Tuesday, December 20, 2011

Clubbed Breech.

Sunday was a blissful day of rest. After church I napped and read. It was nice not to have any labors to watch or babies to catch for a few hours.

However just before dusk drew an orange cloak across the sky, Tom told me about a woman with premature rupture of membranes who had just arrived. He’d checked on her, but she wasn’t having any contractions yet. What did I want him to do?

Since I was making dinner (and didn’t want to check her myself) we discussed her case briefly and decided to let her go home to labor. She didn’t live far.

Two hours later she was back.

Since Tom was the one who saw her originally he offered to take care of things again. But as I stood there hesitating on whether or not to go help. God pushed me to go.

I changed out of my pajamas, slipped on my shoes, and wandered over.

Akoot was in obvious pain.

As she lay on the bed writhing, she explained the contractions came fast and hard once she got home.

I measured her belly and counted heart tones. She looked small for a term pregnancy. Could she be preterm?

-- “How many months pregnant are you, Akoot?” I asked calmly.
-- “I’m eight.”
-- “Does that include your first month?” I asked knowing that most women don’t count it here.
-- “No. I’m nine months if you count the first month.”
-- “Okay... but your belly is small,” I pointed out between contractions. “Are you sure you’re really nine months?”

(For those midwives out there. She was measuring only 27 cm. And her baby’s heart rate was erratic --lots of variability but within normal range.)

I was about to do a vaginal exam... but quickly realized I didn’t have time. Thick membranes bulged between her legs, revealing a vernix stained fluid beneath.

Birth was imminent.

Instead I called Tom in to assist. If this baby was preterm, I wanted his help to resuscitate.

Tom took a seat in the corner while I told Akoot my concerns.
-- “Akoot, it looks like your baby is coming soon. But I think he might be too small...” She listened carefully to each word.
-- I continued, “If he is very small he might have a hard time breathing. Do you understand?”

I always hesitate in times like these. How much do I explain beforehand? Will telling the mother my doubts cause more fear than necessary? Should I refrain?

In the end, I usually always tell them. Hard truths take time to seep in. But mostly, it’s what I’d want. I’d want to know of problems earlier rather than later.

-- She listened, nodded that she understood, then explained, “I’ve been sick for one month. Very sick.”
-- “What have you been sick with?”
-- “Bloody diarrhea. Chest pain. Fatigue.”
-- “One month?” I asked again, “Why did you wait so long to come for help?”

Flipping through her prenatal book I saw various entries of where she’d sought treatments for various complaints. She’d been treated for a number of ailments, the latest being dysentery. But she’d only had that for 4 days.

In fact, Tom gave her very effective drugs for it earlier in the day.

Pushing her sicknesses aside, I turned my focus to her baby. Whatever the reason, he’d be born very soon.

Looking back at the bulging membranes, I was disturbed to note they had turned from white to black. Not good. Could this be blood?

No time to worry about that. Everything was set up for the birth, so I encouraged Akoot to push.

At first I thought the membrane-covered object was his head... but I was wrong.

Admittedly, I was surprised to see a tiny butt emerge instead. He was coming out breech. And he was in the caul (aka: born in the membrane sac).

When I broke open the membranes, I realized that what I had confused for blood was actually meconium, and I wiped it away.

This breech birth was different however. His legs were jammed tightly against his face, and I couldn’t release them.
    -- Strange. 

Akoot continued to push and I called over the wall for Tom to come help.

Something was holding up the delivery of the legs though. So I reached up to draw then out. They wouldn’t budge.

So I pulled harder.

Eventually they came free but then hung awkwardly to the left of his body. Stiff as boards.

Both arms were tucked up close to his head. So, I reached in to release the right one first. It came on the first try. But the left arm wouldn’t bend.
         -- Strange.

I ended up having to deliver his head before his left arm.
        -- Very strange.

Once he was born it became clear he was not preterm. But there were other problems to consider.

His feet were severely clubbed and his knees were locked in straight line. His hips were unbending causing his feet to fall naturally at his chin. When I tried to move them his back arched in pain.

Later we realized his fingers were formed but clenched in boxing fists, impossible to open.

Seeing the confusion on our faces, Akoot tried to understand what was wrong.
-- “Is my baby alive?” she asked eagerly.
-- “Yes. Yes. Your baby is breathing well. And the good news is he is not preterm,” I started.

She nodded and searched my face.
-- I continued, “But there are some unusual things about his legs and hands. You will understand more later. Please don’t worry... I’ll explain it after the placenta is out.”
-- “His legs are bad?” she asked.
-- “Don’t worry. Your baby is doing well. You’ll understand more later.”
 She nodded gravely then delivered her placenta.

This is the first time I’ve delivered a baby with clubbing. I wasn’t sure what to say.

I asked her about possible teratogens that may have caused this and she mentioned a fight she had with a family member at 6 months pregnant.
-- “No. That is not the cause. This does not happen at 6 months,” I told her. “This happens before 3 months.”
-- “Oh... well, at 3 months I got injected (vaccinated) by the traveling medical people...”
-- “Do you know what they injected you with?” I asked.
-- “No. They did not tell me.”

Could vaccinations have caused this? I don’t know. I suspect not.

I also asked her if any of her other babies came out breech, and she gawfed.
-- “Ehh..? My baby came out breech?” She asked incredulously.
-- “Yes,” I laughed, “He was born breech. Have any of the others come out this way?”
Shaking her head in disbelief, she looked to her friend for confirmation. They discussed it rapidly in Dinka.

Turning to my translator, I asked him what they were saying.
-- “She says no baby has come out butt first like this. First time.”

She was obviously surprised --almost even more surprised by the birthing position than the clubbing.
-- “Why is she so surprised?” I asked him.

They discussed it with fierce animation, interspersed with laughter, then he turned to me and said, “She says that in the village if her baby had come out with the butt like this they would have forced him back inside and given her lots of alcohol to drink...”
-- “What? .... I mean why?” I stumbled over my questions but smiled at the thought.
-- “They say babies die when born like this one. She is amazed her baby is alive...” he explained.

Only then did it all make sense. Yes. With all the troubles this breech gave me, I think he could very well have died if he wasn’t born at the clinic. He was not an easy birth. And he needed a bit of resuscitation right at the beginning.

When I told Akoot this she nodded enthusiastically, then looked down at her child in wonder.

Over the next day or so, Tom and I helped Akoot understand his problems, start physical therapy, and establish breastfeeding. It was essential to me that Akoot bond as well as she could with him.  

He took some time to breastfeed properly but I am happy to report they are both doing well and were discharged this morning.

Tom decided to put casts on his legs to turn his feet outward. Seeing such a tiny tot with casts like this is new to me. It makes me smile.

Please pray for them. I think he might have signs of down’s syndrome as well. Thanks.