shoulder dystocia

[stella1w]

The doctor thinks I am going to have a big baby so is against a home birth because he says there is a risk of shoulder dystocia that a midwife would not be confident of handling at home.. because she needs a team! er.. what team?? why can't a midwife handle the dystocia manoeuver at home??

depends on the mw.

do you really want to risk it though?

i have a 7yo dd2 with brain damage and cerebral palsy due to birth hypoxia. but apparently the documented shoulder dystocia had nothing to do with it though.

i suspect the 'team' might be the crash team that often get used in these cases to resuscitate, rather than an actual shoulder dystocia management unit, though.

but on the flip side - i never believe anything that docs say about 'oo going to have a big baby'. i had an elcs with dd1 because she was apparently 10lb 13oz and there was no way i could deliver her safely. she was 8lb 6oz.

your baby. your baby's health. i'm actually totally against the medicalisation of pg and childbirth, but if you've been warned, i'd probably advise you to heed it to save any self-recrimination in the unlikely event of anything awful happening.

You might find this site useful for general info, not just if you're planning a home birth
www.homebirth.org.uk/

Also though, what's the "thinks I will have a big baby" comment based on? Even growth scans have a large margin of error. What's more important is the fetal position - a baby who is in a good position with the back of the head presenting has an effective head circumference of 10cm / 4" less than of the baby is a brow presentation i.e. forehead first. That's the same baby, different part of the head coming out first.

good luck

I know your Q was about shoulder dystocia but I just meant that the fetal position seems to be more important than fetal size. From what i understand the shoulder dystocia position (knees to chest) can be handled by a MW otherwise she shouldn't be doing HB! Plus don't they send another MW for the delivery, so there would be two?

I think some additional Qs need to be answered. i sympathise, I'm questioning childbirth advice myself just now.

My baby has shoulder dystocia and i had, what felt like, the whole hospital attending!

The tearing and bloodloss associated with shoulder dystocia is a very high rish. Then there is the risk to the baby, potential erbs palsey, breathing difficulties. Not to mention pain management or need for a crash section before you even get to that point.

Believe me its traumatic enough when the medical help is there if it happens.

a true shoulder dystocia is likely to need more than the knees up position and could result in a number of other procedures being needed. if this occurred in a home situation youd need to be blue lighted to hospital, whihc even with the closest of homes will take valuable minutes.
Having said that a fair few shoulder dystocias are relaeased by widening the pelvic outlet through various positions.
it maybe worth your while asking for further investigation into why your consultant thinks you are at higher risk. A large baby and a small mother do not neccessarily mean that you will not be able to birth your baby vaginally. I have witnessed many a small woman birth 10lb plus babies with no complications and maybe just a few stitches.
arm yourself with valid information, not anecdotal. Research articles form respected publications, research teams etc.

I know that shoulder dystocia can be extremely serious (I have a friend whose baby has erbs palsey as a result), but the thing that jumped out from your post is that it doesn't say why your doctor thinks there is a risk. What is he/she basing their views on likely size and risk of dystocia on? I think it's very easy to be scared by potentially serious complications and to focus on the complication, but to be able to make the right decision for you and your baby, you need to understand both the seriousness and why they think there is an issue.

When we were planning a HB for DD1 (who was expected to be large) our extremely experienced IM had the opinion that you were arguably better off having a SD at home with two confident MWs who'd just deal with the situation, than having the same problem in hospital with a MW who's been trained that the first thing to do is push the panic button and wait for help. In her opinion and experience, there is very little that can be done to resolve SD in hospital that can't be done at home (I think one of the few exceptions is the Zavanelli manouever, which is where the baby is pushed back up into the uterus so that an emergency CS can be performed - but this is a very rare procedure).

All MWs are required to maintain their training in coping with SD - I'm sure they'd rather not use it, but they must be competent or their registration would be revoked.

My understanding is that the actual size of the baby is not a good indicator of SD - and that estimated size (given all the inaccuracies) is very poor. There is a risk of SD with any birth. It would be interesting to know whether this Dr is ever supportive of homebirth...

I'd completely agree that you need to do as much of your own research as possible using reputable sources and then make your own, informed decision.

Tangle - the 'push panic button and do nothing' is exactly what happened to my friend who had the shoulder dystocia in hospital. It then took ages for anyone to arrive...

