Birth question: shoulder dystocia prevention
October 8, 2018 4:34 PM Subscribe
What, if anything, can I do to help prevent (by even the smallest increment) a second shoulder dystocia, medical and midwife types of Metafilter?
I had a shoulder dystocia during my first delivery. All turned out okay, fortunately. I realize that this puts me at a higher risk of recurrence for my current pregnancy and that I should consider a preventive C-section, especially if this baby ends up looking big. (I'm only 11 weeks now.)
What if anything can I do to reduce the likelihood of shoulder dystocia recurring? I've had a few conversations about this and about how we will make the C-section vs. vaginal birth call with my doctors. They're good doctors, but I feel like occasionally they don't say things that (by my logic) might be relevant. Example, if I end up getting gestational diabetes, that'll increase the likelihood of a big baby, so I should look at all the risk factors for that that are within my control (unlike say, the fact that I'm 40) and do what I can do there (like exercise). That has me wondering if there's anything else we're missing.
As a side note, it's possible I was born with a shoulder dystocia, as my clavicle was broken at birth. Then my mom delivered a 10 pound baby (more than a full pound heavier than me) no problem for my younger sibling. Maybe our bodies just stretch out? Is that at all possible? As another side note, my first labor was super long and progressed very slowly, with a bunch of back labor. (I hear that maybe this isn't really relevant, though.)
Please don't weigh in with heavy-handed urging that I should have a C section. That's certainly on the table, and I'll be discussing it with my doctors as we learn more about how this pregnancy goes and what exactly happened last time. I'm not pressuring them away from advising that option. But if they end up thinking a vaginal birth is best, I don't want any fears cluttering my mind.
I would appreciate any and all thoughts on anything I can do or any way to learn more about this topic. Is there a research institute that is coming up with the latest and greatest science on this?
I had a shoulder dystocia during my first delivery. All turned out okay, fortunately. I realize that this puts me at a higher risk of recurrence for my current pregnancy and that I should consider a preventive C-section, especially if this baby ends up looking big. (I'm only 11 weeks now.)
What if anything can I do to reduce the likelihood of shoulder dystocia recurring? I've had a few conversations about this and about how we will make the C-section vs. vaginal birth call with my doctors. They're good doctors, but I feel like occasionally they don't say things that (by my logic) might be relevant. Example, if I end up getting gestational diabetes, that'll increase the likelihood of a big baby, so I should look at all the risk factors for that that are within my control (unlike say, the fact that I'm 40) and do what I can do there (like exercise). That has me wondering if there's anything else we're missing.
As a side note, it's possible I was born with a shoulder dystocia, as my clavicle was broken at birth. Then my mom delivered a 10 pound baby (more than a full pound heavier than me) no problem for my younger sibling. Maybe our bodies just stretch out? Is that at all possible? As another side note, my first labor was super long and progressed very slowly, with a bunch of back labor. (I hear that maybe this isn't really relevant, though.)
Please don't weigh in with heavy-handed urging that I should have a C section. That's certainly on the table, and I'll be discussing it with my doctors as we learn more about how this pregnancy goes and what exactly happened last time. I'm not pressuring them away from advising that option. But if they end up thinking a vaginal birth is best, I don't want any fears cluttering my mind.
I would appreciate any and all thoughts on anything I can do or any way to learn more about this topic. Is there a research institute that is coming up with the latest and greatest science on this?
Sorry, that Medscape quote got weirdly truncated, and should have ended with “but with a glucose fasting level < 95 mg/dL.”
posted by jesourie at 6:50 PM on October 8, 2018
posted by jesourie at 6:50 PM on October 8, 2018
Yeah, reducing your risk of GD is what you can control. I like Lily Nichols’ books about nutrition for both pregnancy and GD—she’s done a ton of painstaking research into nearly a thousand different peer reviewed articles, and summarized them. I think they’re pretty much the best out there, nutrition/diet-wise.
Other than that, do lots of walking and gentle hip movement, especially near your due date, to help shift your pelvic bones and the baby into the best possible position. Don’t do anything that hurts, nothing that might strain your ligaments, but keep being active up until labor.
