Surprise! Footling Breech in Houston on 4th of July!
Picture it, Houston 2020, Fourth of July.
Student midwife MAB and I are already at birth center, (North Houston Birth Center, YEAH!), laboring with someone since 4 am. It’s 11:30 am, I answer the phone on my watch (Yay Apple Watch!) and patient FC (that’s short for firecracker) tells me she is on her way, she’s feeling baby coming and labor is going fast. I’m all like, come on in, I’m already here.
She arrives and I can tell our girl is IN LABOR. Fetal Heart Tones (FHT) are in left lower quadrant, 130s, and I can hear the whoosh of the cord louder than the crisp staccato of the heartbeat, but it’s within normal, WNL, cool. I listen for a long ass time** cause that’s what I like to do, maybe he is more LOP. Ok. Fine.
I’d like to do an exam, she wants me to, so I can admit her and have a general feel for where the baby is in her pelvis. (Birth center regs state that a person must be in active labor for admission.) When I do the exam, her husband is with her, all I feel is bag, and not the taut balloon bag over baby’s head, but kinda loose bag. And its not tight like a forebag, but goosey and jiggly, intact.
I’VE NEVER EVER FELT THIS BEFORE.
WHAT IS WRONG WITH ME – CAN I NOT EVEN DO AN EXAM OR WHAT?
She confirms she wants a water birth. Into the tub we go.
I am thinking the warm water will soothe her, and let baby’s head engage more in pelvis, and in a few hours it will be baby time.
Minutes later the birth assistant comes to get me, “Rowan, she says she’s ready to push. I can see the head.”
I run in there, and there is something poking out, and I feel, and I think it’s an elbow in caul. That means an elbow is poking out past her labia but the bag has not ruptured. (Listen, I know this doesn’t make much sense, bear with me.)
I ask if we can rupture the bag, to see what’s going down, she consents and we do.
Now I SEE this little elbow, but it just isn’t looking right, and I think are there toes? But I feel, and no. Whew.
Quick listen to FHTs, steady at upper 120’s, right above pubic bone. Excellent.
Ok, so now how to get this arm situated, and check baby’s position cause if this baby is being born shoulder-first then we need a new plan.
So I’m feeling down the arm, and then YES THOSE ARE TOES.
So a leg flips out, I’m all cooly saying, “Babies get born breech all the time, let’s do this” but inside I’M LIKE OH NO SHITBALLS WTF EJOLE ACCCCCKKKKKKK!!!!!!
2nd leg gets born.
I’m hands-off (WAIT: WHY AM I TOUCHING, my new acronym) letting baby do his thing.
and nothing. A contraction passes.
I’m not patient. I ask her husband to help get her out of the tub, and he supports her from behind, arms across her chest, she is in a supported squat (one leg on floor, one leg on edge of tub) and baby gets born to top of shoulders. OK! great!
I’m not touching. Nothing is happening.
Three things happen in quick succession.
1) I ask for NRP (neonatal resuscitation equipment), which MAB puts within arms reach,
2) 911 is called,
3) Gentle traction to see if head is gonna give. NADA
I’m a quick anatomy thinker, thank you to Holly Berry, my high school Anatomy and Physiology teacher EPHS class of ’89, cause it’s been something I dig for yearssssss. And have retained. Good freaking thing.
So head is caught, possibly chin hooked on pubic bone, the head wedged in where the diameter is the smallest, between the pubic bone and sacral promontory, that’s the bump on the anterior aspect of the sacrum, so it makes the pelvis smaller right there, ok.
So I reach in as gentle as possible, but I have these huge man hands, and support the shoulders and up over the ears, lift up gently, and rotate the body and neck and head (like everything together, no twisting independently). After the slight rotation, I move the head slightly chin down, get a little flex, and out the head comes.
Recap: Gentle up, gentle rotate, gentle head flex.
Delivered on oblique.
Weak respiratory effort, good tone, heart rate around 100 (I had my Ultrascope that Linz bought me around my neck where it pretty much lives when I’m at a birth). So as mom holds baby in lap because this cord is epically short, the dad has his arm around mom so he can stabilize baby head, and we do 5 inflation breaths with an Ambubag. Stop, listen, and then 5 inhalation breaths.
Stop, listen – 120 and rising, baby starts to CRY.
yes my love, that was intense. I might be crying also. inside.
I look at family, to ask them.
“Baby has great tone, great heart rate, and now great color. Excellent air exchange in lungs.”
Would they like to transfer?
The father says no. “We trust you.”
I look at the mother. “No, I trust you, too.”
I remind them we can ALWAYS change our minds, and go to hospital later.
They don’t change their minds. I give the longest most detailed discharge directions EVER and even after meeting all their discharge milestones I kinda drag my feet before discharging them later that day. They see the pediatrician at the next available appt on Monday morning. He says they are all good.
So. A big day.
And that’s the story of my first surprise breech delivery in Houston as a Texas licensed midwife.
ps. The practice manager asks me for a play by play of the birth, I tell her, including a reenactment of me doing my maneuver on a model pelvis and a bunny I use for teaching fetal positioning.
She then says, “I asked the birth assistant how it went.”
*I have taken Karen Strange’s Neonatal Resuscitation course twice and will be hosting a third in November 2020. I highly recommend you join us.
** Before during and after a contraction so I can hear variability, and response to the contraction action.