Increased chances of C-section the second time around?

[Lady Penelope Creighton-Ward]

If three out of ten women in Massachusetts deliver their babies by C-
section, and I delivered my first vaginally, does that mean I now have
higher than 3 in 10 chances with my second delivery? Just curious...

[Larissa In Aus]

On Wed, 28 Feb 2007 20:56:42 -0800, Lady Penelope Creighton-Ward wrote:

> If three out of ten women in Massachusetts deliver their babies by C-
> section, and I delivered my first vaginally, does that mean I now have
> higher than 3 in 10 chances with my second delivery? Just curious...

I am no expert but would think that you are *less* likely to have a
c-section the second time around if you have already had one vaginal birth.

Goodluck!

Larissa

[Anne Rogers]

> If three out of ten women in Massachusetts deliver their babies by C-
> section, and I delivered my first vaginally, does that mean I now have
> higher than 3 in 10 chances with my second delivery? Just curious...

not at all, it probably makes you much less likely, remember a lot of the
contributing c-sections are repeat c-sections, so even going into a first
time birth (not elective c-section first time), it's probably between 1 in
10 and 2 in 10 chance of a c-section. Having had a vaginal birth first time,
that probably drops your chance (in the the absence of other factors) to 1
in 20, or even less likely, it's relatively uncommon to hear of someone
having a c-section in a 2nd or later pregnancy with a previous sucessful
birth, from people on here, I can think of Engram fairly recently with an
undiagnosed breech and a while back Andrea, with Lydia, her 11th getting
stuck in an unusual position, there are probably others, but the vast
majority of women who have vaginal deliveries will go on to have future
ones.

Anne

[Anne Rogers]

sorry to reply again, but just from a purely statistical point of view
assuming no relationship between previous birth history and current birth,
this is the exact same question as "I've just rolled double 6, am I less
likely to do so next throw", which you find you are equally unlikely each
roll you make to get double 6, it happens 1in36 times regardless of what has
happened previously, but of course birth is not like that, history is
relevant, see my other post about that, so it's false either way.

Anne

[Lady Penelope Creighton-Ward]

On Mar 1, 2:07 am, "Anne Rogers" > wrote:
> sorry to reply again, but just from a purely statistical point of view
> assuming no relationship between previous birth history and current birth,
> this is the exact same question as "I've just rolled double 6, am I less
> likely to do so next throw", which you find you are equally unlikely each
> roll you make to get double 6, it happens 1in36 times regardless of what has
> happened previously, but of course birth is not like that, history is
> relevant, see my other post about that, so it's false either way.
>
> Anne

Makes total sense, of course! Thank you!!

[Ericka Kammerer]

Lady Penelope Creighton-Ward wrote:
> If three out of ten women in Massachusetts deliver their babies by C-
> section, and I delivered my first vaginally, does that mean I now have
> higher than 3 in 10 chances with my second delivery? Just curious...

Why would you? It doesn't really work that way.
The risk of c-section goes down if your previous births
were vaginal births.

Best wishes,
Ericka

[Lady Penelope Creighton-Ward]

On Mar 1, 1:31 pm, Ericka Kammerer > wrote:
> Lady Penelope Creighton-Ward wrote:
> > If three out of ten women in Massachusetts deliver their babies by C-
> > section, and I delivered my first vaginally, does that mean I now have
> > higher than 3 in 10 chances with my second delivery? Just curious...
>
> Why would you? It doesn't really work that way.
> The risk of c-section goes down if your previous births
> were vaginal births.
>
> Best wishes,
> Ericka

I don't know, just being paranoid, I suppose...

[Engram]

Anne Rogers wrote:
> not at all, it probably makes you much less likely, remember a lot of
> the contributing c-sections are repeat c-sections, so even going into
> a first time birth (not elective c-section first time), it's probably
> between 1 in 10 and 2 in 10 chance of a c-section. Having had a
> vaginal birth first time, that probably drops your chance (in the the
> absence of other factors) to 1 in 20, or even less likely, it's
> relatively uncommon to hear of someone having a c-section in a 2nd or
> later pregnancy with a previous sucessful birth, from people on here,
> I can think of Engram fairly recently with an undiagnosed breech and
> a while back Andrea, with Lydia, her 11th getting stuck in an unusual
> position, there are probably others, but the vast majority of women
> who have vaginal deliveries will go on to have future ones.

The only reason I had the c-section the second time around was because they
were unwilling to help me deliver a breech baby vaginally. I was all set and
willing to go.

