Tuesday, January 3, 2012

Primip Breech!

Last year a first-time mom was brought to me after several long days of labor. Exhausted and scared, she lay on the bed for an evaluation. But it was soon clear what was wrong.

Her baby was breech.

Now I’ve delivered my share of breech babies but this was the first time I had to deal with a primip breech (meaning one for a first-time mom).

In any industrialized nation, a primip breech would be an immediate (or scheduled) cesarean as the risk of the baby dying is quite high.

The worry is that the larger fetal head will not mold enough to be born after the smaller buttock is born. The head would then get stuck, leading to suffocation.

Although I’m sure we all know someone who knows someone who had a successful breech birth the first time around, more often than not, the birth can go wrong (or be mishandled) and the baby can die.

But I digress.

My point is that the young girl last year came to me fully dilated with her baby’s buttock already protruding from between her legs. We had no time to transport, so we informed the family of the risk of vaginal birth then prayed like mad.

The birth went horribly wrong. Everything that could have gone wrong, did. Everything. And her baby died. (Read her story here.)

Afterward I asked God to never give me another primip breech, and to always help me diagnose them early so I can get them the cesareans they need... and deserve. 

I grieved that birth for many months. I was haunted by regrets. “If only I had done this instead of that... if only I had insisted on a transport... If only I had reacted better... faster... smarter. If only...”

In fact, I was still grieving it when I went to Switzerland to visit two midwifery classmates last Spring, and we talked about it in detail. One of them also introduced me to a midwife friend who had read about this tragic birth and wanted to encourage me.

Long story short, this midwife poured out sweet comfort coupled with years of wisdom. What is more... she taught me what to do if it ever happened again.

I listened to her words carefully, praying that it never would, but thankful to have options if it did.

Well, it did happen again. It happened last night.

This time, however, I handled the birth differently.

As I readied the room for the birth, her words rang out in my mind: “Make sure you go slow. Allow for the woman’s body to dilate properly. Don’t ever take your cupped hand away from the perineum. Once the buttock starts coming out, push the buttock back in with counter-pressure. Push hard. Make sure the baby does not unfold... that way the arms won’t fly up over the head and get trapped.”

Nyibol, my labor, wanted to push like mad and didn’t like the counter-pressure. She asked over and over for me to “just let her push harder”. But I was determined not to let this baby get stuck. So I explained my reasons again and again, insisting she breathe through her contractions as long as possible and to push only when she couldn’t help it.

She needed to go slow.

Tom came to assist, but since he wasn't needed right away, decided to sleep in the other room. Having him there was a huge comfort.

Meanwhile, Nyibol pushed on. And I supported the perineum.  

The Swiss midwife’s words continued to echo in my head, “Make sure you never take your hand away. Not for one second. The baby must not unfold. Only remove your hand when most of the body is born... then deliver the baby like a normal breech.”

My hands cramped. My forearms ached. But it didn’t matter. The baby was doing well.

Plus, Nyibol was making good progress.

I called Tom in to assist once the body was mostly delivered, and he applied suprapubic pressure as the shoulders were born. I had to reach in to release the baby’s right arm, but the left came out on its own.

The following push the head was born!

Nothing went wrong. None of the emergencies happened. Amazing.

The difference between this primip breech and the last was night and day.

Night... and day.

Thank you Jesus for this healthy little girl. Thank you that she is alive. Thank you for sending me wise midwifery friends who taught me this simple technique. Thank You! Thank You! Thank You!

Nyibol did not get an episiotomy; she did not even tear. Her baby had decent APGAR scores (6/8), needed no resuscitation, and transitioned well.

Night and day.

I share this story with you so that if any midwives out there find yourselves in a surprise breech in a primip, you might remember... cup the perineum. Never let the baby’s body unfold. Basically, make your hands like a second-perineum so the baby stays in a compact position. This will dilate her body most effectively, permitting enough room for the head to emerge without delay.

I realize this is the OPPOSITE of what almost every textbook says on the issue of breech delivery. And for that, I would be remiss not to comment. I agree with the textbooks. Hands off a breech. Never pull on the body.

Never. Never. Ever.

What I am suggesting is that you PUSH on the body --not pull. Give counter-pressure as the baby descends. Provide a place (aka your cupped hands) for the baby’s butt to pivot naturally as it passes over the perineum.

I did not "touch" the baby (and never pulled on her) after her legs and trunk were born. I only assisted in the birth of one arm, so the head could emerge.

I hope that makes sense. If not... let me know.

Thanks for praying for these women. Thanks for praying for me. I could never do this without your love, encouragements, and prayers.