Vaginal Breech

I arrived at Diquini Adventist Hospital for my last day in Haiti, this past Saturday. I knew the 3 midwives that I enjoyed working with would not be there, as it was their day off. Instead I found 2 young American OBs. Since it was their first day and they were getting acclimated to where things were, I was able to give them a quick orientation to where things were located. (I had helped one of the midwives organize the supplies a few days before- so glad we did that.) The maternity unit is located in a separate building from the main hospital. It is just adjacent to the hospital in a little one story building that houses pediatrics, maternity, and the GYN clinic. A cloth curtain separates the pediatric section from the maternity section. To reach the GYN clinic, we have to exit the building and walk around to the other side. There is much construction going on that separates the two ends of the building. The GYN clinic is basically done on the 'back porch' of the building. The maternity clinic has a 4 bed 'ward' with 4 more beds added in the hallway for a total of 8 beds. One of the OBs has a great idea to number the beds and locate all the charts for each patient. Simple as it sounds, this has not been done. I set to work making signs from masking tape and markers. I locate current patient charts stacked on the nurse's desk. We file away the patients that are no longer there, and place signs on the charts denoting which bed each patient is in. Now that we are organized (somewhat) we can better manage our care. Miraculously, the Haitian nurse assigned to this unit, seems to know all her patients, where to find their charts, and is very on top of the patients assessment and medication regimens. She carries on with her duties quite oblivious to us, and seems more annoyed than amused by our attempts at 'organization.' I decide not to give any medications because I'm afraid they'll be given twice, as she has not missed a dosage for any patient. Instead I assess new patients coming in who think they might be in labor. As usual it is a busy day. I set up for deliveries in the delivery room. Our delivery room, and the three surgical suites in the hospital are the only air conditioned rooms to be found in the hospital. As result, we get lots of staff wanting to 'visit' us. But its nice to meet and talk with folks when we have the time. Today the pediatric unit is staffed with ER nurses that came from Quisqueya with me this morning. We had a group of about 14 providers come to Diquini today- a huge group, including several physicians who will be kept busy all day in surgeries. There is never an inactive moment on the maternity unit. I do labor checks on the pregnant women, and postpartum checks on the recovering mothers. I make sure babies are getting on the breast, bleeding is under control, and that vital signs are normal. I chat with the two OBs who are adjusting themselves to the circumstances. One OB orders pain medication for a laboring patient. I assure her I have seen no such meds and that all labors are unmedicated. The other OB goes over to the hospital and brings back one small vial of nubain (1 vial!) It was all he could find. We treat it like gold. At one point, early in the day, the two OBs go over to the hospital to scout out the facilities, while I hold down the fort. While they are gone, one of the ER docs (whom I met at Quisqueya this morning on the truck) comes running in to tell me that a woman just arrived in the ER on the back of a truck in obvious labor. They didn't even get her out of the truck, they are just driving her right over. Do we have a stretcher to bring her in? Well, of course we don't, but no worry, a minute later she comes walking in between two of her relatives, and get on the delivery table (which is really just a rickety old GYN examining table without the stirrups attached.) I shoo everyone out so I can check her, one of the ER nurses from pediatrics stays to help me. I do a vaginal exam to check for dilation (she does appear in great discomfort) and the following thought pops into my head: "What the fuck is that?" I'm feeling something that I have never felt before after doing hundreds of these exams. It was bony and angular and I could not find cervix no matter where I "looked" (ie. touched). I'm not entirely sure what I'm feeling, but I know it is not a head. Besides that, mom was making pushing sounds. I check for cord, but do not feel that either (thank goodness). It occurs to me that I have never felt and actual breech presentation before, because in the US these patients are scheduled for cesareans before they start labor, typically. I withdraw my hand and attempt to find heart tones. Not sure of what exactly I felt, I placed the doppler at the base of her belly, and find heart tones of 110s. At this point the ER doc comes back in, and I relate to him my heart tone and exam findings. Did you check mom's heart rate, he asks. Great question. I get my stethoscope and get an apical pulse of 90s. What I heard on mom's lower belly could have been her. I had placed the fetoscope on her upper belly earlier and couldn't find heart tones. The ER Doc picks up the doppler and finds heart tones on her upper belly in the 130s on the first attempt (shoulda used my Leopold's!). We say simultaneously, 'breech'. Where are my OBs? The ER guy asks, Do you think they'll want to do a cesarean? I said, I'm sure they will. It