Bending the Rules

02 September 2015

Whenever I see a patient I often hear the words of previous senior colleagues in my head, or phrases from books that I’ve memorised for tricky situations. There are many rules and anecdotes that help me in my decision making; a collective memory and combined experience.
 
Sunday had been very busy, starting my day with a 4am wake-up to see two patients who had been transferred from a village. One of them needed an emergency caesarean; the words of an experienced consultant in my ear, “If in doubt get it out.” The woman had been fully dilated for several hours but the head was high and stuck.
 
During the caesarean another consultant whispered in my ear, “Go high, go high.” Caesareans in the late stages of labour can be particularly complicated, but making the incision high on the uterus reduces some of the associated problems. 
 
The day continued with emergency cases through the morning. After a short break, I was called by a panicked sounding intern for a woman who had arrived with very low blood pressure and suspicion of a ruptured uterus. The anaesthetist and I rushed back, we took her to theatre quickly and found about three litres of blood in her abdomen, but amazingly the baby was alive.
 
After repairing the uterus I followed the rule book and clamped, cut and tied her tubes off. We only perform sterilisation with the consent of the patient and her family, ensuring they know the reasons for the recommendation and its permanent implications. We stayed late observing the woman, then another patient who was making slow progress in labour even though she had delivered normally seven times before. A bit of gentle encouragement and we got the baby out vaginally. 
 
A 15-year-old girl who had given birth that day had a seizure earlier in the afternoon and was seen by the intern, who had treated her as epileptic, but I remembered a senior colleague being firm on seizures, “Eclampsia until proven otherwise.” We went to see her and found her dopey and agitated. She had all the signs for eclampsia and as we were getting the drugs in she had another episode of violent shaking, biting her tongue. Needless to say, by the time we had put plans in place for each patient and made it back to the base, we were both exhausted.
 
The anaesthetist decided he needed a rest so stayed in the base the next morning. I went to maternity to round on the patients and catch-up on our cases from the night. As usual there were a couple of women in labour. I picked up their folders to glance over what had been happening. One of them had had four children before, all normally, so according to the rules she should have made smooth progress and delivered hours ago.
 
Instead she had been moving very slowly, several hours for each centimetre. I took the notes over to the night midwife and asked what was happening, the midwife looked at me and said “siege”. The baby was presenting bottom first. A breech delivery should have perfect progress, delays can be a warning of trouble to come with trapped heads and other disasters.
 
The book Labour Ward Rules comes into my mind for all breech deliveries: “Dead easy, or easy dead.” The breech delivery should go easy, when there is slow progress or other complications tragedy can loom. I quickly got changed and went over to the woman who was bearing down hard.
 
I felt her abdomen, it was difficult to feel much as she was moving , grunting & pushing. I decided to find out what was going on down below. Gently I passed my fingers into the vagina, she was fully dilated and high-up I could feel the soft round buttock of the breech. With the contraction I asked her to push, long and hard. The breech moved a bit, but was not descending.
 
Something was not right. A woman who had delivered this many times before with good contractions should be able to push at least the buttocks and body down, it was the head that could cause trouble. Again I felt around the buttock, there was just one. Where’s the other cheek? I pushed my fingers higher and found something nobly, possibly base of the spine.
 
An alarm was getting louder in my mind. “Dead easy, easy dead” ringing in my ears, I pushed further up past the one buttock and then it all became very clear. Beyond the soft mass was the hard round undeniable presentation of a baby’s head.
 
My brain did a full 180 turn, I wasn’t feeling the baby’s breech but the other end. The baby was presenting with it’s forehead (“brow”), the nobly part was the ridge of the nose and the rules are very clear on this: emergency caesarean section. It is mechanically impossible for a brow presentation to pass safely through the pelvis, the diameter is too large. With the strong contractions, long labour and force of her pushing she could easily rupture her uterus (I was surprised she had not already). 
 
I shouted for help. "Get theatres ready and call the anaesthetist to come in immediately." As the midwife sited a venous cannula, I quickly stuck the ultrasound on her belly whilst shouting “don’t push, don’t push”. There it was, the head sitting at the base of her abdomen and the baby’s heart moving as if in slow motion, each part of the beat clearly visible.
 
The usual rules of getting a baby in distress out quickly (in a few minutes) are not achievable in this setting (to get to the the theatre the patient needs to be manually carried on a stretcher outside and to another building) my more pressing concern was that the fetal distress could be a sign of an impending rupture.
 
We were preparing her for theatre, she agreed to the caesarean and as the midwife got the IV fluid running I placed a catheter into her bladder. The forehead was wedged into her pelvis that it made the passing for the urine catheter almost impossible. There was no urine, just a single drop of blood. She was obstructed, and seriously so.
 
After I had the catheter in I decided to quickly feel the presentation again, knowing that the caesarean would be complicated with a high risk for a difficult delivery, uterine tears and haemorrhage, I thought I’d try and push the head up a bit. Despite the swelling on the forehead being in the vagina, the head itself remained high and was unexpectedly easy to bounce up out of the pelvis altogether. A big gush of amniotic fluid came down. The rule for a brow is caesarean, I know that. All obstetricians and midwives know that. But, I guess, some rules can be broken.
 
With the head in my hand and out of the pelvis, I found that it could easily be flexed, moving the forehead up and to the side the vertex (normal presentation) came down. With the next contraction I let her push my hand (holding the head in place) down and fixed the head in the right place. All I could think was, this will never work - it’s against the rules! I was also acutely aware of the ongoing risk that her uterus could rupture. I examined her again, yes, the presentation had changed to vertex. “Push”. It moved slowly down, I gently helped it rotate so the face was down and asked the midwife to confirm my findings.
 
Knowing the baby’s heartbeat was slow and the long labour that had taken place I chose to use the ventouse so we could get to helping the baby. The anaesthetist arrived for the caesarean as I was placing the metal suction cup on the baby’s head, still quite high-up but good enough to deliver. The baby's head completed it’s rotation and within two contractions the baby was out, its forehead purple and swollen from hours of being squashed.
 
We quickly gave the mother drugs to get the uterus contracted to stop her from bleeding (high risk after the long and obstructed labour) and gave the baby an encouraging rub, soon enough the reassuring cries could be heard and the mother lay there exhausted panting “Merci” with every breath. 
 
Here every caesarean avoided is a potential ruptured uterus avoided too. Whilst a caesarean was certainly indicated due to the brow presentation, the changes that resulted in vaginal delivery reduced her immediate risks of haemorrhage, infection and internal injury. The absence of a caesarean scar on her uterus, in a context where medical assistance can often take a long time to find and is of varying quality, greatly reduces her risk of uterine rupture in future pregnancies; a serious and life threatening complication.
 
Respecting the rules of obstetrics keeps us all safe, following the dynamics of a situation and bending them a little, with reason, makes for moments of pure joy.
 
At the time of writing all the patients mentioned in this blog continue to smile and are making excellent recoveries.