Birth Story #471 & #472

Some days on call are just a bit too rich for my blood. At first the pace is nothing, then--you wish you could vaporize from one room to another. Here's a recent call I took when I wished for wheels, not feet.

I was covering a weekend of OB call when Carly called me and asked if I could induce her labor. She wanted to be induced out of concern that her baby was getting too big. Her first child had been born at 35 weeks gestation after PPROM. He only weighed 5 pounds, 10 ounces. This second pregnancy progressed to her due date and a 3rd trimester ultrasound was suspicious for accelerated fetal growth. Carly's weight gain also raised some concerns; she'd started this pregnancy at 225 and put on another 40 pounds. The third trimester was correspondingly uncomfortable.

I don't usually give in to induction requests if there is no medical indication to get a labor going. I'm not a huge fan of inductions because they require so much fetal monitoring and, in my experience, can result in frustration and discomfort for the woman being induced. So I try to avoid inducing a woman unless she has significant gestational diabetes, preeclampsia, cholestasis, or has gone more than 10 days over her due date. Some women don't want to be induced if they go over due, but the other medical indications are the ones that press the issue.

In Carly's case, she was at her due date, her baby was indeed larger this time, her dating criteria were excellent, and she wanted to be induced. Her cervix was almost favorable, the term used to describe a cervix that is slightly dilated, largely effaced, and soft. A favorable cervix means the likelihood of successful induction with Pitocin is high. I started Carly on Pitocin feeling the day was going to go well for both of us.

I went pretty well for Carly. Once the Pitocin had effaced her cervix further, I broke her waters. Thereafter, her uterus provided more than enough powerful contractions and the Pitocin was turned off. Carly was able to labor in the tub, but this wasn't enough to help her cope with contractions. I tried fentanyl and offered an intrathecal, but she really wanted an epidural. She was afraid of the burning, out-of-control sensation of crowning that so many women dislike.

I was in the middle of calling the anesthesiologist when the sounds Carly was making changed in quality. Roberta, her nurse, stuck her head out of the room and said, "I think you'd better check her." I did. Her cervix was almost fully dilated, only a very small anterior lip remained.

There was no time for an epidural. I was explaining this to Carly when suddenly I heard screaming from the hallway.

I looked at Roberta. All day long, Carly had been the only patient in Labor & Delivery. No one else was in labor, no one was pushing, so why screaming? And why this strange, panicked, frantic screaming I heard coming from the hallway? For a moment I thought someone was being stabbed to death. Roberta dashed out to check on things.

I looked back at Carly and her support people and saw they were alarmed. "Don't worry," I said with more authority than I felt. "Whatever that is, it has nothing to do with how you're doing in here."

Roberta re-entered. "A patient just came in by ambulance," she whispered to me. "No prenatal care but was going to see Dr. X next week. Are you back-up?" She was asking if I was covering for patients with no prenatal care, a responsibility I share with all the other birth attendants at the hospital.

"I don't know--" I began, but then Carly had a contraction and I helped coach her through it. I wondered how much longer she had before the urge to push was irresistible.

The new patient next door was still screaming. I was about to ask Roberta if Dr. X had been called, when Vicky poked her head through the door. "Theresa, can you come?"

Carly was close but not pushing yet. I glanced at Roberta who nodded yes, she would stay in the room with Carly, and I slipped out into the hallway.

"I was about to check her when I saw mec coming out of her vagina," Vicky said. "No way was I going to check her after that."

A fetus will occasionally pass meconium while still in utero, resulting in green-stained amniotic fluid. I assumed this is what Vicky meant and I thought she wanted me to insert an intrauterine pressure catheter through which saline could be infused to dilute the meconium. When I entered the room, I saw she meant something different.

The newly-arrived patient was writhing on a labor bed and hollering to the skies. Instead of the thin, dark-green amniotic fluid I was expecting, she had fresh meconium staining the introitus and her inner thighs. The meconium sat like little spoonfuls of chocolate pudding (albeit green chocolate pudding), just as it comes out of a newly-born infant.

The passage of fresh meconium often signals a breech lie, in which the buttocks of the fetus present first through the birth canal (image credit for all following illustrations):

It is also possible for the fetus to present with one or two feet first, a so-called footling breech:

In the United States, the standard recommendation is to deliver breech babies by C-section. Occasionally a mother who has had a successful vaginal delivery in the past may opt for a vaginal breech delivery but this usually requires CT pelvimetry and an available anesthesia team in case of a crash C-section. Obviously neither was going to be an option in this young woman's case.

I examined her cervix. It was completely dilated, and I felt the fleshy give of fetal buttocks halfway down the vagina. "Breech, complete," I said to Vicky.

"I'll call Dr. X again," she said, running out of the room.

I turned back to the young woman who was now in between contractions. "What's your name?" I asked.

