C/S or V/B after shoulder dystocia.

[HotKim]

This is my first post so Hello! to you all and thanks for sharing!


I have three children Miss11, and Masters 4 and 6. My children were all born naturally weighing 3800, 3950 and 4590 grams and I recieved care from midwives for all three. I am an advocate of women being well-informed during pregancy, labour and delivery. My last child (the whopper!) was delivered at a birth clinic and suffered shoulder dystocia during delivery. My midwife was able to deliver him after I went on all fours but he suffered a Brachial Plexus injury and endured 18 months of intensive physio.

I am currently pregnant with another child due in June 08 **YAY!** and while I tried to obtain midwifery care through the local hospital I have been unceremoniously dumped into the care of a doctor considering my previous problem. My doctor (I should say A doctor) has suggested I consider a c-section considering my last child's birth weight and BPI.

I've done a fair bit of research which loosely suggests that macrosomia is key in SD. (There are other factors but I have none of these such as GD, maternal obesity etc) However, what's worried me is the suggestion that having had a previous SD I am now more at risk for another. I have no fear of birthing a large child as I have had no stitches for any.

Considering how lucky we were that Master4 has no residual effects from his BPI and that I know a mother who refused a C/S for her macrosomic baby who then suffered brain damage after V/B I feel between a rock and a hard place.

I was hoping for some inspiration, advice or support from other mums or midwives who have faced the same dilemma.

[BellyBelly]

Shoulder dystocia is an unfortunate positional problem and even babies of 7lbs have been known to get it. Just bad luck. Check out spinningbabies.com which is an optimal fetal positioning site and its a great help/read.

If you read the Cochrane database, there is a study on induction for suspected marosomic babies where mothers had GD - but with or without GD, results showed induction for suspected macrosomic babies resulted in more c/s without improving outcomes including dystocia or other trauma.

Have known mums to go on and have normal births without SD after prior SD experiences.

[Lucy]

My daughter Olivia (7lb6oz) was born naturally with shoulder distocia.

In hindsight it was a positional issue.

I then went on to have my son Charlie vaginally, and then Lexie naturally.

I was encouraged to have a CS for my son, but inisisted against it. I did end up being induced with him, which was a shame for me, but the birth was easy. I gave birth standing with him.

HTH.

I can understand your dilema.

[HotKim]

Kelly, thank you for your input. Unfortunately I 'm finding it hard locating info to help me resolve my dilemma. I have read in other posts, your comments about SD maybe being related to an inactive birth but feel confident that I was very active throughout Master4's labour and delivery. I guess my biggest problem is that there is so much conflicting info on SD that it's hard to feel like I'm making a properly informed decision. Research suggests that anywhere between 48 - 89% of SD occurs in non-macrosomic babies. Not only that 'there is evidence to suggest that delivery of a previous macrosomic baby is quite a reliable sign of pelvic adequacy to deliver a macrosomic infant. However, previous SD constiutes an apparent risk factor, despite a lcak of consistency'. The same report then goes on to say that one should avoid VD in a patient with previous SD as 'these patients carry a 7 to 16 times increased risk of repeated SD and should better avoid VD.'

Gah! It's no wonder I'm confused!!

[HotKim]

So I went to see a physio therapist today and he gave me the name of a site that has the result of actual studies into thousands of medical problems etc.

Here's what I've found,

Gurewitsch ED, Johnson TL, Allen RH.
Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. dgurewi@jhmi.edu

Among risk factors for shoulder dystocia, a prior history of delivery complicated by shoulder dystocia is the single greatest risk factor for shoulder dystocia occurrence, with odds ratios 7 to 10 times that of the general population. Recurrence rates have been reported to be as high as 16%. Whereas prevention of shoulder dystocia in the general population is neither feasible nor cost-effective, intervention efforts directed at the particular subgroup of women with a prior history of shoulder dystocia can concentrate on potentially modifiable risk factors and individualized management strategies that can minimize recurrence and the associated significant morbidities and mortality.

PMID: 17531900 [PubMed - indexed for MEDLINE]


Ginsberg NA, Moisidis C.
Department of Obstetrics and Gynecology, Northwestern University, Illinois, USA
...The mean fetal weights were 3885 g in the recurrent dystocia group and 3702 g in the group without recurrence (P <.03). Gestational age, operative delivery, and gestational diabetes were similar in the two groups. CONCLUSION: Factors that appear to increase the recurrence risk of shoulder dystocia include fetal weight and maternal parity. Prior shoulder dystocia is the single greatest predictive factor.
PMID: 11408863 [PubMed - indexed for MEDLINE]


Lewis DF, Raymond RC, Perkins MB, Brooks GG, Heymann AR.
Department of Obstetrics and Gynecology, Louisiana State University Medical Center, Shreveport 71130-3932, USA.

