Friday, January 30, 2009

Happy Days.

Forgive my absence this last few days, I've been struggling a bit with the delayed impact of so many hard things to see and a gastro thing which is honestly probably a sequela of too many delicious peanut butter sandwiches (My thoroughly handy pregnant in Vanuatu craving). I've also had some incredibly frustrating and enraging news from my school back home, who threaten to not allow me to graduate on schedule on an administrative technicality which I should have been informed about months ago, rather than a week ago. Needless to say I've had my plate full trying to retain my sanity and my health.

Yesterday however, my first day really trying to be a bit less manic here, take a bit more care of myself, turned into a marathon which ended with what honestly is one of the most amazing things I've ever done in my life.

I'd asked the midwives to please call me if the twin mother Dr. B had informed me about, presented in labor while I wasn't there at the hospital. In the end they didn't have to, as yesterday afternoon, my last admit of a very long shift, who should present in active labor but a gorgeous 17y.o primip with an impossibly All-American name and TWO babies in her impossibly large belly.

I checked her - presenting part of twin A was definitely cephalic, Twin B was virtually impossible to identify, but she'd had an ultrasound the day before and Twin B had been transverse breech so felt pretty safe assuming s/he still was in the interim given how little room this tiny woman appeared to have remaining. The CTG strips on both babies looked peachy and her cervix was buttery soft, effacing nicely and 4-5cm. Better yet, for the first time in ages I could feel that baby'd head was low and well applied. By this time it was 4.30pm (shift ended at 3) and I really needed to eat, shower and rest. So I made the decision to run home, do all that, and then run back to the hospital when they called me to tell me she was 9cm or so. After flirting gently with the lovely male RN (who I adore) and bribing him with timtams (chocolate covered, chocolate biscuits from Aus) he agreed to call me. As it happened this worked out nicely as they had to do 3 deliveries and manage a hemmorhage case who had been flown in from Tanna in the hour and a half it took me to do what I needed to do (including a 30 min catnap!). Quite honestly they didn't have the hands to manage another lengthy twin delivery and were happy for the help.

I raced back to the hospital, finding all 4 beds in the labor ward occupied and my twin mama pacing the hallway looking not unlike she looked when I left her - though she said with her eyebrown knitted into a frown that her belly was "much mo soa". I found her a bed, popped her onto it, ruptured the bulging first set of membranes neatly into a bedpan (knowing full well that this birth was likely to get messy), which effectively bought her cervix to complete. For the first time here I put on a plastic apron and joked with the RN that "I get dressed up for twin births!" and settled in to wait as she began to push.

This birth was a birth full of firsts, even though it's the second twin birth I've done here. This birth was different, and honestly more challenging because the mother was a primip. 40 minutes into her second stage the head compressions I was hearing became honest-to-God, freeze-your-blood decels into the 60's. The first few were very quick, and rebounded to the 130's amost instantly, but green though I may be they had my antenna all sorts of tweaked. They persisted after each time she pushed, obviously late decels which grew in duration and were slower to recover. I cranked on some O2 and, during one particularly long decel, made the decision to cut an episiotomy (my first) to try to expedite this kiddo's exit. Fortunately baby was nice and low at almost the textbook place for an epis to be cut (can't believe I'm typing that). I quickly drew up some lidocaine and told her what I was going to do. I injected her perineum and then cut an inch long mediolateral episiotomy at about 7 o'clock, baby's heartrate far slower than mine at this point. I felt rather sick as I did so, but was really worried about baby, and felt sure that it was a decent decision. Two pushes later (and yes, the epis did help that baby clear her primiparous perineum faster), at the exact time my first born was birthed she pushed out a very cute little girl. She took a little work to get her to come around, but pinked up nicely in time for respectable APGARS then lay around looking at the room with wide, wide eyes.

