Has anyone had a home birth after previous shoulder dystocia?

[AntoinetteCosway]

Just that really. I've done a lot of reading about the various risks but I don't know anyone who's actually done it and it would be useful to hear stories from women who were in exactly that position.

Bump.

One more bump!

Bumping for you, hope somebody who's been in the same position spots this.

Post on the Yahoo! Homebirth group - the women on there have given birth at home after pretty much every kind of high-risk previous birth :)

Thanks both! I didn't know the Yahoo group existed-I'll look it up

Watching with interest.

I don't know whether I just don't understand how Yahoo groups work or whether I've just had no response, but I think I sent them a message-I haven't heard anything back.

I really think it depends on how serious your shoulder dystocia was as there is a large spectrum. The advice for subsequent pregnancies will vary a lot depending on this. Was the baby stuck for a long time? What manoeuvres did they have to do to help? Were there any issues for the baby afterwards? Do you have any additional risk factors for it happening again? My personal experience was a good going shoulder dystocia with a large baby and with thankfully no ongoing neurological issues. The conversation with my obstetrician regarding delivery this time around was fairly in depth. I was offered the opportunity to labour as normally on an obstetric unit (with the hope that things will be easier with 2nd baby), an elective caesarean, or induction at 38 weeks. Risks quoted to me were 15% chance of recurrence, and if it does, a 20% chance of some kind of neurological damage (temporary or permanent). What seemed pretty clear was that with a true dystocia, time may be of the essence. I was told I would be allowed to push for 20-30 mins but if baby not out by then, I would be taken for an emergency caesarean as it would be presumed the baby was stuck again. I didn't ask specifically about a home birth but it was clearly not on the table as a safe option given the type of discussion we had. I really think it depends on the specific circumstances of your previous experience. If it was relatively minor, a home birth may still be possible. If there is any doubt, I would have a frank discussion with your obstetrician. A really severe dystocia gives no oxygen to the baby and they need out as soon as possible, ideally delivered within 5 minutes. Obviously this would not be possible if you were not in a medical environment.

The consultant at the hospital signed me back to midwife led care at my 20 week appt and was happy for me to have a natural birth with no planned interventions, but this was before I began thinking about home birth so I don't know his opinion on that. Since I poste the OP I've spoken to an independent midwife who said it sounds like the dystocia last time was caused by the combination of induction/epidural/being on my back for ages, rather than a true dystocia where the baby's stuck due to size issues. I've got a community midwife appt this morning so am going to discuss it with her and see what she thinks too...

Also watching with interest.

My first was a shoulder dystocia. I don't think I want a home birth with our (planned but not yet conceived) second but would love to go to our mlu.

I was given the impression I would be under consultant care for my next, although that might be because of bleeding in my first pregnancy.

My gut feeling is you'd have to push for it a bit

Why would you want a home birth with a previous shoulder dystocia?? If it does happen it's potentially life threatening for your baby and wouldn't you prefer baby be born in hospital with access to the pediatrician if necessary? I can't imagine any scenario where an obstetrician would say it's ok to have a home birth with a previous shoulder dystocia. Being signed off as midwifery care antenatally just means your antenatal care is low risk, not that your labour is low risk!

Because I feel (and the midwife agreed on reading my notes) that the dystocia was caused by the interventions I received in hospital. Also the procedures for resolving it are identical whether you're at home or in hospital. I'm not really looking to justify myself here I'm just interested in hearing from other people who've faced the same decision.

Have you seen the homebirth.org.uk page on shoulder dystocia ? There are some birth stories there that might be interesting/useful to you.

Yes-such a useful site! I now have an appt next week with a consultant to discuss it. Hopefully he'll be happy with it!

