#6 Breech

Rat a tat tat.  The nurse knocks on the door at 6:30am.  I was already awake the day after Christmas to do some post Christmas shopping at the local mall.  Just kidding, but I was already awake with Lyol.  

Since my French is so bad, I thought the nurse said to come for a face presentation to labor and delivery (when the presenting part of the delivery is the face as to the back of the head).  I quickly look up again which face presentation is able to deliver vaginally, grab my headlamp (NEVER leave home without it), and head over to maternity.  I discover a breech presentation (butt first), which the nurse knew the whole time and had already written it down on the admitting paper.  (I just didn’t understand her.  I thought I had even pointed to my face.  Oh well, you just roll with things here, and it goes better).  

Now those of you who did residency with me know that I have been SEARCHING and WAITING for a breech presentation to deliver vaginally for me.  But....they just don’t happen in the states very often anymore!  They usually end up having a cesarean section.  Silly lawyers!

So, I check the fetal heart and it sounds good.  The woman in front of me is exhausted, and delivering her 8th baby!  The baby's bottom is still pretty high, and though she’s having contractions, they are not very frequent.  

What?  A chance to do a vaginal breech delivery and she is done with her contractions????  And...on her 8th baby, it should be easy for her!  I do not want to do a cesarean on her.  Even in good hands, cesareans are still hard here.  During my second one last week the lights went out and all I had was my headlamp to keep going (that patient bled like crazy too).  The lights came back on with the generator, but it’s just not as easy as in residency when we had all of the help needed!  

This is only my 2nd week here, but already I’ve learned to do a somewhat barbaric pitocin drip to increase contractions.  In America we use a machine to program the amount of IV pitocin the patient receives.  Add pitocin to the bag, watch the drips.....and turn it up or down based on the contractions.  I don’t have a protocol yet, but hopefully soon I can make one.  These little IV lines are not that wonderful at controlling the rate either.  

So...I decide to start the pitocin SLOWLY and give her 2 hours before going the surgery route.  Maybe there was another reason why she wasn’t delivering (like maybe malformation???). 

I head back home for a quick bite to eat, check on my sick malaria ridden husband and child, and then head back to maternity.  I’m a little sad that this will probably end in a c-section. 

When I return to maternity, I am surprised; the butt and legs have already delivered and the nurse is pulling on the body.  In my head I yell no!!!!!, but rush over there silently and slip on gloves.  Even though we didn’t have many breeches in the states, I know that you are supposed to try to let the mother push a breech baby out, otherwise things get stuck easier (keep your hands off!).  The arms were stuck over the head, but easily came down after sweeping around each shoulder.  

Now for the head.  I had searched earlier for some piper forceps just in case I would need them if the head were to get stuck, but couldn’t find any forceps.  I know the assistant is supposed to help hold the baby with a towel so you can delivery the head, but....we had no extra towels.  The mothers don’t even have much to clean up with here after a delivery.  You just use the clothes they were wearing to clean up the blood and poop.  With the head in a tucked position while pressing over the mouth, the head delivers easily.  Thank you God! 

The baby boy is a little floppy.  I put it on the mother’s belly for warmth, and grab the ambu bag (with no oxygen since we don’t have that here!, I learned the hard way last week).  After suctioning out the thick mucus, I give a few breaths with the ambu bag.  The baby starts to revive and I stimulate the back and feet, and then cut the cord.  I hope this one survives.  

As if delivery is not hard enough sometimes, it seems like the babies here have all the odds against them.  Only 1 of my first 6 deliveries here are living from last week.  I truly miss my labor and delivery nurses and NICU team!!!  Two had died before delivery, but the other 3 should have lived!  They were “term.”  It’s difficult sometimes to know if the babies are being fed during their first day of life.  Two of those babies died because they were just not checked up on.  Found out later they hadn’t eaten all day.  The nurses leave it to the patients to tell them if there is a problem, and the patients don’t know when to tell until it is to late.  With my improving French, hopefully I’ll be able to educate more and help these little ones survive.  They have a hard enough life ahead of them to start off with difficulties.  

As most of my ex-co-residents could guess, this same mother went on to have a post partum hemorrhage (8th baby), but thankfully we have pitocin here, and I was able to evacuate all of the clots.  I found out we even have methergine (another drug for postpartum hemorrhage) and used that too.  I explained to the husband to press on her belly every 10 minutes to make sure he felt the hard uterus and tell someone if she was bleeding a lot.  

It was a most GLORIOUS post Christmas day with the good health of a mother and new baby, and for me....the present of a vaginal breech delivery!!!  It is nice to be an obstetrician here.  It’s not about the lawyers, it’s about trying to save a life (or 2).  Now I need to learn to be a pediatrician as well. 


Posted by Danae Netteburg, the well, non-malarial doctor.