point to try and help get baby out. Is it possible that she herself isn't comfortable with the idea of homebirth? It certainly wasn't something that was mentioned to me when I planned my first homebirth.

If you can find it, there is an episode of Home Birth Diaries where the baby suffers shoulder dystocia, the MWs change mum's position immediately and tell her exactly what to do, baby and mum suffer no ill effects. Baby was about 12lbs I think!

Thanks all (hi Yorky, its ChocOrange from Nov 2008 AN thread )

I appreciate all your comments and I know HB are not 100% risk free, no birth is really but I couldn't believe the way she was saying this to me.

She also mentioned that she wouldn't be doing the HB and hadn't done one for 4 years. It didn't feel like she was trying to scaremonger me but the way she said it has made me feel almost neglectful for even considering it.

My mums friend is a community midwife (who does HBs) so I've asked her to call me and hopefully I'll get a more informed opinion!

DH is away and back tonight but I can imagine his reaction would be to veto the whole HB option as he is very risk averse so I want to arm myself with information before we discuss it.

FWIW DS was 8lb 2oz and this one is measuring normally (think it was 36cm at my 38 week check on weds)

Hi ChocO love your new name :D

Out of interest, did she give you any stats for how likely shoulder dystocia was - yes its not great, but I also thought it was reasonably rare?

My biggest was DD at 9lb9 although I was told about 5hrs before she was born that MW thought she'd be about the same size as her brother, who was 2lbs1oz lighter it turned out!

Hope all goes well for you

Just about to pick up dd. Will come back later but it's the Gaskin technmique - will post details. Ina May has 100% success rate with it. Don't worry and your cmw should be ashamed scaring you like that!

I thought my name was quite clever!

She gave me nothing except "we don't know which baby it will happen too" and she said they are more frequent now as babies are bigger (but that she hadn't done a HB for 4 yrs )

I was so confident about my choice before that this has just knocked me for six. Going to have a good chat to DH tonight.

Yorky, there can be oxygen deprivation in prolonged causes of shoulder dystocia due to neck compression and obstruction of cranial arteries.

Yes Flisspass, the community midwife would follow the same drill as in hospital, mcroberts, rubins, woodscrew but the key is having as many hands
on deck as possible. Depending on mum's size and position it can sometimes take two people per leg to do mcroberts correctly while two people do rubins, eg. It is also good to have people waiting for baby to be fully prepared with resus equipment etc.

laluna thanks for your comments, do you have any experience of Shoulder Dystocia or homebirths? Your comments sound quite informed so just wondering what they are based on. Thanks :)

Hiya Terrys, I've had much the same conversation with 2 cmw's and a consultant. Felt very much like they felt like we were being irresponsible! They said that my babywas 'at risk' because my BMI is slightly high and that I needed to be aware of the risks. I asked for more guidance then went off and did some research. When I have discussed it with clu led mw's they felt that there was no more risk at a hb than at the clu. Really it is entirely your choice and I'm sorry that they have scared you with their bluntness. There are risks we need to be aware of with hb and any birth! I feel my decision point is how able we are to justify it or evaluate these against our own beliefs/thoughts/risk assessment. If that makes sense! I can highly reccomend trying as best you can to put it out of your mind for tonight at least and re-evaluating when you have had time to try to relax and 'sleep on it'! Not sure how much help that is but didn't want to not answer you when I have had much the same discussion and the same panic and worry! I've had many conversation on the nov thread and have also started a thread on homebirths which might be interesting for you (or not!).

TerrysNo2,

I've been a midwife for 15 years - currently in charge of delivery suite in a 5000 births per year unit. Had hands on experience of shoulder dystocia a few times!!!! Had three last week while I was on duty - fortunately with good outcomes.

It is a hard call - this concept of risk isn't very helpful because noone can ever predict an outcome. An obstetrician will always err on the side of caution simply because it is their job to be involved when things go wrong. It is often all they see and when you have experienced a poor outcome it is easy to see where they come from in wanting to take no chances.

For what it's worth, my opinion would be based on your previous delivery. If you had a vaginal birth (including instrumental) of an average size baby and there are no other medical/obstetric risks I would look after you at home and have no worries. My first baby was 8lb - ventouse delivery. If we had known about my second in advance (9 lbs 7 oz) it may have been reasonable to consider shoulder dys. as a risk. However he flew out in no time!!

Are there concerns about the size of your baby?

Hi voodoo thanks for giving your input, its really good to hear other experiences. I am very conscious that all births involve some degree of risk but it was how she put it that really scared me. I feel much better now with a bit of time since her visit but I was so upset before, poor DS (almost 3) was watching me cry and said "what that lady say" and " you read my chuggington book and you feel better" - he really is PMA in a gorgeous package

Having done some research and spoken to my mums friend (the CMW) it seems that there are less instances of shoulder dystopia at home because you are more active and it is more likely when you are lying in a hospital bed (because your pelvis doesn't get as big) and in addition I can't fully understand what they could do in a hospital which they couldn't do at home. I will have 2 MWs here helping. Next time I speak to my CMW I will ask them too as they will be the ones actually doing the birth.

laluna thanks for clarifying your experience, it sounds like lots! AFAIK there are no concerns about size, I have put on 1 stone in weight (compared to 2.5 with DS) and am measuring slightly smaller on FH (36cm at 38wk check) - I am quite tall but slim and have a average BMI usually. I certainly haven't had any comments whatsoever about not being suitable for a HB, had a very easy pregnancy (as last time) and a relatively simple first labour.