During labor, if you and your doctors decide to go that route, bounce and rock and sway on a yoga ball, move side to side, and walk—anything to help shift baby and pelvis together to help get them out and through smoothly.
Congratulations and good luck!
posted by Illuminated Clocks at 7:01 PM on October 8, 2018 [2 favorites]
Other than that, do lots of walking and gentle hip movement, especially near your due date, to help shift your pelvic bones and the baby into the best possible position. Don’t do anything that hurts, nothing that might strain your ligaments, but keep being active up until labor.
During labor, if you and your doctors decide to go that route, bounce and rock and sway on a yoga ball, move side to side, and walk—anything to help shift baby and pelvis together to help get them out and through smoothly.
Congratulations and good luck!
posted by Illuminated Clocks at 7:01 PM on October 8, 2018 [2 favorites]
So little is known about labor and birth complications. It's really bizarre, actually. I had a major complication with my first pregnancy (placental abruption at 24 weeks, all turned out okay) and was very concerned about it happening again. My doctor said it was like being hit by lightning, but the fact that it happened made it more likely statistically that it would happen again. There was only one intervention available - 20 weeks of progesterone shots - which she felt probably wouldn't help but certainly wouldn't hurt, so I agreed to that.
I guess a few things you could ask about are: early induction depending on size or positioning, delivering in an OR in case an emergency c-section is needed, any gestational diabetes prevention/treatment, ecv for optimal positioning, ultrasound during early labor to determine positioning, labor positions for you to improve outcomes (standing, stool, water birth).
I don't know if Emily Oster of Expecting Better has covered this or if she takes questions but she and Alice Callahan of Science of Mom are the only two writers I trust for gathering this kind of information.
posted by peanut_mcgillicuty at 7:02 PM on October 8, 2018 [2 favorites]
I guess a few things you could ask about are: early induction depending on size or positioning, delivering in an OR in case an emergency c-section is needed, any gestational diabetes prevention/treatment, ecv for optimal positioning, ultrasound during early labor to determine positioning, labor positions for you to improve outcomes (standing, stool, water birth).
I don't know if Emily Oster of Expecting Better has covered this or if she takes questions but she and Alice Callahan of Science of Mom are the only two writers I trust for gathering this kind of information.
posted by peanut_mcgillicuty at 7:02 PM on October 8, 2018 [2 favorites]
There's no clear evidence for early induction after a previous shoulder dystocia. While it sounds like it would make sense to deliver a fetus before it can get too big relative to the maternal pelvis, many dystocias happen with fetuses whose weight is average for gestational age. The jury's still out on this one and it's the kind of thing you and your provider will need to explore together. (The one PDF I found specifically addressing the management of a pregnancy and birth after a previous shoulder dystocia is so full of condescending, fat-shaming language[1] that I link to it here only with reservations.)
External cephalic version (ECV) is only performed when the presenting part of the fetus is not the head. An ECV doesn't optimize the position of a fetus that is already head down and isn't used as such.
Ultrasound of a vertex fetus in early labor would not provide any actionable information. For many women who have already had a baby, the fetal head does not fully engage in the pelvis until active labor. And even if it does, the vast majority of fetuses descend into the pelvis in a right or left occiput transverse (ROT or LOT) position before the cardinal movement of internal rotation moves the head to an occiput anterior (OA) position. An ultrasound in early labor might show you either a fetus in ROT or LOT (which is normal) or a fetal head that is floating above the pelvic brim (which is also normal).
Shoulder dystocia is resolved by one or more specific maternal and/or fetal maneuvers, none of which are surgical; delivering in an OR provides no benefit.
[1] While it is true that shoulder dystocia is most prevalent among obese women with diabetes who have large babies, suggestions that a clinician is "fortunate" to have a "motivated" patient who "wants" to modify those risk factors, as opposed I guess to the rest of us unmotivated cows who just want to laze about getting fatter and making life harder for those unlucky doctors, should be met with nothing but a hearty fuck off.
posted by jesourie at 12:10 PM on October 9, 2018 [2 favorites]
External cephalic version (ECV) is only performed when the presenting part of the fetus is not the head. An ECV doesn't optimize the position of a fetus that is already head down and isn't used as such.