Try not to get too paranoid (if you can :) Just recently we had a thread
about fearing the second birth more than the first one. Seems like it's
something that many of us go through.

Hang in there. As Anne said, your chances for a vaginal birth are as good or
better the second time around if there are no unexpected complications.

Engram

[Anne Rogers]

> The only reason I had the c-section the second time around was because
> they were unwilling to help me deliver a breech baby vaginally. I was all
> set and willing to go.

I think that just shows the relevance of care providers, with the right care
provider, the chances are that breech delivery would have gone fine (if I
recally rightly, it was progressing speedily, which is a jolly good sign for
spontaneous breech delivery).

Often women are less worried when choosing a care provider 2nd time, as if
things have gone well before, chances are things will go fine again, but new
care providers could have all sorts of different protocols that could tip
things the wrong way. Women with previous problem births will often pay very
close attention to detail choosing providers in future, but with a problem
free history it's easy to get complacent.

Anne

[Pologirl]

"Lady Penelope Creighton-Ward" > wrote:
> I don't know, just being paranoid, I suppose...

I know you are afraid of a C-section, but I am thinking you may be
even more afraid of the alternative: needing one and not getting it
because you chose a homebirth. Try to relax. That is not the only
alternative, by far. And from all your accounts your midwife knows
her stuff and if you do need a C-section she will be sure you get it.
And unlike me with my first baby, you are in a major urban area with
many good hospitals and good OBs with lots of experience doing C-
sections.

We are all looking forward to reading your birth story...remind us
please: when are you due?

[Lady Penelope Creighton-Ward]

On Mar 2, 9:44 am, "Pologirl" > wrote:
> "Lady Penelope Creighton-Ward" > wrote:
>
> > I don't know, just being paranoid, I suppose...
>
> I know you are afraid of a C-section, but I am thinking you may be
> even more afraid of the alternative: needing one and not getting it
> because you chose a homebirth. Try to relax. That is not the only
> alternative, by far. And from all your accounts your midwife knows
> her stuff and if you do need a C-section she will be sure you get it.
> And unlike me with my first baby, you are in a major urban area with
> many good hospitals and good OBs with lots of experience doing C-
> sections.
>
> We are all looking forward to reading your birth story...remind us
> please: when are you due?

Thank you Pologirl, those are encouraging words, and you are
absolutely right about the source of my fears.

I am due on March 13th, and the OB has told me today the baby is
already measuring half a pound more than my first was at delivery
(when we had the mild shoulder dystocia). This is according to the
ultrasound. Apparently I have high fluid levels (not too high but
high), and so the contrast between the baby and the surroundings is
high enough to get a nice read on his size. Also, he hasn't dropped
too far yet, and the head circumference could be measured clearly.
The previous ultrasound was done a week ago, and the numbers are all
consistent so far.

I'm told I have a 10-30% chance of a shoulder dystocia with this baby,
if I should deliver in the next week. Of that, a 10% chance of
something more than a mild case, and a 1% chance of shoulder dystocia
bad enough to cause permanent injury (that's 1% of the 10-30%, ie).
The OB said should the last case occur, I would need to be on the
operating table within 10 minutes. Realistically, I don't think we
could make it that quickly if I go for the home birth.

So the question is: given a 0.1 - 0.3% chance of something quite bad
happening due to the shoulder dystocia, should I risk delivering at
the hospital where they are most likely to book me for a C-section?
Ie. are the risks of a C-section comparable, better, or worse?

[Ericka Kammerer]

Lady Penelope Creighton-Ward wrote:

> So the question is: given a 0.1 - 0.3% chance of something quite bad
> happening due to the shoulder dystocia, should I risk delivering at
> the hospital where they are most likely to book me for a C-section?
> Ie. are the risks of a C-section comparable, better, or worse?

If you want to play the numbers game, the booklet from
http://www.childbirthconnection.org/article.asp?ck=10164
is very good. Scroll down to the bottom of the page to
get the evidence tables for specific data.

Best wishes,
Ericka

[Pologirl]

Is his EFW over 4kg (8.8lbs)? Is any measurement (HC, BPD, AC, FL)
over 90th percentile?

Per this paper:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=17127493

"The sensitivity of EFW >or=4500 g to identify a newborn with shoulder
dystocia was 0% (95% CI 0-21%), positive predictive values 0% (95% CI
0-46%), and likelihood ratio of 0."

