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

Thumbwitch Fri 21-Sep-12 23:46:50

Nicecup, it may not be too late to hire a Doula for the birth if you are concerned that you are unable to stand up for yourself and you do go ahead with the hospital route. They will advocate for you when you are unable to do so, and if your partner isn't any use. You need to have someone there who will speak for you.

foronethreadonly Fri 21-Sep-12 23:57:43

My sisters younger child had shoulder dystopia.
He's 13 now, has a partly functioning right arm, it was damaged during delivery, and has global development delay due to lack of oxygen at birth.
He also happens to be autistic.

The risks to the child are real IMe.
He was a real struggle to turn, apparently.
I would go for the most medical ir thief there was any risk tbh, but I don't have any acts and figures t say what the risks are.
My nephew may be a really severe case...

Dorisday13 Sat 22-Sep-12 08:15:27

Hi I haven't read all the posts, I'm booked for a home birth and had a conversation with the Community mw who would attend the birth about shoulder dystocia specifically, she said that they all had emergency training it in and although rare does occasionally happen at home, they said they could handle the situation but would request a hospital transfer after the birth to check the baby for any problems. Obviously this advise is different to that you have received. I think in your position I would make an appointment to see the supervisor of midwives so you can discuss it further, that way whatever you decide you know that you have all the available information and have made the best choice for you and your baby. GL whatever you decide xx

Dorisday13 Sat 22-Sep-12 08:17:29

Also try not to listen to anecdotes and scare mongering its not helpful, speak to the supervisor of midwives, discuss training and procedures, and listen to your own feelings xx

HecateHarshPants Sat 22-Sep-12 08:22:10

I wouldn't risk it.

My first was SD and he has been left with Erbs Palsy. I wouldn't go for a home birth after that, even if the risk was small.

Whatever you decide, make sure that everyone knows about the SD and get them to tell you about their SD training and go through what would happen in the event of SD

ChiefOwl Sat 22-Sep-12 08:39:59

Having had a baby with sd I can't even believe you woud consider a home birth. I actually had an elective section with dc2 on consultant advice, he said although there were no guarantees it was very likely the same would happen again. My dd needed resuscitating after her sd birth - horrific experience all round.

What happens if you deliver the babies head and the mw can't get the baby out? There must have been 10 people in the room when I had dc1... Whats one mw going to do? I had my feet up in stirrups, one person physically pushing her down out of my stomach as two people pulled her out.

Northernlurkerisbackatwork Sat 22-Sep-12 09:50:04

Rainbow - I'm sorry for your loss and I hope you have a lovely birth. Thank you for clarifying what you meant. I have to say I am a little bit hmm about your midwives claim to take high risk cases the NHS won't touch for homebirth. Undoubtedly a medicalised approach can lead to complications and a cascade of interventions. Undoubtedly this is avoidable HOWEVER there are some risks that can be predicted and the NHS guidelines are evidenced based and designed to protect parent and child. I hold no particular brief for them myself. I've gone against several in my time grin However there are some risks that I would take more seriously. For example having had a PPH and being overweight, my local Trust would want me to have a cannula put in when I was in labour in case of further PPH. Now I don't much like that idea (and tis all academic as I won't be having anymore dcs!) but I would accept that because the relatively minor intervention would be worth it if it helped me in the face of a more likely complication. On the other hand the same policy would like a woman like me to have an epidural as soon as I hit delivery and they could go whistle for that! grin You are right, informed choice is vital. I just think we have to be cautious about the safety of home birth because home birth is very safe, safer than hospital for most women but not for all women. If you're in the latter group then it's important to recognise that. Once again all the best for your delivery.

Mumlar Sat 22-Sep-12 10:25:48

Here is my experience:
Dc1: 8lb 13oz, failed ventouse, forceps delivery.
Dc2: 9lb, straightforward labour, shoulder dystocia, third degree tear, baby eventually delivered by moving internal shoulder, no movement in arm, recovered in a few days.
Dc3: 9lb 2oz, straightforward labour, difficult to deliver, not true SD but got stuck.