You would have to be pretty unlucky to get a midwife that pushes the button and then stands back waiting for the docs - not saying that it cant happen though. As its part of our mandatory annual update, all midwives should be capable of dealing with SD, and in fact, in all but the most severe SD (in almost all the hospitals that I have worked in), it is generally the midwife that resolves it, with the team being used for assisting to get the woman into the mcroberts position, and with suprapubic pressure etc.

However, there are very few genuine shoulder dystocias, most are easily dealt with by the manueveres as above, and they can mostly be dealt with at home as well as in hospital. What cant happen at home is the level of resus for baby if it is a rare severe SD, as we only carry fairly rudimentary resus equipment, and if it takes 5 mins or so of manipulation to get baby out, then is going to need resus.

There shouldn't generally be any more blood and tearing etc than normal - in many years working as a senior labour ward midwife, and dealing with literally dozens of SDs, I have never had to perform an epis for access and it is purely a mechanical condition where the top shoulder is stuck behind the pubic bone, so once it is turned or manipulated into a better position, it shouldn't cause any more damage than would have been seen otherwise.

It can happen with any size of baby, but it is true that statistically, bigger babies are slightly more prone to causing SD, but the worst SD I have experienced was only 3.4kg and I had delivered her previous baby which was bigger with no problem.

Sometimes tbh, some doctors (and midwives) will use any excuse to get you into hospital.

the mws dealt with dd2's sd. but the original mw (who had a student with her) called for the senior mw on duty to help, and crashed the paeds so that they were in attendance when dd2 was finally delivered. i did have an episiotomy, and one of the mws was prepping the ventouse kit as well (although it wasn't used in the end).

without a shadow of doubt the combination of two mws and immediately accssible resus team saved dd2's life. she's still got a permanent physical disability, but they did save her life. i don't think the sd caused the birth hypoxia - but i don't think it helped, either. she wasn't huge btw. only 9 lbs.

i'm just a bit reluctant to chance fate, now.

the doctor thinks I am having a big baby because the abdominal circumference is on the 95 percentile..
I spoke to a midwife at UCH who said that sd could be spotted by a midwife if labour was not progressing and then you go into hospital.
I am frustrated because I was measuring bang on for dates and only a chance scan after a fall in the street has led to this doc questioning my birth plans.

I had true shoulder dystocia with my dd1, she very nearly didn't make it, she spent a week scbu and when we took her home no one could tell us she would be ok thankfully she is. Her birth was a hospital birth with 2 midwifes in with me the whole time neither realised, she was my third and I didn't realise. By the time we did she already had no heartbeat and once she was finally free which was done by the midwife cutting me so she could get her hand in a turn to release the shoulder the team had not managed to do so by any positioning techniques.it took 10 mins+ to resuss that was with a full medical team drugs etc. I was left needing to go to theatre due to PPH from the trauma.

She was 9lbs11oz so big but not huge, and now a lovely almost 5yr old.

stella - the midwife is wrong as SD cant be foreseen until the head is delivering and it then 'turtles', where it is pulled back a bit after is out. By then it is too late to transfer.

But like I have said it is very rare.

Sorry to hear about your experience insanity...:(

insanity - dd2 spent 5 weeks in scbu and was left with no gag or suck reflex and needing suctioning periodically so she could breathe. horrid, isn't it. they managed to wean her off the o2 after a couple of weeks, and gradually a suck and gag developed. she's 7yo now, and remarkably able, considering.

i'm still in favour of hb for low risk pg though. just not my own.

mad -In comparison to your dd we were lucky but I really thought we had lost her, once they had got her breathing and stable enough they moved her to scbu where they sedated her for 5 days to allow her brain to recover then they woke her up and two days later we were able to take her home, the words used to tell us we could take her home were literally- you can take her home tomorrow as there is nothing we can do for her here that you cannot do at home. The pead on discharge told us only time would tell what damage had been done, thankfully she has always met her milestones or exceeding them.

I had a s/d with an 11lb baby at a home birth.

Very successfully resolved and pale, floppy baby resuscitated calmly by two fab midwives. Baby and me both fine.

I think it would have been a vastly worse experience if it had happened in hospital. I think the way it's sometimes handled in hospital (people rushing into the room, adrenaline surging) can traumatise mothers.

