It’s a Thursday evening at my hospital clinical site. I knew I would probably see 6 deliveries before 8:30 in the AM. My preceptor on this day is Mary. Mary is an incredible teacher and CNM despite only having passed her boards two years before. The two of us have earned the nickname “double trouble” from one of the physicians because well… interesting occurrences out of our control seem to be our norm. I could make a long list of “firsts” that we have experienced together. I have yet to have a dull rotation with Mary. I had just returned to the call room from examining a pt when the phone rings…
“ Hey Jessie,” says Mary, “Come on down to RM 15, we have just gotten a pt in that’s 7 cm, bulging bag and traveling fast. She’s a G3P2 VBAC, 36 and 5, Come break her water and we will have a baby” Off I go, I sure do love this calling of mine!!!!
I enter the room and spy Ana and her husband, I’ve seen them several times for prenatal visits in the office this was Baby Girl # 3 and I had even helped name her “Jennifer,” a fantastic perk of my job. Ana was from Mexico, she spoke enough English and I spoke enough Spanish that we had managed to build a very nice rapport. I was very pleased to be present for Jennifer’s birth
There are several nurses in the room readying for delivery. I lower the bottom of the bed, glove up and Mary hands me the amniohook. Nice hard vertex presentation, large bulging bag, just a bit of an anterior lip, then AROM, and clear fluid. It was going to be easy. Ana bears down, my fingers still in. But… something is just not quite right, palpate around, what is that at 3 o’clock? Lips? Nope. Ear? No. Scrotom? Yep!
I glance over to Mary and in a remarkably calm voice, say:
“Glove up”
“Huh?” says she.
By this time Mary is taking in the rather “unable to ignore” saucer- sized eyes that I’m exhibiting.
“We’re breech”
Mary gloves and examines, “No I don’t think so”
“Three o’clock,” I reply.
“Oh Shit!” she says under her breath.
We were frank breech indeed, RST to be exact.
The nurses begin to scramble, NICU team is called. The physician is notified but in the middle of a section and can’t come, no other physicians are in house. It’s up to us, a fairly new CNM and, me her student.
I’m a girl of faith. I wear around my neck a silver Hebrew childbirth amulet that says “El Shaddai” or God Almighty. I repeat Psalms 121: 1-8 on my way into clinical. I know my help truly does come from the Lord. God is with me in RM 15, I am so very calm. During this birth, I am replaying our section on breech delivery in my head, the one that was on the IP test review recording. I could hear our instructor’s voice on what to do (thank you nice instructor and Ana and her husband thank you too). Above all, remain calm, don’t rush a breech and don’t let the baby rotate into OP.
Buttocks are crowning, I allow birth to the umbilicus and gently place my hands around baby’s hips. Mary pulls down legs one by one, baby emerges to neck, then I deliver arms one by one, shoulders following the Curve of Carus. The room is most definitely at a level of high tension, but I’m not paying any mind, all of my attention being focused on….
Now at the foot of the bed standing directly behind me is Abebi. Abebi is from Nigeria, where she was a midwife, but, here in the US, she practices as an RN. Once we were to the baby’s head she whispered to me “Put your finger in the baby mouth, put your finger in the baby mouth.”( I’ll never forgot those words, or that lovely accent, being whispered in my ear) .Oh yeah, Mariceau-Smellie-Veit, for some odd reason I even remembered the name of that maneuver, I performed it, keeping baby’s head flexed. With the help of suprapubic pressure per Mary, and a little bit of coaxing baby’s trunk up and then down (Curve of Carus) birth was accomplished. Cord was clamped, and baby was taken to the warmer where the NICU team was waiting, Apgars were 3, 7 and 9, EBL 300, weight 6# 8 ( impressive being that Mom was a petite 5.0). By the way, those weren’t testicles, just very swollen labia. It was a “Jennifer” after all.
In review, I realized I was reflexively chewing my gum that I hadn’t had time to discard (perhaps an oral version of a worry stone?), at the time, I wasn’t afraid, I didn’t panic, and I agreed with Abebi who later told me “ A frank breech will often be the easiest delivery you will ever do, no shoulders.” Thank you God for never, ever leaving me and keeping me calm. That first clue something was wrong? The smoothness of the presenting part, I didn’t feel any hair on this baby’s head. With my couple being from Mexico, I was expecting a full head of hair, and when Jennifer’s head finally emerged (last but not least), indeed there was!
By the way, Ana’s perineum remained intact and she was so very happy with her vaginal breech delivery, that when I saw her recently at her PP visit she was still beaming but did request a very reliable method of birth control.
Know those textbook instructions for a vaginal breech delivery, practice them in your head, it’s will happen sooner or later. Also if you are lucky enough to have a Nigerian midwife present, LISTEN TO HER!!!
21 comments:
What a wonderful story!
Blessings!
Dawn
wowza! way to go!
Tears. You are a beautiful midwife. A gift to many women already.
