A Birth you won't find in William's Obstetrics

Hello all - greetings from Kampala. It's a hot Saturday afternoon and I've been exploring the city with my friends Lindsey and Andrea. It was time to get out of the heat and take refuge in an internet cafe with air conditioning! I'm hoping the power doesn't go out so that I can complete this post.

Yesterday was an amazing day. Cathy, Anne-Marie, and I spent the day at New Mulago Hospital on the high risk ward. While there were plenty of interesting cases to manage and a lovely spontaneous vaginal delivery for a woman with high blood pressure, there's one birth in particular that I'm going to write about today. It was heart-stopping, incredible, scary, and exhilarating. In the afternoon we were managing various women's induction IVs and checking in on fetal hearts and trying to ensure other women were getting their meds when the intern from admissions came down to the ward telling us they had a woman with twins already pushing. We looked down the hall to see her awkwardly making her way down towards us, her plastic in hand. The intern quickly told us that the first baby was breech, and that the second one probably was too! Great, we thought, a twin birth and two breeches, all in one! Anne-Marie had put a wish out for a breech that morning and I had said that I wanted to see twins - here it was, all in one. As the saying goes...be careful what you wish for.

Thankfully there was a spare bed - we didn't have to dislodge anyone to find a place for her to birth her babies. But a birthing bed in Uganda is pretty different than a birthing bed in the typical hospital in Canada. Metal frame, no break-away, no stirrups, heck, half of them are partially broken and lurching at strange angles. We got her plastic spread and helped her on to the bed, having her lie down sort of across it at an angle so that her hips were at the edge of the bed. The maneuvers that you do to assist a breech babe require having some room to lower the babe's body after it's born but before the head is out. As soon as we got her settled, we could see the breech at the perineum. Anne-Marie and Cathy managed the catch, with the Intern David standing by and me providing support as well. It was a fairly straight-forward breech delivery - Cathy splinted and removed one leg and Anne-Marie did the other. The arms came easily as they weren't up above the head. The head was slightly difficult but was birthed after a few moments. Babe was great - she was breathing shortly after birth with just some stimulation and drying.

Cathy did a vaginal exam to find out where the second twin was. The presenting part was really quite high still so David and Cathy thought we should hang some oxytocin, a medication that stimulates uterine contractions, to keep the contractions strong and bring the second babe down into the pelvis. Before we could do this, there was a major gush of blood, spurting from the woman's vagina. A placental abruption. The blood kept pouring out. We couldn't get a fetal heart (we're using a manual fetoscope - no doppler here). We started talking about taking the woman to surgery because there was a good chance of her bleeding out before the second twin could be born. Things started to settle a wee bit, so Cathy did another exam. She feels a foot, or, no, it's a hand...and beside the hand, a placenta. A hand (which might mean a shoulder presentation)and a placenta presenting. What do you do? The pace picked up, trying to get an IV hung, blood taken for typing and cross-matching in preparation for C/S. But in the mean time, the placenta came down into the vagina and was at the introitus. What do you do with a placenta that's coming before the second twin? They don't write about that in text books! And the scariest part is, you don't know if this placenta is only for the twin that's been born or for both twins, which is a real possiblity. Often twins share a placenta, whether it's simply one or two that have fused.

Cathy was holding the placenta at the introitus of the vagina, and then it was born. And there was only one umbilical cord attached to it. The next exam, Cathy felt the 2nd baby's head, and the hand, and the umbilical cord. Which was pulsating. But there's an umbilical cord prolapse. There's a strong chance of asphyxiation for a baby when the cord comes down before its head. Take a breath. Be calm. This babe will be born. There's no time to get to surgery. We were stimulating the woman's nipples, trying to provoke more contractions, oxytocin was running, Cathy had some success pushing the hand back to allow the head to come down. David was praying, the Ugandan midwife Eunice was praying, I think we were all sending our prayers to the spirits and deities. And then suddenly, the babe was born, hand waving at us. The cord was tied and cut, she was stimulated, she made a few grunts and was rushed off to the resuscitation room with A-M. And she had a little positive pressure ventilation with a bag and mask and was fine. We gave the mother more oxytocin, both intramuscularly and IV, and the second placenta came quickly. Her bleeding after the second babe was fairly minimal. Her uterus contracted beautifully. She had two healthy baby girls after a breech birth, placental abruption, hemorrhage, hand presentation, and cord prolapse. Turns out she also had high blood pressure. Oh my. How blessed she is. How strong she is. After Cathy sutured her second degree tear, she was ready to get up and get some food. She couldn't understand why we wanted her to stay lying down with an IV running for a a while.

Despite a few challenges, including the unwillingness of various midwives to take her blood to the lab for type and cross-match ("I'm not working on that ward, it's not my job, you'll have to wait for the correct midwife to come back from lunch."), I think that we worked wonderfully well with the intern David and the midwife Eunice. As further complications appeared, we dealt with them. It was an amazing birth. It was a scary birth. It was birth in Uganda.

With blessings for you all,
Heather