[Pologirl]

"Lady Penelope Creighton-Ward" wrote:
> So the question is: given a 0.1 - 0.3% chance of something quite bad
> happening due to the shoulder dystocia, should I risk delivering at
> the hospital where they are most likely to book me for a C-section?

The quite bad outcomes are significantly associated with mode of
intervention in the event of severe shoulder dystocia. What mode of
intervention would your MW use?

I think it comes down to this: do you plan a vaginal delivery or a C-
section? If you plan to go vaginal, I'd have to say don't do it with
your current OB. The question then wuld be do you stay with your MW,
or find another MW or OB with hospital priviledges?

[Anne Rogers]

> I'm told I have a 10-30% chance of a shoulder dystocia with this baby,
> if I should deliver in the next week. Of that, a 10% chance of
> something more than a mild case, and a 1% chance of shoulder dystocia
> bad enough to cause permanent injury (that's 1% of the 10-30%, ie).
> The OB said should the last case occur, I would need to be on the
> operating table within 10 minutes. Realistically, I don't think we
> could make it that quickly if I go for the home birth.

what orifice is the OB talking out of?

seriously, the only need to be on the operating table with shoulder dystocia
is when all manouvers have failed and the last resort is zavanelli's
manouvere where you replace the foetal head and deliver by c-section, but it
is an absolute last resort, as even when done instantly the SD occurs, it
gives much worse results than other manouveres, I think something like 20%
death rate and almost a 100% brain damage, which is a far far smaller
occurance than a permement bracial plexus injury. Zavanelli's manouvere is
performed incredibely rarely, so rare it's impossible to find stats on how
rare it is, it's something most OBs will never perform and those that do
will do it once in a life time, but always after everything else has failed.
Even in someone with an increase risk of SD, it's not a 1% chance of
Zavanelli's being the only delivery option, probably not even 0.1% chance.
When I've discussed this with midwives regarding SD management at a
homebirth, no one has ever even come across a documented case of it getting
to that point at home, so whilst they still admit it is a possibility, it is
so incredibly unlikely that it's best left out of discussions and when you
compare other management, all the same options are available, possibly
better so because the women cannot possibly be immobile due to an epidural
at home. Supposing things did go that far at home, and this is only a
theoretical what might happen, the general feeling seemed to be that it's
the fact the SD occurred that has done the damage to the baby and determines
death or brain damage and that provided transfer to hospital was carried out
with the midwife holding the baby inside the mother, no further damage
should occur, unless the cord is irreversibly damaged (I don't know enough
about cord anatomy to know whether this is likely) and transferring in this
position is something that does happen when cord prolapse occurs, so should
be something the midwife is familar with, even if the ambulance crew aren't.

>
> So the question is: given a 0.1 - 0.3% chance of something quite bad
> happening due to the shoulder dystocia, should I risk delivering at
> the hospital where they are most likely to book me for a C-section?
> Ie. are the risks of a C-section comparable, better, or worse?

Well, as I've discussed, with the only management difference being the speed
at which c-section performed post zavanelli's manouver and how vanishingly
rare that is (you may want to ask if she does use zavanelli's as a last
resort, if she doesn't, you may want to run a mile, the vast majority of the
evidence points at it being an absolute last resort and not something to try
after 5mins), then I think it still comes down to scheduled c-section versus
homebirth and from what I've read about this OB, I would not want her
handling a SD, she has consistently spouted untruths and scare tactics and
to be honest, I think you'd end up with a c-section in labour, which is
actually better for baby, but if you're going to go that route it's easier
if it is planned, even if it's planned for labour.

What does your midwife say at this stage? Do you know exactly what
manouveres she did do last time to resolve it?

Anne

[Pologirl]

Here's an eye-opening new article from India. Of 200 women in the
study, only 1 got a C-section.

J Pak Med Assoc. 2007 Jan;57(1):19-22.

Child birth in squatting position.

Nasir A, Korejo R, Noorani KJ.

Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical
Centre,
Karachi.

