Tuesday, September 20, 2011

Heads or Tails?

Mondays always seem to bring the strangest cases, and this week was no exception. When I arrived at the clinic a G2 was in active labor. She kept insisting that she wasn’t sure if it was labor or not though.

“Perhaps it’s malaria,” she said then knelt as if to push her baby out.
After a quick (guilty) glance at the crowd waiting for prenatals, I chuckled to myself and set up the room for her birth.

When I did a vaginal exam, she was fully at a +2 station with her membranes intact. I told her that it was time to deliver and encouraged her to push when she was ready.

She wasn’t.

Instead we waited expectantly until I realized she needed some space and sent her for a walk. Meanwhile I finished taking vitals on my prenatal ladies and did my health teaching.

Thirty-odd preggos listened politely as I rattled on about the importance of monthly check-ups and delivering at the clinic. It’s a message many of them have heard before; but I don’t care. It’s a matter of life and death for some of them, so I don’t mind repeating myself over and over.

Half-way through however, my labor called me. I arrived to see her pushing well, and soon after she delivered a beautiful baby boy.

Once the dust settled, I cleaned her up and moved her to our observation room, promising to check on her regularly.

Turning my attention back to the preggos, the morning flew by. I was able to see the majority of them before lunch (with Margaret’s help of course!). But those that remained had strange complaints, so I gulped down my soup and hurried back.

I didn’t want them to wait too long. I never do.

My first patient after lunch was one of those strange complaints though. She was reporting leaking water for 2 days. Normally this is not something that I would ignore for so long, but I didn’t have a choice. Malaria trumps leaking water in my book and I’d seen almost a steady stream of malaria cases all morning.

Plus, there is no difference in Dinka for the words ‘water’ or ‘mucus’ in the vagina. In the past I’ve rushed a woman inside with this complaint thinking she had premature rupture of membranes only to learn she has a little extra discharge. Nothing more.

So when I finally got around to assessing her, I spotted the contractions with ease. They were every 10 minutes, but they were regular.         --Not good.

Her fundal height was only 28 cm and we had assessed her to be only 33 weeks pregnant. Plus her baby felt like it was breech by palpation and the fetal heart-tones were high in the abdomen.

This was too soon; and I told her so.

Did I have a preterm breech birth on my hands or a simple case of malaria-labor? I couldn’t tell.

When I reached inside during her vaginal exam, I was perplexed to feel itsy-bitsy parts.    
        --Could that be a foot?

As I explored a bit I discovered a soft smoochy bag which told me her baby was definitely male, and I smiled.        
        --Yep. This baby was footling breech. And he was all boy!

But since she was only 4 cm dilated I didn’t mess around in there for very long. I told her that she was most definitely in labor and that the baby was coming out breech.

She took the information in stride and decided to walk around to augment her contractions a bit. I told her about nipple stimulation and she promised to do it. Then I turned my attention to the rest of the girls.

I finished them within an hour then went to find her again. She had spent the time exercising just as I asked. And as a result, her labor was well underway with strong contractions every 2 minutes.

Plus she was showing me all the signs of transition. She was sweating profusely, grunting and baring down with contractions, and starting to tremble from the pain.

But it had only been an hour. She couldn’t be fully already. Could she?

So I discharged my first labor, sending them off with prayers and then waited on my second one.

But 15 minutes later I was convinced she was close and did another vaginal exam to be sure.

Lo and behold she was fully! And while I was in there, I couldn’t resist tickling his toes. They were so tiny.

I called for Margaret and told her what we were up against, and she helped to prep the room. Once we were ready, we suggested she start pushing.

Again I did the same breech guarding maneuver I was taught last Spring and it worked like a charm. The foot and then buttock pivoted on my hands, delivering with ease. Then the rest of his body came out without a hitch. It was seamless and beautiful!

When I wiped him down and suctioned his mouth, I was relieved to see that he was term --just small for gestation (SGA).

He weighed 2.4 kg and had the sweetest dimples!

The rest of the day, he and his mama bonded beautifully as her family came to lavish love on their newest member.

Before I discharged them they informed me that his name would be ‘Doctor’ in my honor. (Yes, they think I’m a doctor here.) I laughed and tried to convince them that Nathaniel would be a better choice.

But they couldn’t pronounce it and insisted ‘Doctor’ it would be!

At the end of this perfect day, I looked back in my notes and learned that this breech birth was the 5th one I’ve done this year and my 2nd footling.

I share this only to point out that this breech was by far the most rewarding. The fear I had during my first breech was burdensome and vexing. Even though it ended well, it didn’t go as smoothly as I would have hoped.

However, this birth was different in a good way. This birth was delightfully routine. I honestly didn’t think that a breech birth could ever feel routine. But I confess it’s nice that it does.

Have I told you all lately... I LOVE being a midwife!
      --Cuz I do! I really do.

Thank you so much for praying for these women to have safe deliveries. Please pray for me to grow into a culturally sensitive midwife with the skills that will bless them the most. Thanks.