After a truly terrifying second delivery, (dd navy blue on delivery, needed rescuitating with an Apgar of 1), I assessed all my options and plumped for paying for an obstetrician to deliver my third in an NHS hospital. I would NEVER have attempted a home birth and was worried that I might go into labour and be unable to get to hospital on time.

SD is not a predictable event unless you have had one before. I did put a lot of weight on with all my babes but my own BMI was around 20/21 when I got pregnant. As a previous poster said, position of the baby is very important, dc1 was back to back, dc2 came out flat on her back which is why she got so stuck I believe. These factors do play a part but, in my case there was no indication of impending SD until after dc2's head was delivered, I had a textbook labour up until that point.

I am not being judgemental, but please think very carefully. Initially on pregnancy 3, I wanted a C section, but with the advice of my obstetrician I successfully delivered my baby normally. I would never have attempted it at home. For my third delivery there was one obstetrician, two midwives and two paediatricians in the room with me- that gives you some indication of how risky they thought it was. Thankfully they managed the situation carefully and everything went well, but it could have been different.

Mumlar Sat 22-Sep-12 10:28:13

I forgot to mention, NHS midwives are regularly drilled on SD procedure using the HELPERR mnemonic as it is viewed as a true emergency.

Shagmundfreud Sat 22-Sep-12 17:46:24

Your pelvis is capacious enough to get out (with a small amount of suprapubic pressure and with your thighs aducted) a very large baby, despite being unable to push or move effectively because of an epidural.

Honestly - to me this says that there is NOTHING to worry about as far as your pelvis goes. As long as your baby is a normal size I can't see why you are any more at risk of a SD than anyone else.

By the way - I speak as someone who experienced a shoulder dystocia at a homebirth with an 11lb baby. The SD was easily resolved, as they usually are. Even with a very large baby.

Shagmundfreud Sat 22-Sep-12 17:50:48

Want to add - both induction and epidural (because of higher risk of forceps) are associated with increased incidence of SD. I'm surprised that people are so clear about a homebirth being inadvisable in this circumstances, but no concern about any other issues that might make a SD more of a likelihood this time around for the OP.

LilyBolero Sat 22-Sep-12 17:58:02

I absolutely wouldn't risk it, have had 1 hospital birth (1st), and 3 homebirths, and on the 3rd homebirth, ds3 had shoulder dystocia; such a scary few minutes, and my amazing mw did brilliantly to get him out, but she was so scared too, because it is a sudden, high-consequence event. He has no ill effects, but it was a close run thing.

Fwiw, all mine were average or small on the scans, none were under 9lb12, and the biggest was 10lb12 having measured bang on average.

Shagmundfreud Sat 22-Sep-12 18:22:28

Lily, there's always the argument that hospital birth makes SD more of a likelihood (because of high rate of epidural/induction/supine birth). Why is higher rate of SD associated with hospital birth not a problem?

Would also like to point out that most SD's come out of the blue - to women with no risk factors. This means you'd expect a good number to happen at home every year. And yet for second time mums anyway there is NO increase in poor outcomes associated with homebirth.

I think my questions now are starting to be things such as "if I go to hospital can I avoid internal examinations/being strapped on my back/having a canula/epidural/forceps/being timed and told how and when to push?" it seems that once one gets into hospital there begins a pattern of intervention, none of which I wanted last time and some of which I believe may have contributed to the SD.