How did you get on with the obstetrician? I'm sure they will also be able to shed light on exactly what the issues were. In terms of my own decision making process - I really wanted a natural birth this time as I had such a rotten experience last time that I felt it could only be better! I also did not like the idea of a prolonged recovery with a 2 year old in tow. However, once I heard the statistics and the nature of the potential complications I found it hard to justify holding out for this. My plan (after weeks of reading, talking to people etc) is to have a date booked for c/s at term, but if I labour spontaneously before this my hope is the baby won't be as large as last time and I will give it a damn good shot myself. I have to say I would not personally take the chance with a home delivery. Yes, they can do SOME of the manoeuvres at home but some need more than one trained professional to be done effectively. Also, if baby is very distressed the ultimate step in the management of dystocia is an emergency caesarean, which obviously cannot be carried out at home and is very time critical. Speed of access to skilled paediatricians is also a factor. I was just thinking - you can be in hospital and refuse epidural and mobilise etc, which definitely will reduce your risk for your 2nd delivery but there is no guarantee you will eradicate it. The biggest problem with shoulder dystocias is that predicting them is a nightmare, as you can see from any guidelines you read on the RCOG website or other sources. The best indicator is a previous event. A non-instrumental delivery is definitely less likely to cause dystocia but you could think of the hospital as being your insurance policy, which hopefully you will not need, but if you do you will be glad of it

I don't see him till next week annoyingly! Will update once I've seen him though.

Re. Emergency c-sec in case of SD, I believe that hasn't been done for years and years-it would involve pushing the baby's head back up the vagina which makes it a last resort of such unlikeliness that I'm not even considering it to be honest. All the other procedures can be done at home and there'd be two midwives there plus resus equipment so I'm not too worried about that.

I do know what you mean about having the resources of the hospital available though. We only live a couple of minutes drive away so I'm thinking that we could get there as quickly in an ambulance as we could get into surgery from the labour ward anyway-our hospital have a 20 minute window for prepping for emergency surgery in order to get the room/staff ready, so there's not a lot of difference in being at home or on the ward. (Which is actually a bit crazy! My midwife said that even in really urgent emergencies they don't get you onto the table in less than 20 mins. I was a bit gobsmacked by that-I assumed it was a case of knock you out and get on with it!)

For a category 1 emergency section the total time between decision and delivery should be 30 minutes. If a hospital fails to meet that guideline as repeatedly as that midwife led you to believe they would be in big trouble. And there's NO WAY they could get you blue lighted in from home, get the clinical decision made, you on the table and baby out in that time in a true emergency. That is always the risk you take with home births. Some people weight it up and feel comfortable with that risk, other don't.

Personally I think your better bet would be to discuss exactly what parts of your hospital care you felt led to the shoulder dystocia in your last labour with the consultant, and then to work together to put together a birth plan that allays your fears about it happening again.

That's my plan

"That is always the risk you take with home births. Some people weight it up and feel comfortable with that risk, other don't."

But nobody is ever asked or expected to weigh up the different, but real risks that come with opting for a hospital birth......

OP - I tried for a homebirth after a sd at my second birth, also at home. I ended up transferring and had a normal birth at hospital. It's a hard decision to make. For me the deciding factors were: I had previously delivered an 11lb and a 9.5 lb baby vaginally, without damage to me or my babies, despite the previous s/d. I figured I have a pelvis you can drive a bus through. This was the deciding factor for me.

I had a shoulder dystocia with ds1. He was born with an Apgar score of 1 (dark blue) and had to be resuscitated. It was 8 min between when they declared it as a shoulder dytocia and resuscitation which took a minute or two I think. They had to do the Alexander technique thing with my knees up by my ears and 2 people pushing on my stomach. Crash team and paed in to resuscitate him. Luckily, and amazingly, after 5 days in special care he is seemingly unaffected and is a normal 9y old now. I had been very keen for a natural, water birth during the pregnancy. I was really pissed off that they would not let me have one due to high blood pressure at the end of the pg. In hindsight, he possibly wouldn't have lived if the shoulder dystocia had happened while I was in the pool. Or maybe he wouldn't have got stuck if I'd been in the pool, who knows? The crash team were also just outside the room in the medical ward, wheras they wouldn't have been if I'd been in the MLU on a different floor.