OBJECTIVE: To assess the risks and benefits of squatting position
during second
stage of labour and its comparison with the supine position. METHODS:
The study
was conducted at the Department of Obstetrics and Gynaecology, Jinnah
Postgraduate Medical Centre, Karachi from 1st January 1999 to 31st
January 2000.
A total of two hundred patients of similar ante partum, intrapartum
and
socio-economic conditions were selected. Only patients of gestation
more than 37
weeks, presenting in active labour with cephalic presentation were
included.
Patients with multiple gestation, malpresentation, previous scar,
maternal fever
and prenatal diagnosed fetal malformation were excluded from the
study. Random
selection was done after informed consent and alternately divided into
two
groups A and B. Both groups were ambulatory during first stage of
labour. In
second stage, group-A adopted the squatting position, while group-B
remained
supine in lithotomy position. The third stage of labour in both the
groups was
conducted in the supine position. RESULTS: There was no difference in
the
application of episiotomies in both groups, however extension of the
episiotomy
occurred in 7% patients of the non-squatting group (P < 0.05). Para
urethral
tears occurred in 5% patients in squatting group, but all occurred in
patients
who were not given an episiotomy. Second degree, and third degree
perineal tears
occurred in 9% patients in the non-squatting group but none in the
squatting
group (P < 0.05). Forceps application was also significantly less in
group-A 11%
and 24% in group-B (P < 0.05).There were two cases of shoulder
dystocia in group
B but none in the group-A. During the Third stage of labour there were
no cases
of retained placenta in group A but there were 4% cases of retained
placenta and
1% case of postpartum haemorrhage of more than 500 ml due to atony of
the uterus
in group-B. One patient in the non-squatting position had to have a
caesarean
section due to persistent occipito posterior position. There was no
significant
difference in the apgar scores, foetal heart rate patterns or
requirement of
neonatal resuscitation. CONCLUSION: It appears that squatting position
may
result in less instrumental deliveries, extension of episiotomies and
perineal
tears.

[Pologirl]

Here is another study, from England.

Reading between the lines, there were 134-101=33 cases of moderate
shoulder dystocia: 8 delivered by OBs, 25 delivered by MWs. Babies
damaged: 3 of 8 OB, 0 of 25 MW.


J Obstet Gynaecol. 2000 May;20(3):267-70.

Review of shoulder dystocia at the Birmingham Women's Hospital.

Olugbile A, Mascarenhas L.

Birmingham Women's Hospital, UK.

A retrospective audit was performed of all deliveries between 1
January 1991 and
31 December 1995 at the Birmingham Women's Hospital, the main
University
Teaching Hospital in the West Midlands. This was performed by using
the computer
database of all hospital deliveries, at the Women's Hospital during
the
above-mentioned period, by entering a CCL code for shoulder dystocia.
During
that period of time there were 28 932 deliveries with a mean caesarean
section
rate of 16.7%. One hundred and fifty-four cases were identified, of
which 134
case notes were available for review. The incidence of shoulder
dystocia was
0.53%. Audit was performed of pre-pregnancy, antepartum and
intrapartum risk
factors, the severity of shoulder dystocia, the category of person
delivering
the baby, fetal outcome at birth and subsequent pregnancy outcome in
cases of
those with subsequent pregnancies. Overall, the majority of cases of
shoulder
dystocia were mild, and dealt with by midwives (101 cases 74%). No
severe cases
were encountered, however three out of eight moderate cases delivered
by
obstetricians had evidence of fetal trauma (one Erbs palsy and two
limb
fractures). Twenty women had a pregnancy after the pregnancy
complicated by
shoulder dystocia. Of these, 18 women delivered vaginally and there
were two
cases (10%) of repeat shoulder dystocia.

PMID: 15512549 [PubMed]

[Larry Mcmahan]

In article . com>,
says...
> If three out of ten women in Massachusetts deliver their babies by C-
> section, and I delivered my first vaginally, does that mean I now have
> higher than 3 in 10 chances with my second delivery? Just curious...
>
>
I agree with the posters who comment that having successfully given
birth once vaginally, you have better than average odds of repeating.

However, that said, 3/10 is just plain scary!

larry

[Pologirl]

Here's a paper about the effect of gestational diabetes. In short,
controlled GD has a similar outcome to no GD.

Diabetes Res Clin Pract. 2007 Jan 31; [Epub ahead of print]

Outcomes of pregnancies affected by impaired glucose tolerance.

Kwik M, Seeho SK, Smith C, McElduff A, Morris JM.

Perinatal Research Group, Kolling Institute, University of Sydney,
Royal North
Shore Hospital, Pacific Highway, St. Leonards, NSW 2065, Sydney,
Australia.