I don't want to go to hospital but I also know I could never forgive myself if something went wrong at home and I'd been warned that being at home was not deemed as safe. I have an appointment with the supervisor of midwives on Monday and intend to give her a grilling ask her lots of questions. She was with me on my transfer to hospital last time and I feel comfortable asking her advice, I just hope that if I do choose the hospital route that I am able to express my wishes and actually be listened to. A doula would be great but fortunately DH is passionately on my side, I know he will diplomatically argue my corner if needs be

Shagmundfreud Sat 22-Sep-12 19:56:17

Well - whatever you do NiceCup, just remember that your pelvis is big enough to accommodate a very large baby, and that's with all the obstacles that an epidural put in the way of you giving birth normally. In fact, I suspect you could probably drive a bus through your pelvis!

smile

Would an epidural really make that much of a difference? I'd pushed for 2 hours before having it and DS was out in 2 pushes with the forceps once it was given. I've been so at peace with the whole 1st labour because I felt I tried my hardest at each stage before 'giving in' to each intervention they were suggesting but now I'm starting to go over it all in my mind wondering if it will really be possible to avoid them all if I go into hospital again.

As an aside has anyone had an SD in a birthing centre and can tell me how it was handled? Especially as a comparison to a hospital or home birth?

My head doesn't feel much clearer today, how on earth am I going to get a baby, a toddler and all our stuff back from the hospital without a car? I'm so pfb about our rf car seats that I don't want any of the gps to pick us up (1 won't fit, 1 awful driver, 2 smoke in the car) - there's just so much more to consider if I'm not at home. I wish I could think straight!

Ushy Sat 22-Sep-12 21:55:59

NICE if you were pushing for two hours before having the epidural, it is hardly likely it caused your problem - you gave it your best shot and it sounds like bad luck. It sounds like you had a really difficult labour and the interventions only happened as a result - they didn't cause the problems.

Have you thought about making a list of what is really important?

If you do, you will probably put you and the baby being safe and well (physically and mentally) right at the top of the list.

Forget the car - tell someone that problem and I bet you'll be amazed at how many people offer to help. People like to help and like to be asked.

Take care and good luck

fuckadoodlepoopoo Sat 22-Sep-12 22:00:55

I had various problems with my first labour which made me high risk for the same complications for my second labour. I didn't even consider being anywhere other than a hospital during the birth.

In the end there were complications, similar to the first time. Why would i have wanted to take the risk.

Viewofthehills Sat 22-Sep-12 22:10:32

I have had one hospital and two straightforward home births. Sorry, but I wouldn't feel this was worth the risk. I would go for a more active hospital birth, less monitoring and possibly early discharge home. I went home after less than 12 hours with my first.
I found it quite inhibiting to be in labour at home in broad daylight, on a lovely spring Sunday with the windows open and people mowing the lawns outside on our busy estate- I certainly didn't feel I could make a noise. I think I assumed all my DC's would be born in the depth of night. Hospital seemed quite attractive at one point.

Thumbwitch Sun 23-Sep-12 00:29:58

Taxi back from the hospital? Depending on what type of carseat you have, fixing wise, then that should work ok for you.

Glad your DH is able to advocate for you - just give him very clear instructions about what he needs to challenge smile

Shagmundfreud Sun 23-Sep-12 07:00:30

NICE - SD is handled the same way where ever you are.

The people who are caring for you use the same manoeuvres to try to free the baby, whether at home, in hospital or in a birth centre. There is no difference.

Northernlurkerisbackatwork Sun 23-Sep-12 09:29:02

The drill is the same but in a hospital the resus facilities available to the baby after birth are obviously much better.

Freud so it's more a matter of more hands on deck and access to more advanced resuscitation equipment if in hospital? Rather than a different way of handling the situation I mean

I suppose I could call local cab companies and see what cars they use.. Both car seats come with a list of suitable cars. I wish RF was the norm in this country, it always seems to be such a palava to travel anywhere with them but I won't compromise on my children's safety so we'll have to find a solution.

So I'm thinking the birthing centre is probably my best option - I just want to find out how much of my birth plan will stand/be acknowledged there. Of course the health and safe delivery of my baby come top of my priorities list but I know from last time that if I don't have freedom of choice/movement in labour I'm not going to be able to relax enough to let it happen. I'm very keen to avoid the medicalisation of what I feel should at least be attempted to be a natural thing (I'm purely talking about the experience for me and my body, I know lots of people feel differently) - thank you to everyone for your input, I'm starting to be able to put together all the pieces in my head, it's important to me to do this in order to feel ready for labour so all experiences and opinions are gratefully received.