Ultrasound of a vertex fetus in early labor would not provide any actionable information. For many women who have already had a baby, the fetal head does not fully engage in the pelvis until active labor. And even if it does, the vast majority of fetuses descend into the pelvis in a right or left occiput transverse (ROT or LOT) position before the cardinal movement of internal rotation moves the head to an occiput anterior (OA) position. An ultrasound in early labor might show you either a fetus in ROT or LOT (which is normal) or a fetal head that is floating above the pelvic brim (which is also normal).
Shoulder dystocia is resolved by one or more specific maternal and/or fetal maneuvers, none of which are surgical; delivering in an OR provides no benefit.
[1] While it is true that shoulder dystocia is most prevalent among obese women with diabetes who have large babies, suggestions that a clinician is "fortunate" to have a "motivated" patient who "wants" to modify those risk factors, as opposed I guess to the rest of us unmotivated cows who just want to laze about getting fatter and making life harder for those unlucky doctors, should be met with nothing but a hearty fuck off.
posted by jesourie at 12:10 PM on October 9, 2018 [2 favorites]
Basically have a smaller baby earlier? It's not really under your control and calorie restriction during pregnancy is not recommended.
Another way to look at your question is, "how do I avoid interventions for a shoulder dystocia?". The biggest way to impact that is selecting a provider and facility that has a low rate of c-sections. I'm not giving you medical advice, but I am sharing my knowledge as a nurse and former midwifery apprentice and doula, that intervention rate varies considerably by where you are and who is taking care of you. I think for a layperson, the general concept of "better safe than sorry" seems intuitively true, but if you really pick apart the evidence, there's not always a compelling case for say, a "preventative" c-section, given that c-sections also have the potential for harmful side-effects.
In conclusion, if your true goals are to a) have a safe birth to a healthy baby and b) to avoid a c-section, then check in with a variety of providers (for example a certified nurse midwife if covered by your insurance) to ask about their c-section rates and outcomes.
posted by latkes at 12:27 PM on October 9, 2018 [2 favorites]
Another way to look at your question is, "how do I avoid interventions for a shoulder dystocia?". The biggest way to impact that is selecting a provider and facility that has a low rate of c-sections. I'm not giving you medical advice, but I am sharing my knowledge as a nurse and former midwifery apprentice and doula, that intervention rate varies considerably by where you are and who is taking care of you. I think for a layperson, the general concept of "better safe than sorry" seems intuitively true, but if you really pick apart the evidence, there's not always a compelling case for say, a "preventative" c-section, given that c-sections also have the potential for harmful side-effects.
In conclusion, if your true goals are to a) have a safe birth to a healthy baby and b) to avoid a c-section, then check in with a variety of providers (for example a certified nurse midwife if covered by your insurance) to ask about their c-section rates and outcomes.
posted by latkes at 12:27 PM on October 9, 2018 [2 favorites]
A couple more thoughts:
1. You mentioned that you had a long slow labor with your first and likewise you were a big baby but your younger sibling was born more easily. This is a very common scenario: First labor long and slow, second labor easier and faster. So perhaps that can give you a little relief to know!
2. Consider hiring a doula? This person can support you and your family and also help provide some support if you have to make decisions in the moment during labor. Or, and this may not be under consideration for you, but if you're here in the East Bay you could consider a freestanding birth center.
posted by latkes at 8:36 AM on October 10, 2018
1. You mentioned that you had a long slow labor with your first and likewise you were a big baby but your younger sibling was born more easily. This is a very common scenario: First labor long and slow, second labor easier and faster. So perhaps that can give you a little relief to know!
2. Consider hiring a doula? This person can support you and your family and also help provide some support if you have to make decisions in the moment during labor. Or, and this may not be under consideration for you, but if you're here in the East Bay you could consider a freestanding birth center.
posted by latkes at 8:36 AM on October 10, 2018
This thread is closed to new comments.
posted by jesourie at 5:28 PM on October 8, 2018 [1 favorite]