You just need to finish up on a little more "schooling" and those pesky little boards... but yeah... you're a midwife my friend.
I'm so blessed and fortunate to have been able to get to know you.
Thank you for this.
What an amazing story! Loved it and linked to it. Let your fellow SNM know how very impressed I am!
awesome!!
Loved that story! God was with her indeed!
That's a great story! Thanks for posting it. :)
Great job!!! My complete and (almost) crowning breech in triage not too long ago was rushed for a stat c/s under general...too bad you weren't there!!!
Nice story. I wonder if the narrator knows just how lucky she was, since she didn't even check to see what the presentation was at the outset [vertex presentations don't just change into breech -- although the opposite can occur, right up to the onset of labor]. The first part of a midwife's exam upon admittance is to establish the presentation by performing Leopold's Maneuvers. Unless the woman is extremely obese, as a multip the midwife should be able to feel the way the baby is lying.
BTW, you CAN have extended arms [requiring a Lovset maneuver to free them from under the pubic arch] with a frank breech. And lastly, that midwife is doubly lucky that she didn't have problems by not performing an episiotomy. With a breech, you need the extra room for the aftercoming head, and/or for the shoulders [which come down in the transverse, usually], and in fact it is the one time you cut an episiotomy early.
And perhaps her greatest stroke of luck was that she didn't have to give over her case to the medical staff. Midwives in general don't get to deliver breeches, especially VBAC breeches, any more.
Elle writes: You just need to finish up on a little more "schooling" and those pesky little boards... but yeah... you're a midwife my friend.
~~~~Actually, AYC has yet to do a single "hardcore" midwifery course. All the stuff up to now has really been padding that she'll never really use.
Is the high and mighty attitude REALLY necessary? So Elle misread the context, so what? AYC has a midwife's heart and passion, and she's working hard a succussfully to become an outstanding care giver. AYC posted a story about a really great birth demonstrating that a calm hands off approach to breach birth is successful. Also, the student midwife in the story was being actively observed by two experienced midwives (at least one of whom, CLEARLY had experience in successful breach births) - it's not like she was flying solo. Midwives outside the US(and OBs like Marsden Wagner and Michel Odent) are more than able to confirm from experience that watchful alertness is better for correctly and successfully approaching variations than frantic cutting and pulling. The fact her baby was born over an intact perineum doesn't show that the mother was "lucky" - it shows that many other woman are subjected to needless genital lacerations from anxious and impatient care givers. Hands off the knife until or unless the baby actually becomes stuck.
Now, I know you're going to write back and it will be filled with all the normal piss and vinegar you are famous for. And that's ok, because the student midwife in the story isn't being precepted by you and she's clearly going to be outstanding. AYC isn't being precepted by you and she's also going to be just great. I'm not your client, so that's a good thing too. You are passionate about what you do, Antigonos, and often eloquent, but if you'd stop getting so torqued about the non-ACOG-approved techniques you might find that the less interventive/more watchful care givers who get under your skin so badly actually have valuable insight to offer.
All the stuff up to now has really been padding that she'll never really use.
Serious question here - If the above is true, WHY IS IT BEING TAUGHT???
[Sorry, just a little rant-y today, with people from children up through adults having to jump through hoops apparently just for the sake of jumping through hoops, or filling up time, or "padding" a course. Why isn't education and schooling, teaching what needs to be known, rather than a bunch of stuff that doesn't? Makes me glad I'm homeschooling my kids, so that they can learn what they need to know without just filling up a set amount of time or a set number of days.]
-Kathy
Thanks Aron & Kathy! Oh, and about the "padding that I'll never really use"? It's similar to the education you receive in the classroom when you're going to nursing school. It gives you a whole heck of a big, overall view of things, and is the basis for the more advanced studies that will be taking place over the next two years.
Research, pathophysiology, reproductive pathophysiology, pharmacology, even the other "fluff" - it's all useful as a basic building block of a midwife's education.
Isn't it amazing, that you did all the work, and not the baby or the mother. Congratulations, you are truly becoming part of the birth business.
Putting you finger in the baby's mouth could have resulted in a refusal of breastfeeding. But as you didn't hand the baby to the mother, so its first experience outside the womb, was the mother's skin and breast, I don't suppose you think that matters.
You may as you progress in your profession, find the title you have is someone who is 'with woman', not delivering babies. You didn't deliver this baby: the mother did. Hopefully, as you progress, you may twig to this, and how vital it is.
The excellent student questions the wisdom of the status quo....
Wow! How amazing!
Putting one's finger in the baby's mouth does not make the baby refuse the breast, full stop. In fact, when Mariceau-Smellie-Viet is properly performed, the finger pushes the chin, in order to flex the head more, is not put into the mouth.