Anyway, with my second and third pg we decided wherever I gave birth would have to have a resuscitaire in the room. This meant medical ward again unfortunately. I was reasonably confident it wouldn't happen again but my DP was so traumatised by watching ds1 being born, effectively, dead that he really wouldn't entertain a MLU or water birth for ds2. I felt I had to go with this really as he had been much more aware of how close we came to losing ds1 and actually saw it all unfold (wheras I was a bit out of it by then). In the event, ds2 was a quick and easy birth in the medical ward, no issues.

With ds3, I was again tempted by the MLU but with a previous shoulder dystocia and high BP at the end of all 3 pg I pretty much gave up on pushing for it as they were very opposed. In the event, I had a mild shoulder dystocia with ds3 (he is very similar to ds1 so I think it is something about their big heads!) but because they knew about the first one, the mw had called in a senior mw as soon as it started going pear shaped again and he manually manipulated him and turned him so he wasn't stuck for very long.

I managed to have a natural birth with all 3 with just gas and air and TENS, even in the medical wards and, in hindsight, 3 healthy children was all that mattered really.

Long story short, probably not worth the risk imo. MLU yes, home birth no, for me. I just couldn't get beyond the fact that ds1 would probably have died if I'd been at home. Everyone has to make their own assessment of risk though.

Thanks both. It's really helpful to hear of other people's decision. For me, this is th crux of it:

'In hindsight, he possibly wouldn't have lived if the shoulder dystocia had happened while I was in the pool. Or maybe he wouldn't have got stuck if I'd been in the pool, who knows?'

It's that not knowing that is driving me crazy! Everyone (me, midwife, consultant etc) has an opinion on why it happened and how the circumstances might have affected the outcome, but no one actually knows. Argh. Unless the consultant is able to shed real light on it next week I suppose-fingers crossed for that!

Antoinette if it helps at all I feel that my first labour was very badly managed. I had a useless midwife who was severely hungover (I'm not kidding) who basically left me to it, As far as we both remember and according to my notes (I eventually got hold of them) she didn't do any checks as my labour was progressing towards the pushing stage and left me in one position (being a first timer I didn't know about the importance of moving around) which was on my knees over the back of the bed. She gave me no assistance, advise or help whatsoever so I just tried to push with all my might constantly. I always wonder if that is why he got so badly stuck. I do feel if she had checked how he was coming down the birth canal before his head was out and everyone then realized he wasn't coming any further, perhaps a change of position, some controlled breathing etc would have avoided it.

So after ds1 I really do/did feel that I had a sd because of a mis-managed birth. Or if not, that it definitely contributed to the severity of it. However, ds3 birth could not have been more different. The mw was amazing, did yoga and relaxation with me, I was mobile, not in much pain, stood up circulating my hips right until the very end. And yet, still he got stuck at the end and I had a mild sd - which was properly managed and anticipated but still a minor emergency, push the buttons, call for help etc. This did change my outlook a bit _ I was convinced the first one was bad luck/fluke/crappy labour and mw - wheras it happening twice makes me think I probably was prone to them. I am now glad I didn't try a water birth as it worries me that it that the sd wouldn't have been spotted in time. Saying that perhaps they would simply have got me out of the water at the end. Same with a home birth. It took a team of paeds clustered round my ds1 to do whatever they had to do and his oxygen levels were extremely low according to my notes (but recovered quite quickly luckily) - but having never had a home birth, perhaps 2 midwives are equally capable of doing this?

It's a tough decision. Only you know how traumatic and risky your first birth felt. And whether you are confident the midwives will be aware and able to handle a possible second sd. Would a MLU birth be a good compromise? Any issues and the paeds are up the hall rather than an ambulance ride away?

this is the crux of it for me:

Speed of access to skilled paediatricians is also a factor

having seen the state my first son was born in, compared to then seeing 2 normal newborn babies (and it's consequences - delayed skin to skin contact, difficulty establishing bf, shock, jaundice, incubator and special care, parental pst) - but I have to stress this was only my experience and I think it might have been a fairly scary one/bad sd? Maybe not typical?