Head Entrapment

Katie, the Australian midwife, wakes me up at 4:30 am.

“There is a mum with 5 previous births. She’s a breech, and they’ve called me saying she’s been pushing for an hour and hasn’t delivered.”

I am woozy. I sit up, and think. I’ve done several breech (butt or feet first) deliveries at home, even though they are unusual. But I learned the most about breech delivery from the midwives that I worked with in Uganda, who do them all the time. The most important thing in a breech delivery is patience. They take much longer to descend and delivery than cephalic (head first) infant. So maybe this one is just slow to descend. A woman with 5 previous deliveries is a good candidate for a breech delivery. She obviously has an adequate pelvis, and has experience pushing. But the midwives here are less experienced, so I know that we should go in and assess, at the very least to support them.

Katie and I get ready within a couple of minutes and shuffle out to the front of the base compound, where we wake the driver and get a ride to the hospital. We have just gotten out of the MSF car and are entering the hospital when the radio crackles. It’s hard to understand, but it sounds like “The head has come, but it has not delivered.”

The head has come? That doesn’t make sense. In a breech delivery, it’s the body that should come first. I assume that they probably got the presentation wrong, and it was cephalic all along, but now it’s a shoulder dystocia. Shoulder dystocia is very dangerous, because the head is out, but the body is not, and the cord is usually squashed alongside the body. The infant can die quickly, or be injured in the process of pulling it out. We sprint to the Maternity Ward.

When we reach the ward, we find the patient sprawled on a delivery bed, and the body of the infant hanging out of her vagina, face down. The head is still inside. The South Sudanese midwife is trying to remove the head. It’s even worse than I thought.

Head entrapment is one of the scariest things we can encounter. The infant has delivered breech, but either the cervix was not fully dilated, or the head is too big, and the head cannot come out. Katie and I race to the bedside and throw gloves on. She tries first to deliver the head, but she can’t. I try. It’s quite a big head, and it’s quite stuck. The trick with breech delivery is to flex the head, because an extended head is harder to deliver. In order to flex the head, you have to find the baby’s face, and put pressure on the cheeks or on the mouth/chin in order to flex the head. But I can’t find the baby’s face. I feel around but it’s very difficult. Is that an ear? Is that the cord? Based on the body position, the face should be downward, and there is a lot of room posteriorly, but I don’t feel it. I feel around while trying to get it out. I am able to get my hand all the way around the baby’s head to the top, but it still won’t come out.

I ask for forceps. Katie has to run all the way to the Operating Theatre (OT) to get them. Meanwhile I keep trying. I also notice that the body is extremely limp, and I can’t palpate a pulse in the cord. Is this kid already dead? I don’t know, but I have to assume not. Katie arrives, and I try to place the forceps. I can place them on one side, but not the other. The anterior part is very, very tight.

It’s at this point that I start cursing. Cursing helps me in emergencies; it’s a way for me to express how hard something is, but also to maintain focus. Motherfucker, this is hard.

Katie takes over. I look at my arms, and realize they are covered in blood. I also look at the baby, and know that it is dead. I ask the nurses, and they confirm that it is dead. I tell Katie to slow down, and be careful with blood exposure, because the emergency is over. We need to get the baby out, but there is no chance of saving it, so we can slow down.

I wash the blood off my arms while Katie tries to get the head out. The mother is splayed on this delivery bed, thrashed and exhausted by our efforts to remove this baby’s head from her vagina. Katie has a good idea of flipping the mother onto her hands and knees. While she is doing that, I put on gynecological gloves, which go all the way past the elbows, to avoid getting blood all over me again. I also put on plastic clogs, and make Katie change out of her sneakers. The woman was on her hands and knees, but now she is prone on the bed, making no effort to hold herself up. That is no position for delivery. We force her back onto her hands and knees, and Katie keeps pulling. We are both worried that we will decapitate the kid, and we are both thinking that we will need to go to OT for a destructive delivery to get this head out. There is a special instrument there that allows us to remove the head of a dead fetus. Ugh.