OBJECTIVE: Gestational diabetes mellitus (GDM) is associated with an
increase in
both maternal and neonatal morbidity. There remains uncertainty,
however, about
the diagnostic criteria for GDM. We compared pregnancy outcomes across
three
groups of women, with the aim of establishing a threshold for
diagnosis of GDM
at our institution. METHODS: Women with a glucose tolerance test (GTT)
were
identified on the hospital's pathology database. Those women with a
singleton
pregnancy, in whom a GTT had demonstrated a fasting value </=5.5mmol/
L, 2-h
blood sugar >/=7.8mmol/L and who confined </=34 weeks gestation were
eligible
for inclusion. Outcomes were collected from the medical records and
obstetric
database. These women were managed with either diet modification,
regular
endocrinologist review and standard antenatal care if the GTT met ADA
criteria
(n=265, TREATED), or standard antenatal care alone if the GTT did not
fulfil ADA
criteria (n=213, UNTREATED). A third group comprised of women with
normal GTT
who received identical treatment to the untreated group (n=197,
COMPARISON).
Statistical analysis was conducted with chi(2) and ANOVA. RESULTS: In
women with
untreated GDM, there was significantly more macrosomia, shoulder
dystocia, and
preeclampsia, compared with the comparison group. These rates were
similar
between the treated and comparison groups. There were no significant
differences
in induction of labour, caesarean section rates, or gestational age at
delivery
between the groups. CONCLUSION: Untreated GDM is associated with
larger babies
and more birth trauma. We recommend the diagnosis of GDM be made with
fasting
glucose >/=5.5mmol/L and/or 2h >/=7.8mmol/L on 75g GTT.

[Anne Rogers]

> fractures). Twenty women had a pregnancy after the pregnancy
> complicated by
> shoulder dystocia. Of these, 18 women delivered vaginally and there
> were two
> cases (10%) of repeat shoulder dystocia.

hang one, 20 case, but only 18 delivered vaginally? 10% SDs delivered by
zavanelli's manouvere seems extroidinarily high, leaving me wondering if
they were cases of stuck shoulders during c-section, which does happen, it's
anatomically different, but rarely, a baby does end up with a broken
clavicle in a c-section delivery. The fact that in that sentence 18+2 equals
the 20 cases, makes me wonder if there is some incorrect sumarising in the
abstract, perhaps 18 had had previous normal vaginal deliveries?

Anne

[Anne Rogers]

> fractures). Twenty women had a pregnancy after the pregnancy
> complicated by
> shoulder dystocia. Of these, 18 women delivered vaginally and there
> were two
> cases (10%) of repeat shoulder dystocia.

sorry, my misreading, it's talking about later pregnancies, but there is no
mention in the abstract of any zavanellis being performed, out of 134 SDs
they had the case notes for, I think that's a useful stat as it certainly
doesn't tally with the stats LPCs ob gave her about needing to be on the
table. Unfortunately the numbers for the repeat would not likely be
statistically significant so the confidence interval on the 10% incidence of
recurrance is probably pretty wide.

Anne

[Pologirl]

Abstract:
>>18 women delivered vaginally and there were two cases (10%) of repeat
>>shoulder dystocia.

Anne Rogers wrote:
> Unfortunately the numbers for the repeat would not likely be
> statistically significant so the confidence interval on the 10% incidence of
> recurrance is probably pretty wide.

Yup. Here is another paper, which puts the rate of recurrent SD at
about equal to the rate of primary SD. Both roughly 1%.


Obstet Gynecol. 1995 Jul;86(1):14-7.
Perinatal implications of shoulder dystocia.
Baskett TF, Allen AC.

OBJECTIVE: To assess the antecedents of shoulder dystocia, the risk of
recurrence, and the perinatal morbidity associated with the different
maneuvers
used for its management. METHODS: We conducted a 10-year (1980-1989)
retrospective case record review of all instances of shoulder dystocia
in a
teaching maternity hospital. RESULTS: There were 254 cases of shoulder
dystocia
in 40,518 vaginal cephalic deliveries (0.6%), with 33 cases (13.0%) of
brachial
plexus palsy and 13 fractures (5.1%).
[...]
There was only one case of recurrent shoulder dystocia in 80 women
having
93 cephalic vaginal deliveries after their original delivery coded
with
shoulder dystocia.

[Anne Rogers]

I also query where the 10 minute figure comes from, it can often take longer
than that to work through the other manouveres to determine that zavanellis
is the only option and if you get to that point, replacing the head is not
straightforward and putting the mum under a GA is one way to do it.

You may want to check out the figures for decision to cut in crash
c-sections at the particular hospital, if they only have one theatre, if
it's in use, it's in use, if they have two, chances are one operates daytime
only, for elective c-sections and you've got a similar situation with the
2nd theatre. Target decision to incision time is often 30minutes and it's
not reached universally.

