Shoulder dystocia and subsequent birth - consultant conversation

[Londonwriter]

Just wondered if anyone had a shoulder dystocia in a first birth and then had a discussion with a consultant before 30 weeks with their second? What happened with the subsequent birth?

For background:

I had PROM with my first birth at 40/41 weeks, a couple of days before I was due to be induced with high blood pressure. Due to the PROM, I had induction with pessaries, and entered a very fast first labour (about 8 hours total) with no regular contractions, which I did unmedicated. Because it was a first labour and the midwife didn’t want to check my dilation due to fear of infection, she assumed I was eleven hours from giving birth and offered an epidural so I could sleep, as it was 10pm, I was being violently sick and was visibly weakening from the intense irregular contractions with no pain relief.

A short time later, the consultant appeared and it turned out I was 10cm dilated and I started to push with the epidural still in my system. I was already labouring on my side with monitoring because my DS was lying on his cord, and I ended up birthing on my back. After an hour, we realised he was stuck, and I had a failed ventouse, forceps and then the Roberts manoeuvre where you stick your legs next to your ears. My DS was three minutes without oxygen, and arrived grey, but was chittering away within seconds. I immediately established breastfeeding and, by 7am the next morning, tried to discharge myself as I felt fine apart from paracetamol for the tear/cut. Eventually, they let me out around 7pm and I walked to a local cafe the next day.

I was completely non-plussed about all of this and never got a debrief as I’d already left the hospital. I didn’t even realise I’d had a shoulder dystocia and this was serious until I read my notes - because the consultant and I were so calm about the whole thing.

Anyhow, I’m now 20 weeks pregnant with DS2, but have a different consultant (my parents-in-law have paid privately for maternity both times) and am at a different hospital because we’ve moved house. I had a brief discussion about the birth at my booking appointment, but he didn’t really discuss in detail apart from wondering why my previous consultant let me get to 41 weeks. After I had the 20-week scan yesterday, I asked him when we should discuss the birth. He immediately said: “the shoulder dystocia?” And I said: “Yeah” and emphasised that I chose my last consultant specifically because - despite being consultant-led - I thought she would support natural and active birth, and I really didn’t want a C-section, which I thought was a risk with private consultants. I said I was happy to run the risk of a shoulder dystocia again as the risk was only 1 in 10 of a reoccurrence, and the risk of serious injury was lower than that. I explained that my previous birth wasn’t a big deal.

Despite him not saying anything, I got the impression he thought I was a high-risk pregnancy, and expecting to get up off a bed and go home a few hours later was an ‘ideal’. He said I seemed like a sensible person and he expected me to be sensible about whatever was necessary. Just as I went to the door to leave, he said: “It’s not the decision I would have made”, but I didn’t have the opportunity to clarify.

I’m now fretting about what the heck the guy is thinking and whether it’s stupid to expect a vaginal birth.

The issue is that I have non-gynae fertility problems (I have some sort of undiagnosed autoimmune/inflammatory condition) and it took me three years to conceive my DS naturally. By the time I’d finished BF and realised I was still infertile, I was 39, and we ended up going to a fertility clinic and having IVF to improve my chances while my inflammatory disorder was under control.

As such, on paper, I’m a 40-year-old woman with an IVF pregnancy, an unknown circulatory/inflammatory condition, and a history of shoulder dystocia and assisted birth. However, in reality, I had a frozen embryo transfer with no meds (i.e. the IVF was pretty similar to a normal conception). My inflammatory disorder, although unpleasant, is controllable, and I’ve no other conditions. Also, I put a lot of effort into keeping fit - largely because of my chronic condition. I cycled 16 miles to yesterday’s appointment and back, am regularly going to a weights class where I squat 25kg for 100 reps, do zumba, etc. In my last pregnancy, I did weights, swimming and Zumba to 41 weeks. I think this goes some way to explaining why I had an eight hour first labour. My suspicion is that, if I hadn’t had PROM, I wouldn’t have had the induction/epidural/forceps/ventouse/dystocia - I have no other risk factors. I don’t see why an uncomplicated four-hour second birth with no meds is unachievable.

