Being advised against home birth due to risk of shoulder dystocia

(86 Posts)

Hi I'm 36 weeks pregnant with DC2. DS was born via forceps delivery and his shoulder got stuck briefly - it was released with the mcroberts manoeuvre and supre pubic pressure (sp?) within a matter of a few minutes at most. I had wanted a home birth with him but was transferred to hospital due to his high birth rate, pushed for 2 hours then was taken to surgery for epidural, episiotomy and forceps delivery.

I believe the shoulder dystocia was caused by the following

*high bmi (30 when falling pregnant)
*large baby 9lb 7oz
*being forced to labour on my back despite instinct telling me to turn on all fours
*forceps delivery

this time around
*my bmi was 25 when falling pregnant
*according to growth scan today baby is average size for dates (I am aware this isn't necessarily accurate)
*part of the reason I would like a home birth is do I'm free to move around/avoid time constraints and can push in my own time and whatever position feels natural

I have seen a doctor (presumably obstetrician) today who basically told me to think of my baby, once head is out we've got 9 minutes to deliver or your baby is dead and I should have him/her in hospital.

Understandably I'm very upset, I don't want anyone to think I'm not putting my baby first but feel my needs are important too. I've never left DS for more than a couple of hours and thought that by having a home birth I'd have him close by and therefore feel more relaxed and confident in labour. , I'm also feeling in my gut that the chances of it happening again are reduced by mine and baby's size and would be reduced further by having an active and relaxed birth environment that I don't feel I could get in a hospital.

Does anyone have any light to shed? Am I high risk? Is there really a huge advantage to being in hospital if SD was to happen again? I live 15-30 mins away if that makes a difference

high *heart rate!

MagicMikesThong Fri 21-Sep-12 16:56:43

I completely understand why you want to have a home birth, but I think you need to ask yourself how you would feel if something were to go wrong?

I don't think they would be discouraging you unless they truly felt that there was a risk...

Northernlurkerisbackatwork Fri 21-Sep-12 16:59:34

Shoulder dystocia is hard to predict. It happens in plenty of low risk women - my friend had one only a few months ago. No risk factors at all, scary couple of minutes but baby was ok. The drop in your BMI is impressive but may or may not make a difference. The only way to know is when you're delivering. The baby's weight - scans can be out either way and even if they aren't, a large baby is a risk factor but smaller babies can get stuck too.
I know you want a home birth but in your shoes I wouldn't risk it for a second. You live too far away from the hospital. In hospital you have a whole shift of people at your disposal and if the dystocia happens and is bad you'll need all of them. At home you have two midwives with very little time to get the baby out.

You can have an active delivery in hospital. In your shoes I would be concentrating on a strong birth plan for hospital and not risking the same complication at home.

Thumbwitch Fri 21-Sep-12 17:05:11

I think, in your position, that I wouldn't risk it but I would try to make sure that I had someone there to advocate for me in labour, so that I could do things in a way that suited me better.

I have a friend whose 3rd baby was a shoulder dystocia case - he was oxygen deprived and had to be airlifted to a more appropriate hospital shortly after delivery, where he was cooled for 72h to limit any brain damage and she couldn't hold him for a week because of all the tests and so on that needed doing. She can't talk about how traumatic it was, even now (a few months down the line) - so I don't know how damaged she was in the process of getting him out - but it's not a risk I'd want to take at home, that's for sure.

HotHotNot Fri 21-Sep-12 17:06:12

Speaking as someone this happened to, one of the main risk factors for shoulder dystocia is a previous one. I think your consultant is being factual rather than scaremongering. Of course it is all chance and circumstances but I would be thinking about hospital after staying at home as long as possible.

You need to have someone with you to be strong about your birth plan.

i would be seeking a second medical opinion in your shoes. but if they agree, i wouldn't have a hb against medical advice.

push for an active birth in hospital instead.

LittleBairn Fri 21-Sep-12 17:12:27

I think your point about being able to move around as you please and not going against your natural urges is important.
If you do have a hospital birth you need ( or your birth partner) to be prepared to put up a decent fight against being forced on your back and excessive monitoring.
Have you contacted local independent midwives to see how experienced they would be deal with shoulder dystocia in a HB? That might help make up your mind.

Northernlurkerisbackatwork Fri 21-Sep-12 17:15:12

Why would independant midwives be better able to deal with a dystocia?

lynniep Fri 21-Sep-12 17:15:37

I think you live too far away from the hospital (having said that Im biased - I give birth quickly and had I not been admitted because of the meconium I passed then DS1 would not be here - we very nearly lost him anyway, and his shoulder did get stuck, but it was an entirely different circumstance as he was breech).