As an aside - I have yet to hear a doctor advising a mum carrying a suspected large baby against having an epidural, being induced or attempting to push out their baby while sitting on their arse, all of which can increase the risk of shoulder dystocia...... Seems some risks are more acceptable than others.

actually in hospital they were very calm, there was no rushing around by anyone, two other midwifes joined the two already with me, they explained everything as they went along, and the team whilst i knew they were there remained outside until she was delivered, then they entered and the room was very silent considering, I cannot fault the hospital that night, the midwifes were amazing.
I used a tens machine for the last few minutes gas and air, i also laboured standing then on all fours, my previous labours had been quick and easy, ds2 was 8lb 10oz so not tiny and yet shoulder dystocia happened. I also know of others that have been through similar with much smaller babies, just as I know those that have had 11lb babies without a single tear at home with no pain relief.

If I had a shoulder dystocia, there is no place I would rather be than in a hospital. There are some instances when modern medicine and the speed with which a team of expert professionals can be at your side in seconds IS the best way forward.

I am all for homebirth - and in the OP's case I am confused on her behalf ('we think you might have a shoulder dystocia if you give birth at home' doesn't seem like a very medically sound opinion to me) - but just thought it important to point out that shoulder dystocia is pretty serious and in many cases requires the sort of assistance you can only get in a hospital.

I'm a very pro homebirth midwife, however SD is a very very serious complication and despite this several posters have suggested that being managed by two experienced midwives at home is just as good. It is not something to be underestimated.

Firstly unless you have ever seen these midwives in action yourself how do you know that they are experinced? Where I work often the second midwife at a homebirth will be someone who is inexperienced, gone are the days when you had to be qualified for a while before attending home births, I believe that this is similar in many different areas.

Secondly, even if the midwives do deal with it well they don't have the paediatrician back up that is available in the hospital. I have been in situations where the paeds are only a few minutes away and very grateful that they haven't been further.

Having said this you can't weigh a baby till its out, growth scans can be inaccurate, and on their own may well not be something to base a decision on. However if it is someone who has several risk factors such as first baby, previous big baby, diabetes, overdue, (to name a few) these might well be better reasons to go in.

Please don't think of me as being too negative, I just wanted you to know that it is a serious potential situation although it is very rare, one of the best signs that it may happen are a long labour especially a long second stage by which time it may be too late to transfer in as mintpurple suggested.

I am pro homebirth honest! Have had two myself!!

My DS had shoulder dystocia - I was in hospital and it seemed that it went from about 3 people in the rrom to about 25 in a matter of minutes! I had a midwife at either side pulling my legs to my ears and they eventually had to use a ventouse. The cord was wrapped around his neck as well so every time I was pushing it was cutting off his air supply some more. When he was eventually born he wasn't crying and gasping for breaht and got rushed out the room, but thank God he was fine and is now about to turn 6 in a couple of weeks.

I got told all along in my pregnancy that it was a big baby I was having and he was 9lb 7oz at 3 days early (I was induced due to pre-eclampsia)

Hope all goes well for you

"but just thought it important to point out that shoulder dystocia is pretty serious and in many cases requires the sort of assistance you can only get in a hospital."

Sorry - but this is inaccurate.

The vast majority of s/d are resolved with nothing more than a pair of hands. There are no medical technologies that can help when it comes to getting a baby out of a mother in this circumstance, except if the baby is shoved back up and delivered by c/s, which is EXTREMELY RARE.

I appreciate that if a baby needs significant resus at birth then it's obviously vastly preferable for that baby to be in hospital with a paediatrician and a NICU to hand.

For me the crux of the problem is that simply having your baby in hospital, where you're more likely to need an epidural, have a supine birth, have synto, and have an instrumental delivery, puts you more at risk of S/D, though if it does happen your baby is more likely to be rescued by medics in the rare event of the s/d being catastrophic.

Spudulika, where are you getting your facts from? I have to pop out now but, while I agree with your sentiment in your last paragraph, I'm afraid I do not agree with your stance on shoulder dystocia.

What stance?

That medical technology isn't generally useful for resolving s/d or that induction/augmentation/supine birth/epidural/instrumental birth is associated with increased risk of s/d?

Have a look at the RCOG guidelines. They identify augmentation and instrumental birth as factors associated with higher rates of s/d.

And common sense and logic tells me that birthing babies in positions which restrict the pelvis from opening up as the baby rotates and descends will also make s/d more of a likelihood.

But hospital doesn't have to = augmentation and instrumental birth for a well informed woman. But that is a different argument...

The aftermath of a SD is when most midwives would agree that hospital is the safest place for a mother and child.

I am well aware of the RCOG guidelines.

Are you a medical professional? Have you ever experienced SD?