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

MrsHBaby3 Wed 02-Jan-13 20:29:58

Just because it happened before doesnt mean itll happen again, and ahomebirth is much more relaxing than a hospital birth. Being restricted in moving imo is a big factor why baby got stuck, especially if you felt your instinct was to go on all fours. Theres a well known manouvere called Gaskin manouvere which is basically moving to all fours to release shoulder distocia. Look it up on google, its named after an amazing lady called Ina Gaskin.
Perhaps as a compromise you can go to a birth centre? Personally I would judge each preg and birth on its own merits, and if it does happen again, you are definitely better equiped than first time around. Dont let anyone scare you into doing what they want. Noone would risk their baby, so using that as an arguement is absurd.
Good luck!

AnotherTeacherMum Tue 01-Jan-13 23:30:15

I've only just realised how old this thread is blush you've ppss even had baby by nowgrin

AnotherTeacherMum Tue 01-Jan-13 23:22:45

Shagmund I'm a bit concerned by your post suggesting that SD is no reason to be out off homebirth. I know its a natural process and too medicalised in hospital etc but in countries without medical care 1 in 7 women die in childbirth(disclaimer- I recall reading this in the news but cannot recall where).

What is at risk is the OP's life and that of her baby.

The birthing centre is a good compromise as at least there is extra equipment/ staff SHOULD it be needed.

Everything will probably be fine, but it's just not worth taking the risk (however small) when there is a history of something as serious as shoulder dystocia.

We like to think it is all in our control- low BMI,don't have an epidural, our 'intuitive' idea of how big the baby is- but actually I had a low BMI, active labour, no epidural (fucking wish I had though as he ended up being manhandled out by a burly obs with forceps only after a couple of attempts with ventouse failed) but I still had SD.

I also fully support home birth when there are no indications that there will be a prob. A previous SD is a clear indication that there may be probs.

However I am sure all will be fine for OP- 2nd time is very often easier... good luck xxx

AnotherTeacherMum Tue 01-Jan-13 23:11:40

Hi

I also had shoulder dystocia with my first, although they had a few more probs getting him out. He was 9 lb 13.

It came as a complete shock to all. I had a low bmi before I had him ( I am about 5'4" and weighed 9st), I put less than 2 stone on whilst pg, every scan/ check up they told me his size was normal and there was no hint of a problem until my 2nd stage became very extended (2 hrs) there is no way I could have transferred to hospital in 2nd stage labour - it was lucky I was at a hospital, the MW hit a panic button and in minutes there were more MWs, obs, paed team to resucitate(sp?) ds if neccesary.

I know you are worried about leaving your LO but if all is straightforward as you feel it will be, you will be back home really quick. I asked to be discharged 6 hours after dd was born and they were fine. But if anything had gone wrong at least I was in the right place.

Shoulder dystocia is SERIOUS. You sound like yours was minor, but I have a friend whose dd has no use of one arm because her nerves were damaged by a shoulder dystocia birth.

I really think you should go for hospital.

LilyBolero Mon 01-Oct-12 22:13:57

I honestly think if I had another (which I'm not), that I would go for an elective CS, because that experience of the baby being stuck, and not knowing how or if he would get out safely was too horrible. I feel like I wouldn't want to push my luck!!!

mayhew Mon 01-Oct-12 16:20:18

Just want to say Go Shagmund!

Shagmundfreud Mon 01-Oct-12 13:35:46

Good result OP - glad you've been listened to. Good luck with the birth!

(oh and sorry to hijack the thread)

"but I will say that anyone who chooses to have a VBAC (which carries a small but significant risk of uterine rupture that can be fatal for baby and mother) distant from obstetric and neonatal facilities is, in my opinion, taking an unnecessary risk with the life of their baby and choosing the experience over the outcome."r

TrainTrack - why don't you ASK women who've opted for a VBAC at home why they've done it? Maybe you don't know anyone who's done it.

The women I know who've done it have made the choice because they believe they are more likely to have problems in hospital. Problems like stalled or prolonged labour. Some feel that a uterine rupture is MORE LIKELY in hospital because of these things. Or they have been traumatised by their first birth and feel unable to go back.