I wouldn't risk it I really wouldnt. You've done really well to reduce your weight, but I'm not sure how that impacts on the situation as you werent that obese before (ok borderline by the charts). As you said growth scans arent necessarily accurate (DS2 was 10lb3 but I was told he was 'average' - he didnt fit newborn clothes)

If its happened previously, then apparently this a factor of it happening again (amongst other things - like you said baby being large is one of them)

At the end of the day, its your call. I just think you're so far away from the hospital in my situation I wouldnt risk it.

Rainbowbabyhope Fri 21-Sep-12 17:16:21

My independent midwives who do homebirths are fully trained to deal with shoulder dystocia at home and manage it the exactly the same way as yours was handled in hospital. I don't think NHS midwives have the same level of training which is why the doctors deal with it in hospital - which automatically makes it a bigger deal. On your decision whether to have a homebirth, I would definitely recommend getting as much information from as many sources as possible in deciding whether a homebirth is for you this time - talk to lots of different medical professionals and do your own reading and research - there are a number of good studies out there which are very accessible. It is very easy to get negative responses from people who are ill-informed about the home/hospital birth debate regarding risks and who have never done any research on the topic.

ColouringIn Fri 21-Sep-12 17:24:35

Have you looked at Angela Horn's site...will link to it but if you google "Angela Horn" and "home birth" it will come up.

You sound like you have read the research and definitely you had some risk factors last time. This time your only risk factor is the fact that you have had a previous shoulder dystocia and certainly that rings alarm bells to most midwives and obstetricians. It's knowing if this alarm bells are justified which is the issue.

There are other things which can impact like the pubic arch etc when looking at the mechanics of birth. Angela Horn's site has loads of research to help you along.

An active birth is possible in hospital because you can refuse continuous monitoring and have intermittent etc.

The only other thing to say is that often with shoulder dystocia there are warning signs such as a slow labour, poor descent etc (going back to my midwifery days here) so this needs to be watched carefully....either in hospital or at home.

Northernlurkerisbackatwork Fri 21-Sep-12 17:26:35

Rainbow - did you mean to be rude about the people who have already offered opinions on this thread? I assume you in fact know nothing about our level of knowledge or experience on this matter?
The full medical team may be called to deal with dystocia occurring in hospital. That doesn't make it a big deal. It IS a big deal. Life threatening in fact.

Thank you everyone who's responded so far. It's interesting to hear other people's stories and I am definitely doing research and weighing up the risks. My thought is that I really don't want another hospital birth but I'm not going to be stupid about it. If my baby is in danger I will do whatever it takes to minimise the risks.. My concern is just that the risk is smaller and community midwives would be able to use the same procedures at home as in hospital unless it was an extreme case, but I wonder how likely it would have been to happen if I was allowed to be active last time.

I realise 30 isn't a hugely high bmi, I should probably mention I put on 5 stone in pregnancy, I know they don't measure bmi while you're pregnant but it was closer to 40 by the time I gave birth.

rainbow when you say independent midwives do you mean private paid ones or those working in the community for the nhs?

lotsofcheese Fri 21-Sep-12 17:32:52

I personally wouldn't risk it. How could you ever forgive yourself if it went wrong?

Rikalaily Fri 21-Sep-12 17:33:20

I was in your shoes when expecting no.3, I told them to bugger off with the scaremongering and went for a homebirth. She was born in hospital in the end because they overreacted and called an ambulance when I was in full blown labour saying that I had mec in my waters (waters hadn't broken as it turned out) but she arrived with no hint of SD despite her being heavier than my second and I was on my back when she was born. My second who had been a SD was born on all fours, it was her position that caused the SD, the position is more of an issue than the size.

Frakiosaurus Fri 21-Sep-12 17:36:16

In a hospital you can have 6 people helping resolve SD/caring for baby within seconds of delivery. One on each leg, one applying supra pubic pressure, one guiding the baby out, two to resuscitate the baby if necessary...

That's not intended to scare you, but I would be listening very carefully to the consultant particularly given your history and weighing up whether 2 MWs have enough hands. Or one of you labour quickly and the second doesn't make it in time as happened to a couple of friends of mine.

ColouringIn Fri 21-Sep-12 17:36:31

Shoulder dystocia is a very scary event.

The issue is in predicting those who might be at higher risk of it. The OP sounds like she has done her research with regard to the issues which led to it last time and made changes to reduce those risk factors or eliminate them.