I’m now no longer confident in my birth choices, as the consultant kept saying to me “well, you’ve put so much effort into becoming and staying pregnant”... It’s like, “well, yeah, but I also cycled here through central London traffic and life is full of risk.”

P.S. Should mention - DS was 8lb 5oz (so not huge).

20-week scan predicted DS2 to be 9lb 6oz (which is big), but DS was also predicted to be 9lb 4oz on the 20-week scan - and he wasn’t - so I’m assuming DS2 will be similar in size to DS1.

Shoulder dystocia can be really serious, though OP. I really, really hope you get the active, safe birth you are hoping for, but the consultant does have to discuss risk with you. My first was measuring very large (and he was huge, but his shoulders were smaller than his head, as it turned out).

My consultant had two very in-depth sessions with me to talk through all the risks to me (incontinence, nerve damage, fistula) and my child (brain injury, cerebral palsy, loss of arm function).

Like you, I was dead set on a natural birth and believed I could make it happen, that the hospital was being outrageously risk averse.

But DS had other ideas, he got his arm stuck behind his head and thankfully, it was such a chubby arm, he couldn't enter my pelvis. EMCS after 30hrs of contractions and I thank my lucky stars for that. I would have been severely injured had he been birthed vaginally, and who knows what may have happened to him.

I guess what I'm saying is to be open to other options. Ask questions, seek all the options available to you. And be prepared that things may end up differently than you hope, but that you can insist on consent the whole way through.

All the best.

He didn’t discuss the risks. Had he discussed risks he would have, presumably, cited the NICE guidelines. These are that women who’ve had a shoulder dystocia should not be routinely offered a ELCS because there’s a 90% chance it won’t reoccur and, even if they do, most cases of shoulder dystocia are easily resolved. In addition, 98% of women who had a vaginal birth first time around have one for a second baby.

He didn’t offer me an ELCS, but his behaviour suggested he thought I was mad not to want one.

What we know, medically speaking, is that I have naturally fast labours (8 hours for a first birth). And that I can get to 8cm dilated without pain relief. Given that second labours are shorter and generally have fewer complications, and there’s no reason to believe DS2 is bigger than DS1 (who wasn’t huge), the overwhelming statistical probability is that - if I enter labour - I will give birth in around 3-4 hours with no pain relief.

There is, obviously, a possibility that my cardiovascular system will pack up again around 39/40 weeks or I have another PROM. In which case, given induction and further intervention is a risk factor for shoulder dystocia, it would probably be safer to opt for a ELCS at the last possible moment. The evidence is that I have a high risk of shoulder dystocia if induced, with an epidural and forceps/ventouse. However, that hasn’t happened yet, and it’s not the way to bet.

In short, he made me feel completely crazy for making decisions that I know are broadly evidence based.

Can you make another appointment and revisit this and if you’re not happy after, ask for someone else? Not being 100% happy (or trusting) with your consultant is never good and these are big decisions, you need to be on the same page.
Good luck with whatever you decide.

By the way I didn’t think it was referred to as PROM after 37 weeks when babies are considered full term?

It’s a very personal choice. If you’ve looked at balanced research and facts and carefully thought about everything then it’s your decision alone. As it’s a personal choice, there will always be others who would have opted differently. We all have different ideas about what risks are more or less acceptable to us. Your consultant needs to accept that you are the decision-maker and entitled to choose differently to what he would.

I'd maybe have a look at the risk factors for vaginal prolapse - previous assisted birth (suspect you'd have been very lucky to get away without some levator avulsion from that type of delivery), squatting heavy weights pregnant, your age.... You may be absolutely fine and then five years down the track your pelvic floor gives up the ghost. I was fine after my first water birth and a prolapsed mess after my second. Just one perspective as I wish someone had told me to stop lugging stuff around, not to walk to the park the day after giving birth, consider the existing damage I had and exercise for my long-term health rather than to be that rough, tough pregnant woman still acting like it was no big deal... Forty and twenty-five unfortunately mean very different things for your pelvic health. On the plus side, the dystocia may mean the second will fly out but you don't know you won't need a second assisted delivery and your risk of permanent pelvic floor damage is huge at your age. Sorry to be blunt, I wish someone had been with me xx