Saturday, January 29, 2011

Breech Births Rock!

She came in saying her water broke about an hour before, releasing copious, thick, green meconium stained fluid. It was hard not to miss since it stained everything she wore. Not good.

She also explained her contractions had been going strong, but once her membranes ruptured, they petered out. As I palpated her belly, things were out of place. Instead of finding a hard globular ball wedged deep in her pelvis, I found tiny fetal movements. Heart tones confirmed it as well; her baby was breech.

(A few months before, her baby had been a solid breech but we thought we had turned him with special exercises. Her last visit, I was confident he was cephalic (or head down), but either I was really wrong or this little guy was quite the gymnast!)

The vaginal exam confirmed my suspicions. For a moment, I thought it could be a hand, but once I found the scrotum all doubt disappeared. Not only was he a breech -- he was a footling breech! Yikes. Tickling his toes, my mind wandered back to a teacher I had in school. She loved to tell the story of her ‘nightmare breech’ which also happened to be a footling.

The way she told it --arms flapping with high-pitched tones for dramatic emphasis-- would have made the most daring of students take pause. She described a long labor, two little feet, a trapped head, a freaked midwife and one floppy baby. His resuscitation was challenging, but he lived. She vowed never to do it again and transferred any potential breeches quickly (which was required by law where we worked.... but still.)

Pulling my thoughts back to my patient, I finished her vaginal exam. She was six centimeters dilated which meant there was enough time for her to get to Wau for a cesarean if she was willing. I explained that there were risks involved with breech births (prolapsed cord, low apgars, etc.) and told her it might be safer for her to go to the hospital... just in case. She refused.

She would have unlikely gotten a cesarean for a breech in Wau, now that I think of it. It was silly of me to even suggest it, but I couldn’t help it. Years of training, dozens of so-called research articles, and all those horror stories of breeches gone bad, weighed heavy on my heart.

The real question was: Did I believe breech births were safe? I was sad to admit that I didn’t-- Shocked even. Why else would I suggest an unnecessary (and risky) surgery? What was I thinking? I hate those moments when I am forced to admit my biases and prejudices. This was definitely one of them.

Setting up for the birth was the easy part. I notified Dr. Tom and asked him to be my resuscitation  man if they baby needed it. I also informed Dennis and asked if he’d assist me by doing the suprapubic pressure for the delivery of the head. They were happy to lend a hand. It felt good knowing I wouldn’t have to do this birth alone.

Her contractions were no longer effective, so I augmented with oxytocin. Her baby had a short episode of fetal distress before induction, so we took it slow. He handled the contractions well and she progressed to fully in no time.

Once fully, she labored her baby down in the kneeling position, but when it came time to push she wanted to be on the bed. I figured it couldn’t hurt, so long as she was on the edge. Plus, that way Dennis could do suprapubic pressure easily. Both Tom and Dennis were called as the foot emerged, bringing with them noise and tension. I tried to settle the room down a bit, but failed. So, I ignored them and focused on her pushing. She was doing great!

Watching his little foot push its way into the world shook me a bit. All that I’m accustom to --hairy heads, fontanels and sutures-- was missing. Instead, I was assaulted with toes, testes and bluish buttocks. It was a trip!

One arm slipped out easily but the other got trapped behind his head. I had to reach in and pull it free, then his whole body fell out effortlessly. Tom kept trying to help me maneuver him, but his helpfulness was unsettling. He pushed one way while I pushed the other. (Note to self: Never let two ‘midwives’ grab a breech! What a gong show!)

Fortunately, it didn’t last long, and his head was born. Tom stepped in to do suctioning while Dennis and I held him tight. He was cyanotic and limp (with a 1 min apgar of 5) but perked up quickly. Not long after, he was breastfeeding like a champ!

All in all, it was a memorable birth that taught me many lessons.

As I think back on this birth, I’m confronted with my fears and biases. I thought I was pro-breech until I heard myself recommending a c-section. I would have argued the statistics in favor of breech vehemently, thinking I was a true advocate, but this week, I learned I was just a big faker. I don’t know about you, but it sucks when I realize I’m a hypocrite.

Mulling over my hypocrisy this week, I revisited the research papers and looked back over my textbooks, and yes, I even talked back to my teacher (in my mind). I can now say, without any doubt, that I trust birth -- even the footling breech. I trust it not because this particular birth went well, or because of some midwifery honor code of which I feel obliged to uphold. I trust it because... well... because I trust life.

I trust life in its many infinite forms. I trust the miracle-ness of it all (and yes, I just made that word up!), but think about it, babies have been ‘backing out’ since the dawn of creation. They will do that from time to time. It is our job as midwives (or as women, or doctors, or random people reading this blog) to be prepared and trust.

Lesson for the day: Breech births rock!

Thank you all for cheering me on through these adventures. It helps me get through these tests with a touch of grace. And thank you even more for your precious prayers, I know I’m able to do what I do, in large part, because of you!