Induction or C-section after previous shoulder dystocia?

[Tweet180]

I gave birth to my first daughter vaginally. The birth was pretty standard (I had gas and air - total labour was around 18 hours). She weighed 9 pounds (4kg) at birth. After her head emerged, her shoulder got slightly stuck. My Ob wriggled her out pretty quickly, though in the process, nerves running from her neck to her arm were bruised, resulting in a mild Erb's Palsy (limited movement in her hand and arm). This resolved naturally a few months after her birth. I had 2nd deg tearing but this also healed fine.

Much later, I found out that lying pretty much on my back on the bed, was probably the worst position to be in for birth. I realise that the pelvis is more open if you are squatting or on all fours. So I wasn't helping the situation with my position.

Now nearly 36 wks with my 2nd baby, a boy and with the same Ob, he has suggested a scan at 36 wks to determine fetal size. If this baby is predicted to be larger than 4kg, he has suggested an induction at around 38 weeks or elective C Section to manage the risk of another shoulder dystocia. I think there is some evidence for second babies being bigger than firsts.

I am really not sure what to do as both forms of intervention seem quite drastic. I want to do what is best for the baby - but it doesn't seem an easy decision. Also with a toddler, I would rather avoid C section so I can pick her up!
If anyone has any similar experience, research findings or perspective on this, I would be very grateful. Thanks

[BellyBelly]

Urgh! Scans can be so inaccurate its not funny. I think you've already hit the nail on the head too, being flat on your back is no good.

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Small Pelvis? Here's The Truth About Cephalopelvic Disproportion (CPD)

From this article: Induction of Labour - To Induce or Not Induce?. I know it says GD but its in relation to big babies.

Induction For Gestational Diabetes

Even where there is a medical condition involved, for example, Gestational Diabetes, it is worth researching and asking your Obstetrician and / or Midwife to see if induction is going to offer more risk than benefit. The American College of Obstetricians and Gynecologists has published a study which you can read here (which you might like to print out and show your own Ob), which concludes:

“Based on data from observational studies, labor induction for suspected fetal macrosomia (large baby) results in an increased cesarean delivery rate without improving perinatal outcomes.”

They state:

“Summary statistics for the nine observational studies showed that, compared with those whose labor was induced, women who experienced spontaneous onset of labor had a lower incidence of cesarean delivery and higher rates of spontaneous vaginal delivery. No differences were noted in rates of operative vaginal deliveries, incidence of shoulder dystocia, or abnormal Apgar scores in the analyses of the observational or randomized studies.“

Apart from this, not many Gestational Diabetes babies or other babies believed to be ‘huge’ end up being born abnormally ‘huge’. I have heard more stories of these babies being born early through recommended inductions only to arrive tiny, of average size or to have breathing problems due to unexpected pre-maturity. One midwife recalls a birth in early 2006:

“Overuse of inductions is a real concern to me. So many women coming in for induction and the reasons seem so vague sometimes. I was involved in a birth a few weeks ago where the woman was induced because of previous macrosomic (big for dates) baby. She had gestational diabetes with that pregnancy and previous shoulder dystocia (first baby, this was her 3rd). We attempted induction at 36 weeks and it failed. Induction was again attempted at 37 weeks which was successful – baby was only 2750g – hardly macrosomic! The ultrasound had estimated a baby weighing 3500g so it wasn’t even close. I think if she had that baby at the first induction attempt at 36 weeks it would have had to go into Special Care as it would have been under 2500g which is our cut off. Frightening.”

This is a brilliant article on Gestational Diabetes written by Henci Goer, an academic who wrote The Thinking Woman’s Guide to a Better Birth and Obstetric Myths vs Research Realities, both of which are amazing books. I recommend The Thinking Woman’s Guide as an essential read for every woman.

[Midwife Melissa]

both forms of intervention seem quite drastic ...

They are drastic! Whatever happened to the option of natural birth? It's not too late to change care providers if you feel that your ob is not meeting your needs. You might like to do some research around caesareans, the operation, the risks, the risks for future pregnancies, your chance of ever birthing vaginall again after a caesarean,. and also the risks of induction ... one of which is caesarean.

What you've not tried is a physiological birth positions (like, off the bed, kneeling, all founrs etc) and pushing only when your body tells you that you need to. It makes a huge difference to the body's ability to birth a baby when we work with our bodies, not against them.

[Mildez]

From what you said your daughters birth sounded like a very mild case of dystocia and her Erb's Palsy would of been a result of the Dr pulling her to get her out.
Often knowing your at risk of having another shoulder dystocia with your next birth (or third or 4th etc) is enough to notify your care provider to have you in a position that will facilitate birth by allowing your pelvis to be as wide as possible and preventing the shoulders from getting stuck again. This alone is usually the best possible prevention. Of the bad dystocias I have seen they have always been the ones you are not expecting. The ones you expect usually don't happen as your doing everything you can to prevent it happening and the birth is then very straight forward.
Also biggers babies don't neccessarily mean your more likely to have a dystocia with it. Sometimes you see a much smaller baby then the previous one get stuck when a much bigger one came out without any problems .

[Fleur]

DD1 was 3910, or 8lb10, no dystocia, I birthed on my back.

DS1 was 4410g, or 9lb13, his shoulders were stuck for a bit & required a bit of manipulation to get him out. I was on all fours.

DS2 was an emergency CS (for unrelated reasons). He was 4010g / 8lb13.

DD2 was a VBAC, she was 4710 / 10lb8, I was on my back, there was some manipulation but she didn't get stuck.

Not exactly the same as your situation (my DS1 didn't suffer any nerve damage, it was very mild dystocia) but thought I'd share my experience - every birth is different, and babies do not necessarily get bigger.

Scans for size are notoriously inaccurate, my sister was told she might need a CS because her baby was so big - she was 6lb 12 when she was born!

Good luck

[Mildez]

Yes recently we had a woman birth whom ultrasound said 1week before he was born estimated weight was 5100grams. He was born a very average 3400grams.

[Tweet180]

Thanks so much for sharing these views and information. I do think my first daughter was a fairly mild case of dystocia. My partner said she came out pretty quickly once her head emerged (I wasn't aware of any issue until later).
Also makes me think 2nd birth onwards, your body should be better at it and more 'stretched'. Plus being in a better position would change the angles etc
I would rather have a natural birth but serious shoulder dystocia poses a major risk to baby's health so it's not clear cut.
Will take on board that growth scans are unreliable!
Thanks again - will post an update..