LilyBolero Sun 23-Sep-12 16:38:14

shagmundfreud I think in a hospital setting, you can push for mobility, active labour, etc, but in the OPs position of having had a mild SD, I would not want the risk of being at home when in hospital you can have paeds on hand, NICU and all the other resuscitation facilities.

I'm not having any more, but if I did, I would either have an early induction (my babies all grow in the last 2-3 weeks), or an elective CS, because I don't think I could deliver a bigger baby, and the consequences are too serious.

Also, if the OP chose to have a homebirth, and something, God forbid, did go wrong, she would have a lifetime of wondering 'what if'. Generally I am the biggest advocate of Home births that there is, but I really wouldn't risk it in this case.

LilyBolero Sun 23-Sep-12 16:40:22

As far as making sure your birth plan is observed as much as possible, what about hiring a doula? I think that would be your best option tbh, because she will be a female support for you, and would also represent your best interests (in labour isn't always the best time to give reasoned, logical and calm arguments!!!). And in the event of a problem like SD, she will be there purely to support you, whereas a mw attending the birth would be totally focussed on getting the baby out.

That would be my option I think!

ChiefOwl Sun 23-Sep-12 17:55:46

Why are the car seats a problem?

Shagmundfreud Sun 23-Sep-12 18:16:15

"but I really wouldn't risk it in this case."

Why? Because the OP is especially at risk of a severe s/d? I think the fact that the OP has managed to give birth to a 9 and a half pound baby by forceps (a known risk for s/d) with only a bit of suprapubic pressure suggests to me she is probably LESS at risk than your average woman having an average size baby with NO history of s/d.

A shoulder dystocia which results in severe damage to a baby is a rare event and is usually to do with the baby being extremely large (particularly when there is diabetes present in the mum) or when the baby is of average size but the mother's pelvic shape makes complete rotation very difficult - hence a baby who is well and truly wedged and needing great skill and several manouvres to birth.

The OP knows she has a roomy enough pelvis to safely birth a nine and a half pound baby. Even with an epidural in place.

How is she a high risk for shoulder dystocia? How is she higher risk than a mother who has birthed a 7 lb baby in hospital and is considering a home birth with a second baby known to be around the 9lb mark? And yet almost all midwives would be happy to clear a mother in the latter situation for a home birth.

Seriously - nobody here seems to be considering WHY the OP has been labelled at high risk for another s/d. Her previous s/d was extremely easily resolved - which suggests that her pelvis isn't a problem!

"Also, if the OP chose to have a homebirth, and something, God forbid, did go wrong, she would have a lifetime of wondering 'what if'."

Why is this reasoning only applied to home birth? There are risks associated with opting for a hospital birth too you know!

LilyBolero Sun 23-Sep-12 19:46:48

Ok I wouldn't risk it because, babies tend to get larger with each subsequent pregnancy. I gave birth to 3 10lb babies before ds3, with no interventions or anything, that didn't prove that ds3 wouldn't have a problem, and in fact he did get stuck.

I also wouldn't risk it because there is a history of SD, AND she lives 15-30 mins away from the hospital. If there was a problem, and baby needed resuscitation, beyond the basic equipment the mws carry, she would not have access to the best equipment in time.

And going back to the very first post, she writes "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."

If she had to be transferred in a medical emergency, having her ds around would be a nightmare (imo!). Very traumatic for him I would have thought.

I am very very pro-home birth, but I also think there are circumstances where it is safer to be in hospital. That's why I would advocate a doula who can be your advocate, and support, but you have access to all the medical equipment. I definitely wouldn't risk another homebirth, I nearly didn't with ds3, I dithered about it for ages, because I knew he was likely to be big, but in the end decided to have a homebirth. If the SD I had with him had led to him not surviving or having some disability, I would have always regretted that decision.