Seriously - glibly repeating that women who have been labelled 'high risk' who opt for a homebirth are valuing 'the experience' over the life of their baby is cruel and to be honest, a bit thick. Birth isn't like a fucking spa treatment. Women are desperate to get through it in what they believe is the the healthiest way they can - for them and their baby. And for some women this means choosing a homebirth even when they've been advised not to. It's not unusual for women to reject the advice of health professionals they don't trust or those they feel are not treating them and their baby according to their individual needs and obstetric history. You see posts about it all the time on mumsnet.

"Shagmundfreud, it is all very well to say that it was not a problem to have a shoulder dystocia at home as it was easily managed. Sometimes they are very difficult to manage and the baby can require cardiac massage and intensive resuscitation"

Yes - I understand that Maxbear. It's obvious that a baby born after a severe shoulder dystocia will probably need paediatric input and is not going to get that quickly if they're born at home. But oddly, given that shoulder dystocia is often completely unpredictable, and not that uncommon, it doesn't seem to have impacted on neonatal morbidity and mortality as a whole for babies born at home.

Which leads me to conclude: that's because it's probably less likely to happen at home, and that when it does it's generally managed appropriately and safely by midwives. I appreciate your friend's experience (and the mother's she was caring for) was hideous, but the occasional scary birth (with a good outcome in this case) is not a rationale for a mother who is not at specific risk to be refused a homebirth. And that was the focus of my response to the OP - she was deemed to be a 'high risk' for a birth at home on the basis of a 'possible', mild, shoulder dystocia, which was easily resolved, during the birth of a massive first baby BY FORCEPS and following an epidural! Would you really say this mother was any more at risk of a repeat, severe shoulder dystocia? More at risk than a mum with a BMI of 30, known to be carrying a 9lb baby, who in most places would be ok'd for a homebirth?

The other point I made on this thread, and which I really can't get my head around, is why it's OK for those mothers who are considered at risk of a shoulder dystocia to be positively ENCOURAGED to have an epidural, when we know that forceps and supine birth put them at an additional risk of shoulder dystocia? Is the attitude, 'oh well, it doesn't matter if they have an SD in hospital - the increased risk is OK, because we've got pediatric intensive care services on standby?' I think that's shit.

Just a quick update - saw my midwife in the week and have decided on the birthing centre. She was appalled at the way the consultant spoke to me (I think her blunt manner and patronising tone was the thing that upset me the most) but was very supportive of my feelings and final decision and is very encouraging about my birth plan. She said that the consultant only ever sees emergency cases so her attitude may have been marred by that. Only 2 weeks to go until my due date (although I suspect baby will be late) - it still doesn't feel real. Hope I've made the right decision. Thanks again for all your comments.

exoticfruits Sun 30-Sep-12 22:10:03

I can't see the issue- opt for safety.

maxbear Sun 30-Sep-12 22:06:52

Shagmundfreud, it is all very well to say that it was not a problem to have a shoulder dystocia at home as it was easily managed. Sometimes they are very difficult to manage and the baby can require cardiac massage and intensive resuscitation. This happened to a midwife friend of mine a while ago in an out of hospital mw led unit, the baby was trapped for 5 minutes or so and the midwife had to do mouth to mouth (well bag and mask) ventilation and cardiac massage on the baby in a moving ambulance. The baby survived but everyone wished that it had been born in the hospital, it would have been far less traumatic for everyone involved and the baby would have had help that bit sooner. Yes they are managed the same in which ever place the mum delivers but the difference is that at home there are not the same paediatric facilities and fewer pairs of hands to help with baby and mum.

traintracks Thu 27-Sep-12 11:53:40

I clearly shouldn't have wandered into a mumsnet thread on home birth as I'm so out of step with the thoughts on here ! I don't want to derail the OPs thread so will bow out, but I will say that anyone who chooses to have a VBAC (which carries a small but significant risk of uterine rupture that can be fatal for baby and mother) distant from obstetric and neonatal facilities is, in my opinion, taking an unnecessary risk with the life of their baby and choosing the experience over the outcome. The last comment was very telling, that an IM helps a woman to feel safe. If they are high risk then this may well be a false sense of security

And yes I have met more than one woman who has rejected life saving obstetric care and in both cases it was on the advice of midwives who had the view that any birth could be normal and intervention is automatically a failure.

Shagmundfreud Mon 24-Sep-12 23:06:20

"And yes of course I am being deliberately provocative but I just find it amazing how many people value the experience over the outcome"

You are being INCREDIBLY insulting. sad

I chose a homebirth with an IM because I felt is was SAFER for me and my baby, than going into my local, understaffed maternity unit, where I'd had what I felt to be inadequate care with my first child.