The only benefit I can see to hospital is that if there were signs of delay
earlier in labour, you might go to c-section sooner due to the history, but
unless you had a very precipitous labour, such that even a delay would still
be precipitous, you'd have time to transfer from a homebirth anyway. This
may well be something you want to discuss with your midwife, what are your
comfort levels for this given the past history, labours don't automatically
get shorter with increasing parity and other factors could slow things down,
but I think in this instance there is good reason to treat a delay as a bad
sign, though there is no research to back this up, it's just that you know
you are on the edge, so you want to listen to any signs your body is sending
that the labour is not progressing well. (At this stage is seems appropriate
to mention that there is a link between very fast 2nd stages and SD, but the
theory as to why this is the case, seems to be lack of time for the
shoulders to turn to the best position, but precipitate 2nd stage doesn't
necessarily link to precipitate first stage, it's more linked to multiparity
than anything else, and multiparity is also linked to increased incidence,
probably because increased parity implies increased age, linked to increased
incidence of GD and so on).

Anne

[Anne Rogers]

>> Unfortunately the numbers for the repeat would not likely be
>> statistically significant so the confidence interval on the 10% incidence
>> of
>> recurrance is probably pretty wide.
>
> Yup. Here is another paper, which puts the rate of recurrent SD at
> about equal to the rate of primary SD. Both roughly 1%.

which is rather lower than the figures LPCs OB is working with, or I've seen
quoted from other studies, but I'm sure if I digged deeper I'd find broad
confidence intervals. It makes sense to quote the higher figures because
people do need to know worst case scenario and no one wants to be the doctor
that says you have no higher risk than last time and then have it happen
again, so the reality is, most women where an injury has been caused by SD
are going to have elective c-sections, which makes it harder to find figures
for recurrence in cases like this one, mild, no injuries and easily
resolved.

Anne

[Pologirl]

Two more article abstracts. One says predictive methods are so poor
that anyone delivering babies should know how to deal with shoulder
dystocia (SD). The other syas that of the 140 MWs and OBs in service
who entered a training program, only 43% could deliver a baby with
SD! After training, the success rate was 83% (not counting the 8 who
dropped out of the program). If I were LPCW, I would have some very
direct, probing questions for my OB and MW, about their training and
experience.


Am J Obstet Gynecol. 2006 Sep;195(3):657-72. Epub 2006 Apr 21.
Shoulder dystocia: the unpreventable obstetric emergency with empiric
management
guidelines.
Gherman RB, Chauhan S, Ouzounian JG, Lerner H, Gonik B, Goodwin TM.

OBJECTIVE: Much of our understanding and knowledge of shoulder
dystocia has been
blurred by inconsistent and scientific studies that are of limited
scientific
quality. In an evidence-based format, we sought to answer the
following
questions: (1) Is shoulder dystocia predictable? (2) Can shoulder
dystocia be
prevented? (3) When shoulder dystocia does occur, what maneuvers
should be
performed? and (4) What are the sequelae of shoulder dystocia? STUDY
DESIGN:
Electronic databases, including PUBMED and the Cochrane Database, were
searched
using the key word "shoulder dystocia." We also performed a manual
review of
articles included in the bibliographies of these selected articles to
further
define articles for review. Only those articles published in the
English
language were eligible for inclusion. RESULTS: There is a
significantly
increased risk of shoulder dystocia as birth weight linearly
increases. From a
prospective point of view, however, prepregnancy and antepartum risk
factors
have exceedingly poor predictive value for the prediction of shoulder
dystocia.
Late pregnancy ultrasound likewise displays low sensitivity,
decreasing accuracy
with increasing birth weight, and an overall tendency to overestimate
the birth
weight. Induction of labor for suspected fetal macrosomia has not been
shown to
alter the incidence of shoulder dystocia among nondiabetic patients.
The concept
of prophylactic cesarean delivery as a means to prevent shoulder
dystocia and
therefore avoid brachial plexus injury has not been supported by
either clinical
or theoretic data. Although many maneuvers have been described for the
successful alleviation of shoulder dystocia, there have been no
randomized
controlled trials or laboratory experiments that have directly
compared these
techniques. Despite the introduction of ancillary obstetric maneuvers,
such as
McRoberts maneuver and a generalized trend towards the avoidance of
fundal
pressure, it has been shown that the rate of shoulder-dystocia
associated
brachial plexus palsy has not decreased. The simple occurrence of a
shoulder
dystocia event before any iatrogenic intervention may be associated
with
brachial plexus injury. CONCLUSION: For many years, long-standing
opinions based
solely on empiric reasoning have dictated our understanding of the
detailed
aspects of shoulder dystocia prevention and management. Despite its
infrequent
occurrence, all healthcare providers attending pregnancies must be
prepared to
handle vaginal deliveries complicated by shoulder dystocia.