As I am putting on the gynecological gloves, Katie suddenly pops the head out. Blood spurts out behind the head, splattering both of us. Despite our plastic aprons, our shirts are bloodstained, and Katie has blood on her forehead. I send her to wash, and take over delivering the placenta.

After the placenta comes out, the woman has a minor hemorrhage, but we massage quickly and the uterus firms up. We have moved her onto her back, and clean her up and let her relax. The infant weights 3.56 kg. Not very big for the US, but very big for South Sudan. Katie offers to let the woman hold her baby, and she accepts. She cradles the baby as if it were alive, her face stoic. Her husband is next to her, comforting her.

We are both a little stunned. What the fuck. That was so ridiculously traumatizing, that now we are a little punchy. We fully appreciate how sad the situation is, and how disappointed we are to not have saved the baby, but these emotions are too powerful for right now. Instead, we have to laugh at absurdity. We laugh at the blood spatters on our shirts that look like we’ve been shot. The maternity staff is shellshocked too. The midwife thanks us for having come so quickly. “Not quickly enough. The baby died,” I say. But he says “No, you came very, very quickly.”

On our way back to base in the car, I ask Katie how she finally got the head out. “I have no idea,” she says, and we burst into laughter.

I had read about head entrapment in textbooks, and talked about it extensively in the hypothetical, but I had never seen it, in part because we rarely do breech delivery in the US. And now I have seen firsthand why we don’t. If anyone was ever a good candidate for breech delivery, it was that woman. She had a proven pelvis and spontaneous labor and a baby that was big but not extremely so. And yet, she had the worst possible outcome. A traumatizing, horrifying complication in which her baby died between her legs, with its head inside her vagina. South Sudanese women are so stoic; it’s hard to be certain what they are feeling, whether good or bad. This woman held her dead baby silently, but she held it tightly, and for a long time. There is no doubt that she has been emotionally scarred by this delivery. I hope I never see a head entrapment again.

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24 Responses to Head Entrapment

  1. Beth says:

    I have had breech pregnant clients who I had to send to the hospital for versions or delivery. I have never delivered one. Last week I sent a first time mom at 7 cms after discovering her baby was breech. I was saddened because I felt ready to do so. Thank you for your blog, it is a humbling reminder to why we have the protocols we have……….thank you so much for your work.

  2. Phil Watters says:

    Hello Veronica,
    I’m reading your blogs because it was suggested I do that before I commit to a month in Africa like you. I trained in the UK and Australia 79-85 (Sydney born) and did more breeches than I can remember until the TBT came along and changed everything. I ceased private practice in 2005 so I can’t promise anyone a breech birth anymore, even in carefully selected circumstances, as I can’t promise to be there, or expect anyone with the same skill and confidence to do it in my absence. I just wonder if the “hands off the breech” dictum might have been forgotten by the midwives, leading to head extension before head engagement (before you arrived). What do you think?
    Best regards,
    Phil Watters FRANZCOG FRCOG

  3. Gail Tully says:

    Please Know that I did read your post carefully, and see that you knew the procedure and found the head large and in an unusual and high place, so I am not sending the previous post as instructions to You! but for your readers! Thank you, and again, Comfort and Healing to you, the mother, her family, and the midwives and staff you were with.