All the other mothers I know who booked an IM did it because they wanted to feel safe and guarantee good care in labour.

Shagmundfreud Mon 24-Sep-12 23:02:44

"And I believe that if you adjust the data on home birth complications to reflect the fact that the cohort of women started as low risk, it does show home birth to be riskier, especially for first time mums."

If you are referring to the Place of Birth Study 2011, it does NOT show that home birth is riskier, except for first time mothers.

And actually the study clearly shows that outcomes for ALL healthy mothers, including those having their first baby, are just as good for mothers AND babies birthing in free standing midwife led units, where there are no doctors on site, or neonatal facilites!

"If IMs are brought into the NHS fold then hopefully it will stop some of the crazier ones who offer home births to women who are breech or have bad obstetric histories."

Sorry - you clearly have NO idea how home birth midwives practice at all. Mothers contract midwives to provide the care that they want. The mother contracting the midwife will discuss with her the risks and benefits of her choices and then it is left for the mother to make up her own mind how she wants to proceed. And actually this happens with the NHS too. I know two people who live not a mile from where I'm sitting now who've had 'high risk' home births on the NHS. One who had twins, and the other who has had 2 VBAC's at home. These may not be choices you approve of but the women have a right to make them. The midwife's responsibility is to make sure the mother is making an informed decision.

And the one big study on IM's I did look at showed that when it comes to caring for low risk women, they had just as good neonatal outcomes as NHS midwives, and in relation to birth injuries, vastly better maternal ones

"that when women in many parts of the world would give their right arm for safe obstetric care, we in the UK often reject it, forgetting that modern obstetrics is the only reason that we see childbirth as low risk."

Women in the UK 'often reject obstetric care'? Oh come off it. Women rejecting obstetric care when it is clear their baby needs medical or surgical intervention to be safely born is as rare as hens teeth. I personally have never met anyone who's said 'no' to a c/s or assisted delivery when it's clear that they need one. Have you? Has anyone on this thread?

And I don't for one minute think that as a nation we see childbirth as low risk, modern obstetrics or no modern obstetrics. Most women know that birth can become dangerous for mothers and babies, Which is why we choose to be looked after by midwives whose training enables them to spot when something is not progressing normally, rather than just giving birth alone in our bathrooms!

traintracks Mon 24-Sep-12 22:42:07

And yes of course I am being deliberately provocative but I just find it amazing how many people value the experience over the outcome.

traintracks Mon 24-Sep-12 22:20:11

Why would you sue an IM with no insurance? It would be a waste of money.

And I believe that if you adjust the data on home birth complications to reflect the fact that the cohort of women started as low risk, it does show home birth to be riskier, especially for first time mums.

If IMs are brought into the NHS fold then hopefully it will stop some of the crazier ones who offer home births to women who are breech or have bad obstetric histories.

Being in hospital isn't pleasant but it beggars belief that when women in many parts of the world would give their right arm for safe obstetric care, we in the UK often reject it, forgetting that modern obstetrics is the only reason that we see childbirth as low risk.

Shagmundfreud Mon 24-Sep-12 20:54:41

"Shoulder dystocia kills babies and is unpredictable"

Actually SD VERY RARELY kills babies in the UK. Thankfully.

"It is the main argument against home birth"

Two points here: giving birth in hospital puts you at higher risk of SD, because it also puts you at higher risk of forceps delivery and augmentation, both things which are associated with higher rates of SD. And given that SD is no more easily resolved in hospital than it is at home, that's worth some consideration.

Second point: apart from for first time mothers, there is no evidence that overall babies born at home or in free-standing birth centres (which have no doctors on site) to healthy mothers have higher rates of death or injury.

"Be aware that the last insurance company who indemnified independent midwives pulled out of the market some time ago."