While Mama caught her breath I quickly injected 10u of synto into the IV fluids bag I'd already started and moved the FHR monitor to trace Baby B. who pleasingly looked happy. Her uterus was contracting actively, and it was almost impossible for me to get a decent sense of baby's lie simply with external palpation. With lovely Dr B. supervising I reached up high into her vagina to try to feel for a presenting part. High, high up, once again (shades of my first time doing this) I could feel the tiny bumps of toes. "See if you can find a heel" said the doc. I carefully crept my finger tips sideways along the tiny structure being very, very careful not to rupture her second bag. There indeed I found a small heel and enough other small parts to be convinced that, once again we had a footling breech second twin.

I told the doctor frankly that I didn't want to rupture the bag given how high the baby was, and how hard the mother had to work to push out Baby A. I thought the risk of a cord prolapse was too significant. He asked me what I wanted to do. "I want to wait" I told him. While baby looked good, and we had synto on board keeping things moving, I wanted to wait till baby came down further into the pelvis, or until a spontaneous rupture necessitated intervention. He was happy with this plan.

At about this time, another mother who had taken yet more of the "custom medecine" was being prepped for an emergency CS for fetal distress. Dr B. was about to leave to go do the surgery. He asked if I wanted the other Doc here for the second twin. I told him that I most certainly did want the doc there. He was called, and came quickly right about the time things began to unfold.
I had broken down the bed, Mother's bum was right on the edge.

Unlike the last twin birth, these twins were bigger, and their mother's pelvis 'less proven'. This breech baby did not fly out like the last. Doc followed my exam, agreed that we had two feet, and we'd see what happened when the bag was broken. "I will talk you through a breech extraction".

I should begin by saying that "Hands Off the Breech" this was not. This was the textbook, old-school obstetrical maneuver which I learned in tandem with the less interventive Varney's version. Only this time it was taught in person by an old-school obstetrics professor.

Once again I reached my fingers into her vagina and as instructed I snagged the bag of waters. It ruptured and small parts washed into my hand. "Grab the feet and pull them down." Out both feet came (toes and knees forward - ack) tangled in loops of cord. "Rotate the legs, rotate the legs". It immediately clicked that I was to help baby rotate so her back would face me. I grabbed a towel wrapped it around the slippery baby legs and rotated. Babe was out to the hips, which I grasped (Loveset) and continued to assist the trunk to rotate (all with mom's steady pushes, and an unexpected amount of downward traction, doc's hands over mine). Baby delivered to the scapulae and I could tell immediately that her arms were extended above her head. I lifted her up and to the left and swept my finger up her humerus to deliver the anterior shoulder and arm, before repeating the process on the other side to deliver the posterior shoulder.

Now out to the neck, baby 'dangling' over my arm, I reached my and up and under, reaching for the maxilla or the cheekbones. As I ran my fingers past her mouth, she apparently got some air and was stimulated to breathe, because she let out a tiny glurgling sound (disconcerting when baby'd head is still inside the vagina!). Finally I found her maxilla and with yet more steady downward, then gentle upward traction, the head slid out over the perineum and I swung her upwards onto mothers belly where, eyes wide open like her sister, she lay there a bit stunned for a second (that made at least two of us!) before screaming her cute head off.

Placenta, gorgeous, photos coming. Episiotomy repair - more challenging than I'd anticipated (the mediolateral thing threw me) but I was thankful for that extra room at the end of the day. I hated to cut her, but I do think it did some good. Babies weighed (identical 2.120kgs), poked with vaxes and vit K. Both babies put to breast and both nursed vigorously. Washed the sheets, mopped the floor. Family informs me that baby#1 will have my name.

Walked home through yet another tropical storm in the very black Vanuatu night.
All that AND two sets of twins, two breech babies.


Unknown said...

These stories have me riveted!

Unknown said...

Hoorah! How amazing! How does it feel to have someone name their baby girl after you? :)

Unknown said...

ROCK ON WITH YOUR BAD A** SELF. Way to go girl, super proud of you, loved reading the story!!!

Susie said... more ways than one!

Aimee said...

I was holding my breath during that twin story! Congrats on the are amazing and it's well made for that little girl to have your name. Maybe you can go back there in 10 years and meet her again...