Obstet Gynecol. 2006 Dec;108(6):1477-85.
Training for shoulder dystocia: a trial of simulation using low-
fidelity and
high-fidelity mannequins.
Crofts JF, Bartlett C, Ellis D, Hunt LP, Fox R, Draycott TJ.

OBJECTIVE: To evaluate the effectiveness of simulation training for
shoulder
dystocia management and compare training using a high-fidelity
mannequin with
that using traditional devices. METHODS: Training was undertaken in
six
hospitals and a medical simulation center in the United Kingdom.
Midwives and
obstetricians working for participating hospitals were eligible for
inclusion.
One hundred forty participants (45 doctors, 95 midwives) were
randomized to
training with a high-fidelity training mannequin (incorporating force
perception
training) or traditional low-fidelity mannequins. Performance was
assessed pre-
and posttraining, using a videoed, standardized shoulder dystocia
simulation.
Outcome measures were delivery, head-to-body delivery time, use of
appropriate
and inappropriate actions, force applied, and communication. RESULTS:
One
hundred thirty-two participants completed the posttraining assessment.
All
training was associated with improved performance: use of basic
maneuvers 114 of
140 (81.4%) to 125 of 132 (94.7%) (P=.002), successful deliveries 60
of 140
(42.9%) to 110 of 132 (83.3%) (P<.001), good communication with the
patient 79
of 139 (56.8%) to 109 of 132 (82.6%) (P<.001), pre- and posttraining,
respectively. Training with the high-fidelity mannequin was associated
with a
higher successful delivery rate than training with traditional
devices: 94%
compared with 72% (odds ratio 6.53, 95% confidence interval
2.05-20.81; P=.002).
Total applied force was significantly lower for those who had
undergone force
training (2,030 Newton seconds versus 2,916 Newton seconds; P=.006)
but there
was no significant difference in the peak applied force 102 Newtons
versus 112
Newtons (P=.242). CONCLUSION: This study verifies the need for
shoulder dystocia
training; before training only 43% participants could achieve
delivery. All
training with mannequins improved the management of simulated shoulder
dystocia.
Training on a high-fidelity mannequin, including force perception
teaching,
offered additional training benefits. LEVEL OF EVIDENCE: I.

[Pologirl]

Anne Rogers wrote:
> I also query where the 10 minute figure comes from

Yes. That is so short, it doesn't help much to be already in a
hospital. If 10 minutes is all the time available, then the choice is
between elective C-section and emegency C-section without anesthesia,
possibly not even in an operating room.


> (At this stage is seems appropriate
> to mention that there is a link between very fast 2nd stages and SD, but the
> theory as to why this is the case, seems to be lack of time for the
> shoulders to turn to the best position, but precipitate 2nd stage doesn't
> necessarily link to precipitate first stage, it's more linked to multiparity
> than anything else, and multiparity is also linked to increased incidence,
> probably because increased parity implies increased age, linked to increased
> incidence of GD and so on).

I had to contend with *all* of these issues with my delivery last
fall. No GD, but I did fail the GD screening test; I was an "elderly
multipara" with a history of precipitous labor. So my index of
suspicion was sky high. I am more and more pleased with my choice of
OB and hospital. I could have done without the wet-behind-the-ears
resident, though!

Precipitate 2nd stage aside, I have read some evidence of SC
associated with longer 2nd stage, but it is not clear which comes
first.

[Anne Rogers]

> Precipitate 2nd stage aside, I have read some evidence of SD
> associated with longer 2nd stage, but it is not clear which comes
> first.

it swings both ways, fast is risky because of no time for the shoulders to
turn, but I'm thinking they mean fast as in one or two contractions for 2nd
stage, even though my first delivery was precipitous, it was 7 or 8
contractions for 2nd stage, which is long enough to make the turn, but
probably points to with a baby in the correct position future 2nd stages
could be darn fast, but I don't think it's so much the number of times SD
occurs with preciptous 2nd stage, but the number of times an injury occurs
when SD occurs in precipitous 2nd stage, so that an unexpectedly high
proportion of Erb's palsy cases occur after a precipitous 2nd stage. With a
long 2nd stage, it may be more of a sign that the baby is a tight fit, SD in
itself, except in the most damaging and tragic cases usually doesn't prolong
by more than 10minutes, but even so the evidence is not such that anyone has
ever come up with a time frame for performing c-section based purely on the
risk of SD occuring, the longer you are in 2nd stage, whenever doctors start
getting antsy about lengths of 2nd stages, SD doesn't seem to be something
they are thinking about.

