Today was my second day back in the delivery room after twelve days! We spent a weekend in Jinja (where I focused on white water rafting on the Nile!) followed by a week in Kampala (where I focused on antenatal assessments, observing fistula surgeries, and teaching workshops) followed by a weekend at Lake Mburu (where I focused on taking photos of zebras, leopards, and hippos!), followed by a virus that kept me in bed for a day. My first day back (yesterday) was quite interesting – my first ever 5x nuchal cord (cord was wrapped around the baby’s neck five times!) as well as my first experience of cord prolapse (Having to hold the baby’s head up off the cord while we rushed the mother to the OR was crazy hard to do! We had a positive outcome, though, and there was much cheering in the OR!) It’s been great to get back into the swing of birth.

Today:

1st STAGE ROOM BIRTH! The birth in the first stage room was totally unexpected. I went in to do a simple “early assessment” of a 15 year old primigravida (first pregnancy): palpation, fetal heart rate, maternal vitals, contraction pattern, and vaginal exam. After palpating mom’s belly it seemed her bladder needed emptying. She was unable to pee, so before I proceeded with anything else I catheterized her. As I did so I noticed her pushing… and… the baby’s head suddenly appeared!

“Whoop – there it is!” (lol!)

I was totally unprepared for birth, but Lesley was on it! I was already “sterile” from having just catheterized her so Lesley (who had been assessing a woman with severe hypertension also in the first stage room) speedily gathered the supplies we needed for birth: 10 iu oxytocin in a syringe, cord ties & a razor blade, baby blankets. The mom was 15 years old and her body was noticeably smaller than other women I’ve delivered. Her perineum was only about two centimeters long (short!) and I have to admit I was a bit nervous.

The second stage proceeded quite slowly (the stage where a woman is fully dilated and pushes her baby out), but when the baby girl was finally born she came with double nuchal hands – both her hands were in fists around her face! No wonder her head was slow to emerge! She came out pink and crying, and the placenta came (complete) a few minutes later. She did have a small first degree tear to repair, but overall it was a lovely birth!

TWINS! The twins were, as with the first birth of the day, unexpected (to me). I had just finished telling Cathy that I was starting to feel unwell and thought I should probably head home. I had stayed home sick the day before and suddenly felt the sickness returning. Cathy thought that was probably a good idea, but asked that before I left if I would insert an IV on the mom who had just arrived – a G3P2 pregnant with twins. We had just assessed her as 6 cm dilated and we wanted to get the IV in before we left. Women pregnant with twins are at increased risk for PPH (post partum hemorrhage) due to the distension of their uterus from carrying two babies, and being prepared with an IV can facilitate giving medication quickly should bleeding occur postpartum. Cathy asked me to do it because we have a little skills game we like to play called “3 for 3”. I had successfully inserted two IVs that day, and this would be my “3 for 3!”

I happily agreed.

A few minutes later, after having successfully setting up my “3 for 3” IV, the mom looked at me and simply said, “Omwana” (ie. baby). I lifted up the mom’s dress and again…

“Whoop – there it is!”

A baby was coming! She had dilated from 6 to 10 in about 15 minutes! My call for help came out like this: “Baby, coming out, now!”

Thankfully Cathy and Lesley were both free to come to my aid. In less than 10 seconds Cathy brought me sterile gloves to put on top of my nonsteriles and drew up two doses of oxytocin, and Lesley went to track down the woman’s baby blankets. (The hospital here does not supply blankets to receive babies; the women must bring their own. In this case this woman had neglected to bring her supplies with her into the delivery room, and it can take a while to track down her attendants out in the hallways/front lawn to get her supplies!) The baby was born very quickly so I grabbed the mom’s personal shawl to warm and dry the baby. “Twin A” was screaming just as we like, and though Lesley returned without having found the woman’s attendant and supplies she was able to retrieve one of our donor blankets from the storage closet to wrap the baby in, which was awesome. (Thank you donors!!!)

The thing about a woman birthing twins is that Twin A needs to have their cord cut and clamped right away. With single babies we prefer to do delayed cord clamping. This ensures the baby receives maximum blood post birth and reduces rates of anemia at the 6 month mark. With twins, though, you have to be careful. We did not know if the babies shared a placenta and amniotic sac. If they did, something called “twin to twin transfusion” can occur, and if the first twin continues to take in blood from the placenta after it is born there is a possibility that the second twin can lose too much blood. Because we were not prepared for the birth we didn’t have our clamps handy… but… I had clamps in my pocket for just such an emergency! Thankfully! I pinched the cord and Cathy went digging in my pockets and found two clamps. Perfect. We clamped the cord, cut it, and Lesley went off with baby to the warmer while we prepared for Twin B.

The next step with twins is to determine the position of the second twin. We palpated and could tell the baby was in a longitudinal position, which was good. If there’s one thing you don’t want it’s a baby in transverse lie. According to our palpation the baby was breech, and as I did a vaginal exam to confirm our suspicion I felt a foot. Alarmed I looked to Cathy and said, “It’s a foot! What are we going to do?” (I have it lodged in my mind that a baby in frank or complete breech are fine for vaginal delivery, but footling can be a problem.)

Cathy, in her calm and witty way, looked at me, smiled, and simply said, “It’ll come out!”

Sure enough not 5 minutes later Twin B’s two feet slid out of mom’s vagina – IN THE CAUL! I have never seen that! Breech-in-the-caul! Amazing.

We opened up the sac and proceeded to have a vaginal breech delivery. I remained hands off until I could see the scapula. Then I reached in and scooped out the anterior arm, rotated the baby slightly in the opposite direction by placing my fingers on the iliac crest and my thumbs on the sacral bone and rotating, and then scooped out the other arm in the same way. Then I got into the mariceau-smellie-veit-position with the baby resting on my left forearm with my two fingers on the baby’s mallor bones just inside the introitus and my right hand provided flexion on the occiput. This was only my second breech delivery, and I found this move much harder this time around! We had to ease the baby’s head out by rocking it quite a few times – something I don’t remember being taught in our training and I was so glad to have Cathy’s extensive experience at my side. Baby was born, and though a little slow to breathe at first, he came around within a minute and no resus was necessary.

With the birth of Twin B came a gush of blood and the placenta was right there – there had been a placental abruption! (And boy were we glad we had the IV already inserted!) We gave the mom 10 iu oxytocin IM as well as 10 iu oxytocin IV in 500ml Ringers lactate. We removed the placenta (monochorionic/diamniotic for those of you interested!), rubbed her fundus, removed clots and catheterized her bladder with an in-and-out. The fundus firmed up nicely so we quickly assessed for tears and found a small first degree tear that needed suturing.

All in all, another amazing birth and the mom was delighted with her boys.

During the excitement I had been able to put my feelings of sickness aside… but shortly after the delivery of the placenta and initial postpartum management I started to feel unwell again, so Cathy encouraged me to head out and she would finish up. I was grateful to be part of such a supportive team!

When Cathy and Lesley returned to our accommodations a few hours later they told me that the mom had started to bleed again after I left. They expelled numerous more clots and had to give another 10 iu oxy IV as well as 600 mcg misoprostil. Although we had used an in-and-out catheter, it wasn’t until they actually inserted a Foley (a catheter that remains inserted to continually drain the bladder) that the uterus fully firmed up and the bleeding stopped. Foley’s are in limited supply here in Masaka so we had been hesitant to use one at first… but lesson learned. In the face of bleeding when risk factors are present, get the Foley in if you have it…

What a day!