Breech Twins & Neonatal Resus

MONDAY

Filled with honey toast, ginger tea and unhealthy trepidation, Anika and I turned up at the clinic 8am sharp. Unsure of the fallout we tiptoed around, however handover went on as usual.

I could do the handover for most women without even have attended their birth:

“Mama, Gravida 3, Para 2 now 3, had baby boy, Apgar 9/10 and then 10/10. Blood loss 200ml. Perineum intact.”

Every single woman is the same, interchanging bub’s gender.

I was surprised when the doctor called a collaboration meeting that involved all the midwives and doctors. Through the haze of broken English and Swahili we gathered that the doctor was impressing on staff the varying experiences of pain, highlighting the significance of psychological impact in birth and the need to be ethical and supportive. I feel that if even 1 staff member takes this feedback on-board, I’m self-assured that it was worth taking the fall to provide a positive birth experience for future women.

Our slow morning of dusting and cleaning was interrupted with the arrival of a gorgeous baby girl. Deliveries are starting to blur into one another these-days and Anika and I are super efficient at prepping and often accouchering deliveries whilst the midwives walk in and out of the room.

When I left home I remember strongly expressing that I refused to leave until I witnessed a breech delivery, but I wasn’t expecting the efficient antenatal care that saw most breech babies detected and referred to major hospitals. Today was our lucky day. Upon performing a VE, gorgeous midwife Digna excitedly told us to each have a go and low and behold we felt a heel and toes – a footling breech! Delivery was imminent and we witnessed a giant bulge of the amniotic sac in which we could see 5 teeny toes. When the membranes ruptured, Digna tickled baby’s feet and watched them retract a little: “alive!” she declared. We’ve been taught that breech delivery should be hands off until necessary, but I was not surprised when after two little knees were visible they were gently grasped, pulled and rotated until we saw a trunk and arms. With a screech from Mama the head burst free within the minute, a beautiful baby girl equipped with a good set of lungs.

So fixated on how smoothly the delivery progressed, I thought I’d heard incorrectly when Digna announced “Now next baby.” Undiagnosed twins. It hit me how this news may be considered a burden in a society where raising children puts a huge financial strain on the family; Mama’s reaction was quite indifferent. Digna explained how she considered the possibility of twins from the shininess of the mother’s stretch marks and talked wistfully about how an ultrasound machine would have immediately indicated malpresentation and the pair. An abdominal palpation or fetal heart might have shed some light! Baby number 2 was cephalic and 40minutes later joined his sister, both sharing the same weight of 2.8kg. Mama only had a tiny laceration which didn’t require suturing, and within 15mins of delivery she was snoozing soundly whilst her excited relatives cooed over the bundles.

The other laboring mother who had meanwhile shared the delivery room during the twin delivery was shuffled onto the main birthing bed and neatly popped out her bub, lucky thing got to observe 2 deliveries whilst hers was pending.

TUESDAY

Today was Hannah’s first day of placement, and I was bursting to show a fellow uni student this set-up worlds away from our own. In an attempt not to crowd the delivery room, I went about my cleaning duties whilst Anika and Han assisted in the delivery room. An hour later, I poked my head inside to find the girls and our favourite pocket sized midwife Hawa still coaching the mama to push with no head on view in sight. After an hour pushing for a multigravida (woman with previous pregnancies) back home, doctors would advise intervention. No such luxury is available here however – even monitoring of the fetal heart rate during second stage is considered unnecessary because even if signs of fetal distress are blatant, the midwives are powerless to assist delivery any quicker.

Anika conducted the delivery and did a fantastic job of encouraging the mama in Swahili. Just in case, I prepared the suction, oxygen and resuscitation equipment as none of us had any idea of the condition of this poor squeezed baby. Anika finally managed to deliver the tiny girl through the thickest mec I’ve ever seen, and immediately the situation looked grim. Throwing Hannah the suction, I told her to suction immediately, however being used to complete supervision back home, she hesitated for a moment waiting for the midwife’s instruction. It became very clear to me that we were running the show and I was determined not to watch this baby go downhill under the casual proceedings of the staff.

When suction was ineffective at stimulating the baby to breathe, Anika cut the cord and Hannah and I whisked bub to the resus bench while Anika tried to comfort the mother and complete the rest of the delivery.

Tiny champion

At this point adrenaline kicked in. Working like a well-oiled machine, Hannah monitored bub’s heart rate whilst I dived straight into positive airway pressure with the doll sized ambu bag. I thank God that we’d been so comprehensively taught neonatal resuscitation only months ago at uni, because we were able to sequentially work our way through the process of 30 seconds bag and mask - assessment. At one point when her tiny heart rate dropped to 58bpm, dangerously far from the normal 110bpm, I thought for a millisecond we were going to lose her. Her body was limp as a ragdoll, her skin colour almost unidentifiable due to all the meconium. One midwife pressed a set of adult sized nasal prongs in bub’s nostrils, however after observing no respiratory effort in 10 seconds I pulled off the prongs and attatching the O2 back to the ambu bag continued resus.

I remember looking over at Mama who was tear stained with fear and smiling encouragingly at her, before whispering to Anika “this baby is still so flat.” After 2 more rounds of positive airway pressure, her heart rate picked up to 65bpm and I was so relieved not to have to administer chest compressions (only required if heart rate under 60). With the midwives stepped back and watching us, Hannah and I gave another round of oxygenated positive airway pressure and finally we were blessed with a tiny grunt. Slowly, her heart rate crept up to 105bpm, and despite significant abdominal effort, she breathed on her own.

Words cannot describe the relief that washed over me.

I also surprised myself this morning. I assumed I would be frightened, panicked and emotional in such a situation, but in fact we worked methodically and rationally. I remember rubbing her tiny body over and over whispering “come on baby, come on baby” in a voice that didn’t shake with fear. What an experience.

Midwifery: Massage experience required.

The day goes on. Around lunchtime we had 2 women in the delivery room, both 8cm and such sweethearts. When the midwife left the room, we implemented the tiniest aspects of midwifery care from home by I massaging the mama’s backs whilst Hannah encouraged upright positioning. It turned out to be quite hilarious in the end with each woman wanting what the other was receiving in terms of massage and swaying. We had the room in fits of giggles and for the first time in weeks I rekindled my passion for assisting women on their journey.

Soon enough, I assisted with the delivery of another girl, healthy and perfect to mama Sauma and I really valued having the established rapport with her as opposed to meeting women at the point of upmost pain.

Just as the only thought consuming my mind was that of lunch, Anika made a discovery of a 6 fingered 2 day old baby that was brought in for a – shall we say limb excision? The midwives tied a suture around the 6^th finger on what we learned was a hereditary condition and assured us that in 2 days, “drop off.” Only in Africa would you consider removing fingers like docking a puppys tail. Only in Africa.