Being advised against home birth due to risk of shoulder dystocia

[NiceCupOfTeaAndASitDown]

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

"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!

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.

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.

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

Surely all newborn car seats are rear facing?and surely they all fit in most cars?

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

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

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.

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.

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.

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!

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.

"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.

"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.

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.

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

"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!

"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.

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.

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.