"Phoebe," she said.

"Well, Phoebe, what's going on is your baby wants to be born butt-first--"

"I want a C-section!" she yelled, and I could see a contraction was coming by the tension in her body. "Help me!"

I reassured her that Dr. X was on his way. She grabbed me by the hand. "Don't leave me!" she yelled. "Don't leave, don't leave, don't leave!"

"I'm right here, you've got lots of people here helping you," I said, hoping I was being soothing and wondering where the heck Vicky was. I learned later she was talking into two telephones at once, one to Dr. X and the other to the OR crew to stand by.

I was dimly aware of a commotion coming from Carly's room, but truthfully, I wasn't distracted by it. I tend to get totally involved in whatever situation is right in front of me, especially when there is a crisis involved, however slight. I held onto Phoebe's hand and tried to encourage her to breathe and focus.

Then Roberta stuck her head through the door. "We're having a baby in Room 2," she hollered, then disappeared.

I looked at Phoebe. "I'll be right back," I said.

"Don't leave!" she shrieked, but I had to. I trotted next door to Room 2, where Carly was pushing in earnest. A 2-inch portion of head showed through her introitus when she pushed. I looked at Roberta. "Can we make sure Room 1 has someone with her?" I felt bad about leaving Phoebe alone.

"OK, but stay here," said Roberta, and left the room again.

One of Carly's friends was holding her hand.  The friend looked at me and asked, "Does that woman need someone to be with her? Should I go next door?" Bless her.

There are moments when I love people, I really do. "No," I said. "I think you're right where you need to be." To Carly I said, "OK, you're doing it, you only have a few pushes to go."

Roberta reappeared. "It's OK," she said to me. "Vicky and Linda are with Room 1."

"Linda's here?" I asked. I hadn't seen Linda, who usually works night shift.

"She was dropping some stuff off and walked into all this," said Roberta.

There was no time to explore this with Roberta, because with Carly's next push, the baby's head came down and her vulva bulged. Three more pushes, and baby girl Francesca was born, vigorous and crying. I handed the infant up to Carly who was crying for joy and relief. The umbilical cord was very short and I didn't want it to break open, so I put one clamp on it in preparation for cutting the cords. I felt OK doing this because I knew Carly didn't have any preferences for delayed cord clamping. "Congratulations," I said to the second-time mother, as I hunted for the second clamp.

Then from the doorway I heard a voice yelling: "The baby's coming in Room 1!"

I looked at Carly and her friends. "I'll be right back," I said. "Everything's fine." And I ran out the door.

The voice belonged to Brooke, the house supervising nurse who'd been called to Labor & Delivery to help manage things. "Linda's next door and she needs you," she said.

Fortunately our Labor & Delivery unit is very small. I entered Room 1 and saw Linda, in street clothes, supporting something at Phoebe's introitus. I put on an ordinary set of gloves--no time to search for a sterile pair in my size. Linda moved and I saw the buttocks of Phoebe's baby had been born.

Now, up until this moment I'd assumed I was only going to stand by until Dr. X showed up. I was the just-in-case doctor, sort of like the second-string quarterback if you will. But when I saw the buttocks hanging out of Phoebe, I knew my role had changed.

I had never delivered a breech baby before, but I had read about it many times and been present at dozens of C-sections for breech. One of my attending physicians once told me, "The maneuvers are similar for vag breech as they are for C-section." Here's what I knew to do:

1. First, do not pull. Support the presenting part--in this case, buttocks--and wait for the body to be fully delivered.
2. If the legs do not emerge, gently aid them by flexing the knees and extracting them one at a time.
3. Once the legs are delivered, support the body by the hips:

4. Wait for the arms to deliver spontaneously. If they do not, reach into the vagina to determine their position. If they are flexed in front of the chest, apply gentle pressure to the crook of the elbow to straighten the arm and aid delivery. Repeat with the other arm.
5. Be aware there are other maneuvers to deliver the arms and shoulders if needed, including Lovset's maneuver to deliver the anterior shoulder, and delivery of the posterior shoulder if Lovset's should fail.
6. Once the shoulders are delivered, support the body on your forearm with the face down. Be careful not to compress the umbilical cord between the infant's body and your arm.
7. If the head does not deliver spontaneously, perform the Mauriceau Smellie Veit maneuver:
   • Place 2nd and 3rd fingers on infant's cheekbones, and 1st finger on chin.
   • Exert gentle pressure on these points to flex the head.
   • Using the arm that is supporting the infant's body, exert gentle traction to deliver the head.
   • An assistant may provide suprapubic pressure to help the infant's head remain flexed:
   

(If you are prepared for vaginal breech and are working with a woman who has good physical control, you can try vaginal breech delivery with the woman squatting, as Rixa describes on The True Face of Birth. In Phoebe's case, neither she nor I were prepared to try alternative measures to achieve a breech birth, but Rixa's post certainly illustrates a more comfortable-looking method than the steps described above.)