All my instincts are telling me to stick with the HB but I couldn't ignore what she said as it was so blunt and scary.

voodoo can you link your other thread on here so I can look? Thanks

Wow! the experience and wisdom we can access on MN is amazing. I'd also got the impression you sounded well informed Laluna, so glad to have it confirmed its for real not the kind of 'my neighbours sisters gerbils cousin had a shoulder dystocia they were discussing in the pub' type expertise

this is a dead good link

shoulderdystociainfo.com/index.htm

Lots about research, risk factors and maneuvers (at the end)

Yorky exactly why I asked the question , I like informed opinions too, MN is amazing and I am v grateful to all of you who have commented here, its really helped set my thoughts in order

I think what the MW said was bang out of order! Surprised she didn't throw in some statistics about still birth rising for over due births while she was at it.

She may personally have had a bad experience in the course of her job.

It doesn't mean you will.

THINK POSITIVE

Terrys as you know, I am no medical person but I think you know where I am coming from, from other threads.

A HB has risks, a MLU unit has risks, a CLU birth has risks. The outcomes for HBs are no worse than hospital and sometimes the intervention in hospitals can lead to poorer outcomes (perhaps mentally rather than physically).
If catastrophic outcomes were common, no one would offer HBs.

Anyway, it is my belief that the vast, vast majority of women do not grow babies too big to birth. Yes, there is a risk of shoulder dystocia with a hb but as you state, at home you are much more likely to adopt different positions to help the descent. There is also a risk of cord prolapse, PPH,uterine rupture, tearing etc etc. I wonder why she only mentioned the dystocia? Luckily these complications are rare and mws experienced in HB are well-trained to deal with these.

Ina May Gaskin learnt a maneuver (sp?) from indigenous midwives in Guatemala to deal with shoulder dystocia and has used it so successfully it is now named after her - the Gaskin maneuver. In her Guide to Childbirth she describes how she has helped many many women with babies of all sizes by getting them to turn onto all fours if the shoulders get stuck. It has worked every single time she has used this procedure.

Another mnetter recently gave birth to an 11lb+ baby at home with no tears with an IM, and I am sure if you stay positive and get the risk into perspective - like all HBs there are risks but IMO there are risks with going into hospital.

If you get time, I strongly recommend you read Ina May Gaskin's Guide to Childbirth - it is so empowering.

And watch mybirth.tv, there's a video of SD at a homebirth on there. Somewhere!

My baby had shoulder dystocia. I was in hospital though. The midwives tried the technique they use but could not make it work. The obstetrician was waiting just outside in case they had trouble and came in very sharply. As it turned out the cord was wound around the baby's neck and preventing her from coming out as well as tightening round the neck. The obstetrician dealt with it so fast, it is a bit of a blur. Baby was blue and not breathing. She was oxygenated in the room as all equipment was there. In my case it turned out all right but would not have at home. This could not have been foreseen. However, we were aware the baby was above average size before labour and for me, this risk factor would be key in any decision. She was also a first baby, not second like yours.

volumnia, you weighed up the dangers before hand, and made up your mind to have a hospital birth.

The OP is weighing up the pros and cons and atm is opting for a home birth.

I weighed up the options with for my 3 labours, and decided that a home birth was the safest option for DC3.

As did my mother, with her 4 births. My brother was born at home, with the cord wrapped around his neck. The midwives dealt with is swiftly and safely.

volumnia, your experience sounds very scary and it would be for any pregnant woman, but you cannot say it would not have been OK at home. It may have been, it may not have been. HB midwives are highly trained to deal with emergencies like this and can and do unwrap cords and similar. they also carry oxygen and other medical equipment.

Worst case scenarios are rare and most can be dealt with by blue light to hospital in under 30mins.

I am not saying that a home birth is bad, but like with any other birth option, it is for you to weigh the risks. I fully support a woman's right to choose.

The midwife said nothing wrong, in fact I am happy that there are HCPs out there who are honest about risks.

I want an elective cesarian when I have my baby and it never stops people from telling me that I might die ( the maternal mortality with cesarians is slightly higher ). There will always be people who will run down your birth choice, but you have to take it with a pinch of salt.

The truth is, shoulder dystocia is associated with nerve damage and a risk of cerebral palsy. Just google shoulder dystocia and you will see the explanation in one of the first few links.
This is no offence meant to any midwives, but sometimes it helps to have an an obstetrician around. I think it is common practice to request the help of an obstetrician, anesthesia and pediatrics for subsequent resuscitation of the infant, if required. I'm sure there have been cases where SD has been dealt with successfully at home by midwives, but in emergencies the assistance of an obstetrician and a paediatrician may be required.

In some cases, it may even become necessary to perform the Zavanelli's maneuver followed by a cesarian.

There is no point in being an ostrich. It is better to be informed of the possible risks, rather than to find out later.

I agree wantstobeaman so thats why I wanted to fully research this after she mentioned it. I think its important to know the risks but I think her manner of telling me was very uninformed - no stats, no real experiences, just "it could happen to you".

I am definitely going to complain mention it to my other CMWs.

Just out of interest, does anyone know the stats for Shoulder Dystocia - how many cases, positive outcomes, negative outcomes etc?

Thanks

My DS had shoulder dystocia, I had a homebirth with one IM. MW shouted (scariest bit) for me to change position immediately and DS came out. I'd do it again. No problems for us.