Now the only risk factor appears to be "it happened before" and of course it can be argued that it happened before because of the risk factors which are absent this time.

As a (currently non practicing )midwife I'd be advising caution and to really look into things before going ahead. Also taking into account how relaxed the OP might feel at home if she has the slightest concern that the same scenario will arise again. If there is any doubt in her mind then that WILL impact on how relaxed she is able to be at home.

It's about knowi the mechanics of labour, what warning signs might suggest she needs to go in...like slow labour, poor descent etc.

It's rarely as simple as hospital versus home.....in hospital you do have the time advantage but a clinical environment. At home you have the relaxed environment but need to be aware that if any of the warning signs present then you need to go in while in strong labour sometimes. This in itself can be an ordeal.

HotHotNot Fri 21-Sep-12 17:37:01

Good luck with your decision. I know it is an unenviable one. You can pm me if you like as I don't want to go over much here, but I had a hospital birth first time and absolutely could not have entered one again unless there was a clear risk to me or baby. I have had home births against medical opinion after much research. I had a dystocia at home. As far as I am concerned it would "risk out" home birth for me, not that I am doing it again.

birdsofshoreandsea Fri 21-Sep-12 17:38:15

Message withdrawn at poster's request.

ColouringIn Fri 21-Sep-12 17:43:52

Just as thought OP, but we're you given a drip "to speed things up" last time.....that can actually cause problems because a large baby can be forced down only for the labour ward team to find that when the head delivers the shoulders are stuck.

BedHog Fri 21-Sep-12 18:08:27

I'll give you my stats for comparison. It sounds like I had a similar first birth to you - episiotomy and forceps, big baby (10lb 4oz).

With my second baby...
Pre-pregnancy BMI of 17.
Scan showed a small (2nd centile) baby, she was actually 10lb 5oz.
I spent most of labour on a birthing ball and gave birth on my knees, leaning against a bed. Nobody forced me on my back.
DD still had shoulder dystocia, fortunately freed by 2 midwives but the emergency bell had been pressed and there were around 8 people in the room at time of delivery. So in my case baby and I would probably have been ok with a home birth, but no guarantees. If the two midwives hadn't freed DD then I'd have been whipped into theatre for a CS under general anaesthetic.

Also when your doctor said they have 9 minutes to get the baby out alive, it's actually only about 3 minutes before there is the risk of brain damage, and obviously the longer it takes, the more likely this is.

Don't think I'd risk it. But then I feel reasonably comfortable in hospitals and would be far more stressed giving birth at home.

Rainbowbabyhope Fri 21-Sep-12 20:35:57

Northernlurkerisbackatwork - of course I wasn't being rude to those taking the time to comment here! I was merely advising OP to arm herself with as much information as possible when making a decision about the relative risks or homebirth/hospital birth. It is difficult after a tricky first birth to make decisions and assess risks objectively (on a non-emotional basis). I had a stillbirth earlier this year (a hospital birth) and am now pregnant again, planning my next birth so I know how easy it is for me to be swayed by someone telling me to 'think of my baby' as OP was told as the answer to every decision without undertaking a proper assessment of the relative risks. I think this is a very personal decision and to make it properly you need to have opinions from a range of people and not just one NHS consultant.

Those asking about independent midwives - the independent midwives which I have (private medical care) are specialists in high risk cases that the NHS won't even consider for homebirths (because of guidelines etc) and have amazing successes with people in these kind of situations. I haven't hired them because I am set on a homebirth (indeed I am currently thinking of hospital birth) but because I know that they will help me reach balanced and considered decisions about my care, something which I personally find very difficult to do in the disempowering hospital environment.

dontcallmehon Fri 21-Sep-12 20:48:36

I wouldn't and I've had two home births.

colouringin that's interesting, I did have a canula which I presumed was to stop me getting dehydrated but my midwife informed me the other day it also contained something to make me bleed quicker after delivery - so who knows what else it had in it. This is one of the things that puts me off a hospital birth; you become a patient the minute you walk through the door and personally I feel less able to question what's 'happening' to me when I'm there than I might at home

thank you everyone for your input, I'm starting to be able to build up an idea of the other side, some questions for the head midwife who I'm seeing on Monday (such as would my current birth plan ie; no internal exams stand in the birthing centre) and be a bit more diplomatic about the whole thing. Obviously the most important thing is that baby is OK but I feel my needs need to be considered or I'll never be relaxed enough to give birth!

*rainbow I'm so sorry for your loss, I can only imagine how important these kind of decisions are for you given your experience. I hope the midwives you are hiring take the greatest of care and help you have a birth that's as close to your wishes as possible

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