Shagmundfreud Sun 23-Sep-12 20:15:56

Sorry, meant to add, that my IM and her colleague, also an IM and a consultant midwife at a large teaching hospital, were willing to ok me for another homebirth following a shoulder dystocia at home with an 11lb baby.

Their (and my) thinking was that as I'd managed to give birth to completely healthy and undamaged babies of 9 and a half and 11lbs, (albeit with the second needing McRoberts and some assistance from the midwife), then my pelvis was clearly pretty spacious and I wasn't at increased risk of having a repeat of the SD with more disastrous consequences - as long as it looked like baby number three wasn't going to be signficantly larger than baby number two. And actually he was 2 lbs lighter (though longer and with a bigger head circumference) because I was extremely vigilant with my diet during pregnancy.

chiefowl because (afaik all but perhaps just our) RF car seats are not suitable for all cars. Fortunately we've been able to fit them into my brother's car and will pack the sling so we have the option of the train/a lift or a combination.

Freud you make some very valid points in your last post, what especially resonates with me is that many people see a home birth as a brave choice, to me both times I've considered it have been because I see it as a safer, happier and more relaxed environment.

I feel sad that I will probably never have a home birth now but lily's point of if there being a problem there wouldn't be enough time to get to the hospital is the reason that I will opt for the birthing centre. I still think I would be more relaxed and comfortable in my own home without bright lights and strangers and a whole host of interventions just waiting to be pushed upon me in the 'interests of my baby' (I put it in inverted commas because I do think that medical time constraints mean interventions are used to speed things up and telling women its for the sake of their baby is often the way to get them to consent) - but I need to think with my head and not my heart I think, it's a difficult situation because nobody ever knows how labour will turn out, but if things were to turn ugly (and I've been warned that they might) I want to be within easy reach of as much help as possible just in case.

runningforme Sun 23-Sep-12 20:41:35

Personally I wouldn't risk it. A friend of mine had a homebirth with her 2nd dc and it failed to progress. She was rushed to hospital and baby got stuck - severe sd. She had to be cut from front to back and have ever manoeuvre going and baby was born dead. Luckily she was resuscitated but spent a week having her brain cooled. It was an horrific experience and there were no warning signs. If the sd had been discovered at home chances are her baby would not have made it. I just don't think it is worth the risk if you are likely to be at greater risk of it happening again.

I had all 3 of my dcs in hospital - the first two in a 'home from home's suite with very minimal monitoring or intervention and the 3rd at a midwife unit with even less monitoring. All 3 we're very active births with access to pools and birthing balls etc. Does your hospital offer this sort of setting? It could be the ideal compromise. Good luck with whatever you decide x

MrsHoolie Sun 23-Sep-12 23:54:11

Surely all newborn car seats are rear facing?and surely they all fit in most cars?
<picking up on the least important part of the thread>

foronethreadonly Mon 24-Sep-12 00:04:23

I'll tell my nephew he's an anecdote

Thumbwitch Mon 24-Sep-12 00:32:58

MrsHoolie, I think the OP is talking about her other child's seat also being rear-facing.

Yes both seats are RF, the 'newborn' one is a Britax Hi-way 2 0-25kg, the other a Britax two-way elite 9-25kg - they don't fit all cars unfortunately but that issue at least has been resolved for now

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

I had one hospital birth where I was largely left to labour alone after induction and monitoring and two home births where once the midwives arrived they didn't leave the room. I would trust your instinct, 15 minutes is close to the hospital for a transfer. Obstetricians see

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.

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?

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

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.

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.

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.

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 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!

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.

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

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.

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.

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!

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.

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.

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.

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

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

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.

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.

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

Just want to say Go Shagmund!

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!!!

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.

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 23:30:15

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

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!

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