OBJECTIVE: Shoulder dystocia continues to be a major complication of obstetrics, and several factors have been identified to help predict its occurrence. A previous shoulder dystocia is one of the risk factors. However, the recurrence rate is unknown. The purpose of this study is to report the recurrence rate of shoulder dystocia. STUDY DESIGN: Our obstetric database was used to identify all vaginal deliveries between January 1983 through December 1992. A subset of vaginal deliveries complicated by shoulder dystocia was selected from this database. These records were reviewed to identify subsequent pregnancies, outcomes, risk factors, and demographic data. RESULTS: During the study period there were 37,465 total vaginal deliveries, with shoulder dystocia complicating 747 (overall rate 2%). Of these 747 cases, 101 patients had 123 subsequent vaginal deliveries, with shoulder dystocia complicating 17 of these pregnancies (13.8% recurrence rate, p < 0.0001). Comparisons were made between those patients with recurrent shoulder dystocia. CONCLUSION: Shoulder dystocia recurred at a rate approximately seven times higher than our primary rate. Whether patients with a history of shoulder dystocia should be offered an elective abdominal delivery requires further investigation.

PMID: 7755040 [PubMed - indexed for MEDLINE]


Awwww, not good!

[BellyBelly]

Its up to you what you want. I just have never known someone to have it twice. They are probably out there but never heard it myself.

Try the Cochrane Database, they are independent study reviewers, not biased.

[HotKim]

Its up to you what you want. I just have never known someone to have it twice. They are probably out there but never heard it myself.

Try the Cochrane Database, they are independent study reviewers, not biased.

Kelly, thank you for your response.

You're right, it is up to me. What I'd like tho' is to be sure I'm making a properly informed decision. As you can see from the info I posted, previous SD is the biggest risk factor and at this stage I have up to a 16% chance of it happening again. That's a low-ish risk, in my books, but that doesn't make me feel too good either.

I did try the Cochrane Database and they had no studies on recurrent SD. The info I posted above is from PubMed (also unbiased).

Lucy, thank you also for your input. It is so good to hear that your two children did not suffer the same as your first SD. Despite assertions that SD is a proitional issue, the studies I have looked at indicate that size can be a factor. Since this is in addition to my having already experienced SD I am not as confident as you that I will birth a large baby without problems. That's even if I have a large baby, since estimating size is very inaccurate.

I have an ante-natal appointment tomorrow. Must write a list of questions out for the mid-wife.

[*EmJa*]

hi hotKim,
im in a similar situation as u, im pregnant with number 2 and when my DD was born she suffered SD and BPI to her left arm..ive been told by one doctor that he would advise me to have a c/s or be induced earlier because if bubs shoulders got stuck it could have a worse outcome than DD which is scary but i want nothing more than to have a natural birth.

my new doctor does not seem as worried and thinks i may still be able to have the natural deivery im so very wanting..i have to have a scan at 36wks to check bubs size (which i know is not always accurate) and then they are going to go through everything with me risks etc..but in the end its upto me

its totally upto u, its so hard because we dont have a crystal ball to see wat will happen!

[HotKim]

its so hard because we dont have a crystal ball to see wat will happen!

Hi Blanche!! At last, someone in the same predicament as me!! (not exactly something to be happy about but you know what I mean!!)

I've been meaning to discuss the advantages, if any, of weight prediciton using 3D ultrasounds. Is this something you have considered?? The accuracy of sonographic weight testing is about 60% according to what I have read but you only need to look through the forums to see just how wrong they can get it. (Not trying to put you off here just discussing.)

Yes, if I had a crystal ball that would make this soooooo much easier. It's only since getting pregnant with this one that I have really delved into what happended to Master4 and I am shocked at how lucky we are that he has no residual effects of his BPI. Whilst, I could certainly handle an injury of his kind happening to this baby, I couldn't forgive myself if it were something worse.

How has your DD fared with treatment of her BPI? What kind was it? Master4 had Erb's Palsy (AKA Brachial Plexus Palsy). No movement in the left arm until 6 weeks old. In recent weeks, after reading more into it, I have thanked God it wasn't any worse.

I was considering inducement for this one but again, couldn't make up my mind which was the better of two evils, C/S or inducement?? Neither negates the possiblity of SD or even BPI.

[Captain]

Hi Hotkim

I'm in the same position but I have been unable to find a dr that will support me with a vag birth. I've already been booked for a C-section.

I guess for me I've decided I can't take the risk. DD has a right arm BPI, she had nerve grafts and will probably be having tendon transfers in the next year. So seeing the injury every day has made the decision a bit easier for me to deal with. I don't know if I could cope with the guilt if it happened again.

Good luck with making your decision, I know it isn't an easy one.

