This post is submitted to the let labor begin on its own blog carnival at Lamaze’s Science and Sensibility.
I love the blog Rural Doctoring, especially for her birth stories. She is a wonderful writer, and from what she writes she seems like a thoughtful and conscientious physician. One of her most recent birth stories was about a repeat shoulder dystocia.
I started a reply, and after some researching and a lot of typing, I figured it was a lot better to post it as an original blog post rather than a rather long winded reply on her blog.
Here it is:
I almost wish you linked to the birth forum. (The original post complained that the birth story of this woman’s previous birth was torn apart on a natural birthing site.) I can understand why you didn’t, and I could probably guess where to look.
I have an interesting situation, since I delivered both my children with midwives and trained as a lay midwife for almost two years, but am now in medical school studying to be an ob gyn.
I hate it when I see zealots from either side. I shouldn’t judge the conversation on the site that I have not read. But, I am familiar enough with conversations in which the intention of the commenter is to prove their worldview is right, rather than listen, learn and communicate. And, I did read the comments on the post about Nola’s first birth. Some were wonderful, and I plan to read them again and learn from them. Some were reactionary.
I can think of several illustrative examples on both sides, both clinically and reactionary comment-wise. I know of an unassisted birth that ended up with a shoulder dystocia, and the child now has cerebral palsy and is severely developmentally disabled. I am fairly sure there was no pitocin involved.
Do I think the Gaskin maneuver could have helped? Yes, probably. Do I think EFM and IVs are generally a nuisance in a routine labor? Yes, and so does the WHO.
I actually question her being induced. It obviously didn’t prevent the dystocia. I suppose there is an argument that a larger fetus would have been even harder to extract, but how much would the baby have grown in the short amount of time it would have taken her to go into labor on her own?
She had the history of the large baby, a dubious 3rd trimester ultrasound with a weight estimate within normal limits, and a history of going postdate. That would have to be weighed with the risks of the induction. It was a successful one, and she was in her 39th week.
I thought it may be right that her problem is anatomical, as the physician at Rural Doctoring thought. It may be that any full term delivery of hers may involve a shoulder dystocia, regardless of induction or reasonable delivery date.
But, then I found this article:
Shoulder dystocia: are historic risk factors reliable predictors? By Ouzounian JG, Gherman RB, American Journal Of Obstetrics And Gynecology [Am J Obstet Gynecol], ISSN: 0002-9378, 2005 Jun; Vol. 192 (6), pp. 1933-5; discussion 1935-8; PMID: 15970854
“The triad of labor induction, oxytocin use, and birth weight greater than 4500 g yielded a cumulative odds ratio of 23.2 (95% CI 17.3-31.0) for shoulder dystocia.”
For those who don’t understand odds ratios, it says that with that triad (large baby, induction and pitocin), there was a shoulder dystocia 23 times more times than if this treatment triad did not exist. It seems to me that labor induction and use of pitocin actually increases the risk of a dystocia, instead of decreasing it, especially if it is likely that the baby is large.
So, interventions can cause dystocia? Sure. Lack of a skilled practitioner there can lead to birth injury due to shoulder dystocia? Sure. Can shoulder dystocias, some with fatal consequences, happen in hospitals and at birth centers and in homes? Unfortunately, yes.
I think we can talk to each other and learn without tearing each other apart. I am going to study everything everyone said on the first post and this one about the mechanics and anatomy of the interaction of the descending (and rotating, and flexing, etc) fetus and the bony pelvis. I am not a 3D person.
As much as I can research shoulder dystocia on the internet, I would be proud to have Theresa’s or the first post midwife’s ability to visualize and understand what is going on in there and what the woman can do with her body and what we can do with our hands to affect that.