just so happens I overheard a conversation they had with one another earlier about breeches. One asked the other if they had ever done vaginal breeches, and the other answers they had done 3 or 4 but that they would rather not. ER Guy leaves to scope out the possibility of a surgical suite for a cesarean. I get vitals on the woman and hope the OBs show up soon. I still don't know if she's complete or if I just can't feel the cervix, but I do know she is pushy. If there's going to be a cesarean I'll have to start an IV and foley. Just then, they return, I explain what's going on. (There's been a lot of commotion in the hallway with relatives, ER staff, interpreters, and pediatric staff). They both want to do a cesarean, but when the male OB checks her again, he says, it's too late. The pediatric nurses rush in and set up the warmer (newly arrived and circa 1980s) for infant resuscitation. They spend the entire delivery trying to figure out if and how the thing works, and getting the oxygen going (bless their hearts, they were working really hard with such limited supplies- they kept bringing in supplies from their area when they couldn't find them in ours). The male OB preps for delivery, sending me on a frantic search for a gown. (The midwives didn't bother, but both OBs insisted on being properly covered for deliveries.) I found one, helped him get it on and gloved and the patient is still pushing. We get her into pushing position (I hold one leg, the other OB holds the other) and on the first push like that, out pops a little leg. A couple pushes later, we get the other leg, and the OB delivers the baby to the armpits and wraps a blanket around the body (baby blankets are hard to come by around here, its really just a square piece a fabric we found). Next the OB doing the delivery (the male OB) reaches in to manipulate the arms out. With that done, the baby is out except for the head. We expect baby to be born any minute, but that is not what happens. It takes at least a full 10 minutes of manipulation, praying (The OB doing the delivery was praying audibly right next to me as he worked frantically to get the baby out. At one point the ER doc returned to report back about the availability of an OR. There are no phones, no intercom system, no pagers, nothing. The only way to communicate with another part of the hospital is to send out runners. That's why folks just walk back and forth when they want to find something out. So the ER doc comes back to say that there won't be an ER available for at least 30 more minutes. (Either its still in use or being cleaned.) The OB had just a few minutes before mentioned again the possibility of a cesarean and pushing the baby back up,but now without that as an option, he redoubled his efforts at manipulating the stuck head. I remember shouting to the ER nurses where things were located as they frantically tried to put their supplies together while I held on to mom's leg, tried to comfort and reassure her (in a foreign language!) and instructing our interpreter to glove up and hand the OB whatever he asked for. The other OB offered to do fundal pressure. Not sure about the merits of fundal pressure, I offered to apply suprapubic pressure. He said okay to both. We both applied pressure, the OB on the top of the fundus, and me with a fist right above the pubic bone, with mom's pushing. This made a little progress, then, with time quickly ticking by, the OB handed the wrapped baby to me (limp and blue in my hands) and cut an episiotomy and with a little more manipulation, baby's head finally came, followed immediately by the placenta. (more on that in a minute). We were all holding our breaths and praying. We all thought the same thing, this poor baby probably won't make it. He quickly clamped the cord and passed baby off the the waiting team of nurses at the warmer, two ER nurses and a family nurse practitioner leading the team. (Not a NICU nurse in the bunch!) I quickly turned my attention to mom as the OB and I worked to control her bleeding. I gave her pitocin IM and then set up supplies and lidocaine for a repair. I had the interpreter scrub into the sterile field and hand instruments to the doc because I ran between mom and the baby fetching supplies and equipment for both teams. Several minutes into the repair, we heard a baby start crying! Incredible. Surely this baby was snatched back from the jaws of death. I was amazed that our hodge podge team with our pieced together supplies and equipment had been effective. Even the OB was startled to hear the baby crying, and looked up from his repair with surprise and relief. Later as we all tried to piece together the delivery summary with the correct times (keeping track of the time everything occurred was actually MY job as the delivery nurse, but I had not looked at the clock even once during the entire ordeal) we mused about the placenta. It was worrisome, because we had no way of knowing how long that placenta was dislodged prior to the baby being born. It appeared to already be right there after the head was born. There was some risk of hypoxic injury to the baby, but we could ony speculate. The female OB thought there might have been an placental abruption, but I still wonder if fundal pressure might have had a role in dislodging the placenta prematurely. After mom and baby were stabilized, they were placed in a bed and left to breastfeed. We went on to another delivery.