Blanche, I really hope things work out for your birth.

[HotKim]

Captain, hug for you and your daughter, she has obviously suffered alot because of it.

That's the same reason I am leaning toward a c/s. I think we were lucky the first time and that we won't be as lucky again and I'm not prepared to risk the baby. Like you, I'm scared of making the wrong decison.

Today I had an ante-natal appoinment and spoke to a midwife who gave me a really good talk about the risks. In the end she said that I just need to put my trust and my faith in whatever decision we choose. She's right though, if I don't, it won't matter what I come to it won't work out if I don't have my heart in it.

[*EmJa*]

my DD had brachial plexus palsy/erbs palsy too she hasnt had any surgery and we have been told she wont need any surgery in the near future, we just had to do excerises everyday. i think we were pretty lucky too as it hasnt really affected her that much she crawled at 8 mnths and walked at 10mnths.

they are doing a scan in a few wks to check this bubs size and i know they are not accurate but it will give an estimate and i dont feel as big as i did with DD. i really am more terrified at having a c/s than a vaginal delivery and im praying that SD or BPI will not happen again, i wasnt active at all in labour with DD cos i was induced so im hoping this time i will be able to be more active.

[HotKim]

Blanche, our son hasn't needed surgery either, just lots of physio until he was cleared at 18 months old. To look at him now, you would never know he'd been injured in such a way. He will start playing rugby (Union) in a few months so I'm keen to have him looked at again just to make sure there isn't any problem with him doing sport.

Like you, I was much more afraid of having a C/S than a vaginal delivery, fear of the unknown mostly. I was able to ask my midwife yesterday of the benefits of 3D scans but she didn't have any relevant info on them.

Best of luck with whatever delivery you choose.

[*EmJa*]

Thats great to hear ur DS will be starting rugby soon!

i wish u the best of luck with everything and hope u have a happy and healthy bub, take care

[muming]

Hi Girls,

I just found this thread when I did a search for shoulder dystocia. I too am in the same boat. I had a natural first birth, and SD with the second. You can read about the details in my thread, "any midwives with experience with shoulder dystocia" (something like that).

Anyway I have found it difficult to get support for a natural VD with the OB i have been seeing, and another I saw at the hospital clinic the other day. I am not getting the support that I need to go into this birth as positive as can be. I have also read all of the pubmed articles, and that isn't very encouraging either! I have booked into see Christine Tippett for a consultation to get her opinion also. I have organised a Doula, who will hopefully help me to have a "relaxed" labour, which might help with a good delivery.

I would be very interested to hear how you are going and what you decide to do. All the best with your decisions.

Here's to safe, happy and healthy deliveries!!!

Ingxx

[HotKim]

muming.

First, I wish you and bubs a safe delivery whichever method you choose. I do hope you can find support from a Dr and the doula.

After giving it lots of thought, we've decided to have a c-section. Like you I feel I did as much research as I could (there isn't much support out there) and made the best decision I could come to based on that. I've really felt that it was a gamble all along and all I had to decide was if I was comfortable with the risks. 'Fraid not but that's just me.

Tomorrow I will be meeting a doctor to discuss the procedure and book in.

Did your child recover well from the dystocia?? Do the have any residual effects?

Oh, Blanche (who posted above) had her boy today. From all accounts everything seems to have gone well for her and baby Jack. Well done Blanche!

[muming]

Hi Hotkim,

Thanks for your good wishes.
Sierra didn't have any permanent damage. We were very lucky I guess. After about 7 weeks she was pretty much back to normal. Her clavicle heeled well and her nerve damage repaired. We did notice the other day however that her scapula on the damaged side sticks out a little bit compared to the other. When she runs too, her arm flings out to the side a little. Nothing to complain about though.

I wish you all the best with the CS. At least you have made a decision! Half of the agony is trying to decide what to do. I'm sure once you're little angel is popped on your chest, it wont matter how he/she got there, but that they are safe and healthy.

Ingx

[*EmJa*]

hi ladies

had my little man on tuesday..i did end up going with a c/s as in the doctors scared me saying if i was to have a vag delivery and SD happened again it could be very dangerous and that bub was going to be just as big as DD. said it was upto me but would highly recommend a c/s..kept saying it was my choice and asked if i could live with myself if it happened again, so i got really worried and thought to myself no i just couldnt live with myself if my little boy got hurt....so we decided to go with the c/s

well in the end baby Jack only ended up weighing 7pounds 12.5oz and was 48cms long hc 36cms i feel quiet dissapointed that i probably could have gone with a vag delivery as he wasnt very big in the end, but im also very happy he is here and healthy. i am recovering well from c/s but its hard as it takes longer to recover and i cant even lift my 17mnth old DD

How did ur appt go Kim?