As for Aron's comment -- how long have you been a certified nurse midwife? How many breech births have you assisted? There are reasons for what we do. The chances of permanent brain damage with breech is high enough that it is now standard procedure to deliver a primip breech by C/S. Multip breech was routinely a midwife's case when I studied midwifery in the mid 70s but now is rare; a VBAC breech is ALWAYS under medical supervision. That's not just "because", it is because there are excellent MEDICAL reasons why this should be so. And no, the woman did not deliver herself, she was delivered of a breech baby by her attendants. If she had attempted to "deliver herself" the baby would have died.
When I write "fluff" I mean all the courses in communication and problem solving, etc.
There is currently a movement to make nurse-midwifery require a doctorate in nursing. While I am completely opposed to ALL courses not leading to a CNM for midwives, a doctorate seems really over the top. But it will probably come, and like nurses with advanced degrees, the graduates will know how to talk about midwifery very well, but will not know how to really deliver a baby. I am very unimpressed by academic degrees for nurses; 85% of the nurses who are actually doing nursing [and not supervising or teaching] in the US today are diploma RNs. AYC will use her 8 years' experience in L&D far more than her courses up to date.
@Anon -- hmm... let's see... possibly stuck and dead baby vs. live and healthy baby who may refuse the breast... decisions, decisions! Let me think on that for a year or so in order to make sure I really do want a live baby. ?!?!? [/sarcasm] Besides, I doubt very much that someone else putting a finger in the baby's mouth will be the sole factor that leads to refusing to breastfeed.
Also, it would help for you to read little things like **the introduction** of the story, which states that AYC is reposting from another person, and she herself was not the one at the birth.
~
@Antigonos - I agree that AYC will be better served by her actual L&D experience than by courses; I lean towards apprenticeships rather than classroom teaching anyway for most things, because I think most people (from piano tuners to computer technicians) will probably learn more using an approach that integrates both hands-on skills with "book knowledge", and not just one or the other.
However, a lot of the courses AYC has described have been on things such as pharmacology and anatomy, which don't really sound like "fluff" courses to me. And while we might agree that these non-medical courses are not medically necessary for being a midwife, I can't say that they "won't really be used," but instead sound like they'll be used every day, as people communicate all the time. But now we're quibbling over minor details.
As I am sure you are aware, being able to communicate well is a valuable asset, and the lack of communication can lead to some serious problems and miscommunication, and not just on the internet.
-Kathy
WHAT IS THIS ARGUMENT REALLY ABOUT?!?! IS IT A MISSING CONTEST OR WHAT? YOU ARE ALL, PRESUMABLY GROWN WOMEN, ACT LIKE ONE!!! EXCHANGING IDEAS OF HOW THIS BIRTH COULD HAVE GONE WRONG SHOULD BE FROM THE POINT OF VIEW OF TEACHING SOMEONE, NOT JUST ABOUT BEING RIGHT! I CAN'T BELIEVE HOW MEAN YOU ARE ALL BEING! GET THE CHIP OFF YOUR SHOULDERS AND TEACH, DON'T PREACH!
Congratulations on a healthy baby and mother! You did what needed to be done at this particular labor!
Don't want to participate in the argument at all here.
But - AYC, do you know Rixa over at Stand and Deliver (rixarixa.blogspot.com)? She was able to attend the International Breech Conference last year and got some awesome video of a presentation by a German obstetrician who is re-introducing upright breech birth in hospital. Their selection criteria are pretty rigorous and at the time of his presentation, they were doing MRI on all nullips with a breech and measuring the diagonal conjugate - but they do both 1st time and multiparous mothers who meet selection criteria. The mothers birth in hands and knees, and the technique he is teaching is extremely hands off and their initial case series of 300 or so is fascinating (very few complications compared to what is normally seen in breeches.) Included in the presentation was how to handle the worst complications of breech birth such as needing to reduce nuchal arms - and watching the video was really fascinating.
In their protocol, women birthed in hands and knees, the baby was not touched at all (and I mean AT ALL) unless help was needed for the arms, or the head once the body was out, they do not perform episiotomy (he actually said in the presentation "In my unit, there is no indication for episiotomy"), and all births were attended by pediatric provider to establish the APGAR scores and cord gases were taken on all babies. The outcomes were excellent in their first 300 births. The video, which included quite a few short clips of upright breech births was amazing to watch - especially with the obstetrician commentary about what he is watching for, and when he considers intervening. I consider myself to be a pretty hands off attendant, but even I was amazed at how little they touched these babies and how easy these breech births looked upright compared to the standard obstetrical vaginal breeches I've seen!
Anyway, I know she's hoping to make the video more widely available at some point, but she may be able to share it with just an individual and it is definitely worth watching.
My very third birth I attended as a doula was for a primip who had a vaginal birth for her frank breech baby. The OB who caught the baby (His grandmother was a midwife), regularly does VBACS and breech births, was phenomenal to watch. In fact, families drive all over Texas to have him birth their breech and VBAC babies! This was one of the most special births I've ever attended. No tearing, ten minutes of pushing, 8 and 9 apgars!
Thanks for sharing your story!
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