I'm glad you raised the issue about training, I'd not seen the references,
but it really backs up just how important it is, even though there is now
one screening tool that looks promising, it's still something that all
birthing attendents need to be trained in and practice drills for, I've
heard of times when midwives are concerned that it may happen, that they
take the time to work through the drill, so they are fresh (presuming the
length of labour gives them time), of course more often than not they don't
have to kick into action, but working through the drill 10 times you had
concerns for 1 were it actually does happen is far more reasonable than all
those 10 women having c-sections. I think breeches are similar, even if one
thought that breeches should be delivered by c-section, you are never going
to catch all of them, so attendents still need to be well drilled and sadly
it seems they often are not.

Anne

[Lady Penelope Creighton-Ward]

Thank you all so very much for this extremely informed discussion! I
am SO grateful to have some facts to work with, in addition to the
story I hear from my OB in the five to ten minutes that she sees me
per week.

By the way, she was implying at our last visit that it would need to
be a scheduled C-section since the baby was now estimated to be over
4000g and for mothers with GD their practice was to use that as the
cutoff - the reason we talked of an emergency C-section was in case of
transport during a home birth.

I have much more confidence in my midwife who has dealt numerous times
with SD than I do in this OB, for all her experience with medicalized
births. My midwife has been doing this for 23 years, and is quite
confident she can handle it. She says this baby doesn't feel bigger
than my first.

An interesting thing happened yesterday at the ultrasound: the doctor
who double-checked the resident's findings said everything looked
fine. I said I had GD and we had a concern about the baby's size
(since it's always different doctors and residents, I have to explain
every time). She said nah, you're fine, he's in the 94th percentile
(4043g) but that's okay, not too big. Then I mentioned I was planning
a home birth and this was just to give me an idea of whether it was
still fine to go ahead with that, and what do you know, in the next
sentence she says the baby's too big, yeah, definitely too big.

[Anne Rogers]

> By the way, she was implying at our last visit that it would need to
> be a scheduled C-section since the baby was now estimated to be over
> 4000g and for mothers with GD their practice was to use that as the
> cutoff - the reason we talked of an emergency C-section was in case of
> transport during a home birth.

Each doctor has the right to there own opinion and there is an inflated risk
of SD with diabetic mothers with foetuses estimated over 4000g, but if you
just look at it from the point of view of preventing SD, I think the maths
comes to the order of 1000s of c-sections to prevent 1 permenant injury from
SD. That's pretty costly, both financially and to the health of all those
mothers and babies put through the operation, it's not something that
generally happens in the UK, but with the legal climate in the US, it
happens widely.

Going back to the transfer in a homebirth, the 10minute figure is still
meaningless, foetal head replacement and delivery by c-section is so
vanishingly rare that it's not worth being in hospital for, the other
instances of emergency c-section usually have much more time to work with
any indepth discussion of homebirths would cover that, when it comes down to
it, the truth is that some babies will die because their mothers chose to
have a homebirth, but far more babies will die because a homebirth was badly
handled, so the weight is far more on the choosing of someone who is a
compentant provider and accepting that tiny risk, particularly when looking
at it the other way round, some babies will die because they were born in
hospital, there are hospital accquired infections and many many other
things. Society is much more accepting of hospital deaths and death because
a doctor is wrong rather than a doctor not being available due to the
mothers choice of location is also much more acceptable, but it doesn't make
it right.

I don't think anyone would think any less of you if you decided to go ahead
and have an elective c-section, the risks are so difficult to quantify. Do
you plan to have more children? C-section presents a risk to future
pregnancies and babies too, if the answer to that was no, then you just have
to consider this one, if the answer to that is yes, then it just doesn't
make sense to me when you add up current and future risks.

btw, the ACOG does not recommend c-sections for GD mums with babies over
4000g, it has it's cut off at 4500g, but even then still phrases it as "may
be reasonable".

Anne