In Phoebe's case, steps 1-4 went off without a hitch, step 5 was not necessary, steps 6 and 7 followed and a (thankfully) small baby girl was born. This summary of events fails, of course, to capture how long the whole thing seemed to take, and the sense of rising panic I felt when gentle traction didn't immediately result in the birth of the part in question. Anyone who has been present at a difficult delivery knows how much traction you need to use to deliver a baby. In a breech delivery, the need to avoid trauma to the abdominal organs and extremities means a gentle touch is essential.

The entire birth seemed to take several hours, but in fact it had been less than two minutes since I entered the room. The baby was not breathing well at first, despite drying and stimulation, so Linda and I clamped and cut and took her to the warmer for resuscitation. A few puffs of positive-pressure ventilation and she began crying.

By this time Dr. X had arrived. He stood looking at the baby in the warmer for a moment, then looked at me. "Good job," he said placidly. I love Dr. X.

The pediatrician arrived to assume care of the baby. Dr. X delivered Phoebe's placenta and examined her for lacerations--none! I ran next door where Carly's placenta was announcing its arrival with a gush of bright red blood. One of her friends asked how the woman next door was doing. I said fine. I noticed my hands were trembling as I delivered the placenta, so when it was out and a quick exam of Carly's perineum revealed no lacerations, I made my excuses and sat down. I was sweating profusely and my hands still trembled. I looked down at myself and was amazed there were no stains on my clothes. I never got the chance to change into scrubs.

Carly's baby was born at 6:47pm and Phoebe's at 6:55pm--eight minutes apart. In fact, Phoebe's baby was born within 25 minutes of her arrival by ambulance. Things happen fast on Labor & Delivery. You have to be ready.

The moral of this Birth Story is: even if you never expect to encounter a clinical situation, read about it anyway. Reading about what to do can prepare you, at least partially, to do the right thing when the situation finally arises.

Comments

[CountryMidwife]

I had two primips deliver at our birth center 4 minutes apart the other day -- (both head down, thankfully!) -- it can really get your adrenaline going! Both were pushing and were at EXACTLY the same point - 2 cm head visible, 6 cm head visible, full crown, etc. Tricky to manage, but all was well.

I've had a few surprise breeches, because of the (very) high parity of most of the women I work with. Also a few breech while doing international work. Our OOH birth practice does not do planned breech deliveries. Though typically if it's that fast everything is fine.

I learned -- hands off the breech until the nape of the neck is visible, unless you have to go for arms. Soooo hard to be hands off! Once the nape is visible, grab the feet and somersault the baby onto mom's belly. I haven't had to do the chin tuck, thankfully. All breeches seem to need jump starts, the pressure is so uneven on their poor heads that they're stunned even if it's quick, I think.

I had one mom pop out a breech so quickly it was truly a "catch". I told her about 5 minutes later her baby was breech, she'd had no idea!

That said, our practice has also had two, and only two, intrapartum deaths (in 4,000 births). Both were breech, both truly unpreventable - one a cord prolapse with PROM, well before they called the midwife, and one head entrapment happening en route to the hospital for her planned c/section (35 minute labor, no midwife nearby, paramedics freaking).

I do NOT like breech positions and will do EVERYTHING possible to turn a breech. I think this is an important difference between a midwife and a "typical" OB - we start trying to seriously turn that baby starting at 32 weeks, rather than waiting and assuming it will move. Breech tilt, ice to the head, webster technique 2-3 x per week, pulsatilla, etc etc -- soooo important.

Looking forward to your birth philosophy stuff, thank you!

And, that was soooo sweet of Carly's friend to offer to go to Phoebe. Future doula!

[EnjoyBirth]

Wow, what an exciting hour of your life. You did a great job, stayed calm and focused. I loved reading about it, but am glad I didn't have to experience it.

I agree about reading and learning about different situations is so important. I am a doula and do not do any medical things, but I have a basic knowledge of different situations, because it is interesting to me. I luckily will never need to use that knowledge, but I like to have it in my mind.

Birth is so amazing and unpredictable.

[Rixa]

It reads like a script for a comedy, with all the commotion and running back and forth! I'm glad your first vaginal breech birth went well. That's one reason why I really regret that we're losing the skills of attending vaginal breeches. Even if the standard is to offer a c-section, there will always be these surprises. And, of course, other women who request a vaginal birth rather than a cesarean.

And btw, the position I discussed was kneeling to hands & knees, not squatting...but that's a technicality :)

[rlbates]

You are truely amazing!!!

[Dr. Val]

My hands were practically trembling reading this. Thank goodness the outcome was positive... Great work!