Breech

It’s a word we hear a lot these days.  From a breach in security to army/swat movies talking about busting through doors it’s something that is not uncommon.  Well, I feel like it’s definitely not rare.  You don’t have to argue with me on this, just roll with it.  So it should come as no surprise that we doctor-type people have our own special situation that we refer to as breech.  And that is when the baby is coming out bottom first. 

If you’ve ever seen a normal, uneventful delivery – of which many OB’s would say there never is – then you know that babies are supposed to come into this world sliding head first.  Sounds like a good way to get a concussion (See that?  Full circle.).  A breech delivery carries with it a number of risks to both mom and baby, and being as obstetric doctors like to do everything they can to minimize risk and thus liability (and rightfully so) they’ll often try and turn a breech baby prior to delivery or just perform a cesarean section.  Both reasonable options.  However, anyone who is trained in obstetrics learns “how” to do a breech delivery.  You just never do it.  Except I did.  Just now.

OB is one of those fields that I came into not knowing what to expect.  It seemed pretty simple.  Millions of babies are born all the time without any doctors or nurses present and definitely not with all of the interventions they have us doing at Wesley.  #BusDriveItself  But the more I’ve done it the more it kinda terrifies me.  What am I gonna do that one time in a hundred when there is a shoulder?  How seriously should I take the heart tone phone calls when it’s 3 a.m., I think they’re hogwash for the most part, and I really don’t want a cranky attending?  And a cranky attending can happen either with a phone call or with sitting on the “tones”.  Post-partum hemorrhage?  Stat c-section?  The. List. Goes. On. And. On. Of what can go wrong with the laboring and the delivering…and heck even the after delivery stuff with both mom and baby.

But I’m in Haiti.  It’s the middle of the night.  My wi-fi doesn’t refresh well enough for me to youtube a quick breech delivery.  And…I didn’t really know it was breech until it started happening.  There’s one thing I also forgot to tell you.  The baby was an IUFD and she was somewhere in here early 20 wga based on a femur length.  So we were inducing a still birth.  From a mechanical standpoint it would be really hard to screw this up.  But from a psychosocial standpoint, how do I get it right?  She was “diagnosed” yesterday in clinic after showing up with the complaint of no fetal movement for 5 days.  We sono’ed her, “Ou bebe pa gen couer.”  That’s it.  That was the delivering bad news.  She was still half-naked. 

The time is 0020 and it really seems like her contractions are pretty regular and dammit if she doesn’t act like they hurt #PaGenEpidural.  I really don’t want to, but I’m kinda tired and would like a rough idea of where we are at.  We’re AC with a very tense amniotic sac… That EXPLOOOOOOODES with digital pressure.  #BadTimeToNotHaveShoesOn.  The fluid is a reddish brown, almost like metabolized blood products.  With the bag out of the way I run into something not normal.  But then again, when was the last time you delivered a 24 wga infant?   Never?  Me too.  Misshapen face?  Hand?  Butt?  Anencephaly?  I don’t know.  I depend on smart people to tell me these things. 

With the amniotic fluid still pouring out - I mean, like a fountain.  I decide now might be a good time to throw on some shoes.  The “mom-to-be” is still screaming with contractions and her parents sit anxiously outside the “delivery room”.  Every time I walk by the start talking to me.  And every time I try.  I try so hard.  And FAIL.  No clue what’s being said to me.  For those that aren’t familiar, creole is a language that really lends itself to being “lazy”.  Very guttural.  And then people just make up their own contraction patterns that don’t make a whole lot of grammatical sense.  She when people mumble  quickly and quietly I am just out of luck.  And that’s exactly how I perceived grandma and granddad. 

The child came.  When I realized I was in fact feeling a butt presentation I tried my darnedest to remember the moves.  Leg.  Leg.  Hips.  Arm.  Arm.  Head.  #AndYouShakeItAllAbout #ActuallyTakeThatBack… #NeverShakeABaby  Not sure how it all worked out or looked, but I got baby out.  But now what.  Everyone is still asleep.  I clamp and cut the cord.  “Eske…ou vle…’hold’ bebe ou?”  Confused looks.  “Yeah, I don’t know your word for ‘hold’.”  Porte?  Mette?  Nothing worked.  You’d think everything around it and the context would make it kinda obvious, but apparently not.  I even pantomimed, and anyone who has played charades with me before can tell you how I’m at least mediocre. “ Eske ou vle we [see] bebe ou?”  She said something and it wasn’t a “wi” or a “non”…so I just uncovered him and held him up to her and her parents.  They stared… “Oh Jesi” x 1.  And that was it.  They were done.

I took him away.  Her pain was gone.  Her grief seems non-existent.  She still has that pesky placenta, but that too will pass.  Again, her parents ask me a very lengthy question, of which I understand exactly zero words.  “Mm pa konnen.  Dormi asweya.” 

For those who are curious.  I examined him in another room.  Appears to likely have been chromosomal.  Lymphadema in the hands and neck.  Single palmar crease.  Small jaw.  In Haiti there is no paperwork.  No death summary.  No delivery note.  No formal autopsy with karyotyping.  He is still sitting in the delivery tray with the packaging from my sterile gloves covering him up.  I can only assume he will be burned, but I would at least like to offer the family the chance to take him home and offer him a proper burial.  Just another day in Haiti.