I think you'll find that cases of malpractice bought against IM's over the years are few and far between. Luckily for NHS staff the tax payer bankrolls their mistakes by paying the colossal damages that result from babies being damaged by poor care every year in NHS hospitals. sad

"I think that litigation is on the way to prevent practicing without insurance so that should see the end of independent midwives, and not a minute too soon"

I think what may actually happen is that IM's will be contracted by the NHS to take on case-loading work. This has happened in the past and may very well be happening again soon. Negotiations are under way. smile

jchocchip Mon 24-Sep-12 20:37:23

traintracks that is very emotive. I thought midwife said shoulder dystocia was not in notes and implied obs was just in a hurry to get back to his golf... There are risks involved in birthing in hospital which are not there at home. You chose what risks you are prepared to accept in life, and make the best choice you can. I was advised by the head of midwifery that things rarely go wrong suddenly and with two midwives present at home transfer in can be arranged quickly if required. Can take longer than 15 minutes for the call to be made in hospital especially if you are being ignored by midwives who are trying to look after a number of women at the same time. I did transfer in with my third, (suspected pph) and a 15 minute car ride takes a lot less than that with blues and twos.

traintracks you don't mince your words do you?! You make some valid points though. My only reason for wanting a home birth is that I feel it is a more natural and comfortable environment, an insurance company's job is to think with their heads but I think it's normal for a mum-to-be to be torn between head and heart. As I've said though I'm pretty much decided I won't be taking the risk

sossiges Yes I read it when pregnant with DC1, they were all rectified with labouring on all fours weren't they? I certainly think it's food for thought but I suppose we should be grateful that birth has not become as medicalised in the UK than the US - I have no desire to know the exact date to expect my baby and don't feel the need to know how many cms dilated I am at each appointment or need an epidural the minute I arrive at the hospital... But I digress somewhat, this has become a bit of a home/hospital birth debate which I didn't really intend it to be. I just want to know that I can exercise my right to choose in my own labours to a certain extent.

Thank you all for your opinions, experiences and advice. I knew I could rely on MN to help me get my head straight on a few things!

Sossiges Mon 24-Sep-12 20:03:54

OP I take it you have read Ina May's Guide to Childbirth, interesting bit about SD in there

traintracks Mon 24-Sep-12 19:17:50

jchocchip - 15 minutes, plus the time for an ambulance to arrive and you to get into it is plenty of time for a baby's brain to die.

traintracks Mon 24-Sep-12 19:15:59

Shoulder dystocia kills babies and is unpredictable. It is the main argument against home birth. Be aware that the last insurance company who indemnified independent midwives pulled out of the market some time ago.

Think about that.

Many companies whose job is to identity risk have all independently decided that the decisions made by independent midwives are too risky to insure, at any price. They will have based that decision on previous experience. Did you read about the woman who died recently after negligent management by an independent midwife? If you use one and your baby ends up.brain damaged you will get no compensation to help with the costs of bringing up a disabled child. I think that litigation is on the way to prevent practicing without insurance so that should see the end of independent midwives, and not a minute too soon.

Anyone who would suggest a home birth with a previous shoulder dystocia clearly feels that the experience is more important than ending up with a healthy baby.

In that case it sounds like it might be a good compromise - you can have the same non-medicalised birth as if you were at home, but you are next door to the hospital if something did go wrong.

MrsBugsy the birthing centre is in the hospital. I do feel it's my best bet.

However... Having spoken to the supervisor of midwives today it turns out that DS's shoulder may have got stuck, the surgeon didn't put it in his notes so it would seem that they assumed it would get stuck due to him being big/slow progression perhaps and acted accordingly. I feel a bit cross that I've had pretty much a dressing down for even considering a home birth when it would seem the only risk factor that definitely applies to me would be that I've previously had a big baby and possibly a history of SD but no-one is quite sure.

Not sure what to think now but I am swaying more towards the birthing centre simply because if there is a risk of needing extra help I think it makes sense to be near it. I will however try and be more confident in saying "what happens if we wait..?" and make sure DH is as familiar with my birth plan as I am

for me one of the reasons for planning a homebirth is that, as a low risk woman, I am guaranteed one on one care that I almost certainly wouldn't get in a hospital. I feel that I would be safer at home.

However, your case, you have been identified as high risk, so AFAIK you would be guaranteed one on one attention in hospital, plus you would have the added benefit of being closer to medical facilities that you have been told you have a higher than average chance of needing. You also live quite a long way from the hospital. So, I think if I were in your shoes, I'd feel that a hospital birth is safer than a homebirth.

How close is the birthing centre to the hospital?

jchocchip Mon 24-Sep-12 08:43:42

the results of intervention and problem births all the time and lack experience in "normal" birth ime.

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