  4. Gail Tully says:

    Oh, dear Midwives,
    I’m so sorry to hear of this tragedy and your stress (shown by your somewhat understandable but inappropriate laughter, a stress response, in case some readers were confused why you may have been laughing).
    Recently, I also assisted a breech baby with a trapped head and talked to two other midwives who also recently had breeches with trapped heads. I know in your situation the baby was trapped before you even arrived and so the baby wasn’t likely to live, especially with handling going on. One of the three breech babies also died and the other two were saved by flexing the head. These three were like the one you described with the head ABOVE the brim of the pelvis. So flexing the head is quite difficult compared with an extended head that is within the pelvic canal.
    Ina May Gaskin’s video from The Farm Midwifery Clinic does show how to flex the head very well, so you may want to purchase it. Her video does not address the head high at the brim specifically. Yet, the very instructions she gives are what I was able to do to help this baby at the brim, and saved the baby’s life. The baby had 9-10 Apgars inspite of having been stuck because of Midwife Gaskin’s excellent instructions on video. Also, Dr. Frank Louwen has a technique, now affectionately called, the Frank’s nudge, that flexes the trapped head. It can be used instead of, or before the Mauriceau-Smellie-Veit maneuver. I looked on line to find instruction on the Mauriceau-Smellie-Veit and was not satisfied with instructions as something was off with each description. The Wikipedia description is just terrible and dangerous and doesn’t describe the procedure! Guidelines from Canada are at http://www.ncbi.nlm.nih.gov/pubmed/19646324
    and every midwife will develop their own guidelines and should have them on paper to share with assistants.
    Please come to the Nov 9-12 Heads Up! Breech Conference in Washington, DC, where Jane Evans, Frank Louwen and many breech experts from around the world are gathering to share the best practices. Thank you for your post. Its heart wrenching. I hope this response is helpful to your readers. Blessings.
    Gail Tully, The Spinning Babies Lady

  5. Maryam says:

    I’m a final year medical student just days away from my exams.
    Your experiences have touched me deeply. I hope that I can be as brave as you all are someday. Doctors like you are my inspiration…. helping people in a part of the world that seems to be forgotten by many.

    I hope that you are doing ok over there though… I can only imagine how difficult it must be on your all emotionally and physically.
    Thank you for sharing.

  6. Gemma says:

    Thank you for sharing your experiences.

    Stay strong

    Gemma

  7. Jayalakshmi says:

    Hello Ms. Veronica,
    The culture I “assume” teaches women to be stoic.
    But, “GOD” teaches women/mothers to CARE, LOVE unconditionally and her holding a precious baby (though dead) is still her baby.
    Amazing part is you will be blessed next time when delivering another “head entrapment”. You have been blessed with the experience, and I pray the next time will produce a “miracle” delivering a “life”.

  8. Hassan says:

    We had a entrapment in my country for a first time delivery, it became a public case as they had to decapitate the dead baby!

  9. sandra says:

    Your writing is so real. Thank you for sharing this. True, you saved the life of a mother, what a differnce you’ve made!

  10. Michael Enriquez says:

    Thanks for blogging! I enjoy your stories!

  11. Izzy says:

    Sorry to hear about the outcome, but thanks for sharing and keep up the good work!

  12. Gilly says:

    After working in the ED this morning dealing with all manner of “emergencies”.. (ie things that british people deem to be an emergency but in actually fact elastoplast would have solved)…reading this just further fuels why I want to come work with MSF…these are the real stories of those people who need us…genuine emergencies…sorry it had a grim outcome, but pleased there are people out there like you….

  13. doreen ogden says:

    Awesome seems an understatement. Wonderful people doing wonderful work. Thank you

  14. Clare Weiner says:

    Very scary, very moving. Thanks for blogging, and thanks for working in places where medical staff are few and conditions are not what we have in Europe. Bless you!

  15. claire reading says:

    Hi Veronica (and Katie)
    Your writing is excellent – heartwarming and heartbreaking. You are doing a wonderful job. I look forward to reading more of your excellent blog. Part of me wishes it was fiction though. Well done.

  16. manjeet says:

    THRILLING EXPERIENCE,,,,,,really appreciate what you are doing for those unfortunate people!!!!!but in my country INDIA ,,it is the same situation….we perform at least 2 assisted breech deliveries every week…if these poor people can at least get the facility of antenatal usg , things can really turn around!!!

  17. Leah Minuk says:

    I have attended several births, all with happy endings. I cannot imagine how stressful this situation was for all involved. Thank you for sharing the experience, but more important, thank you for the work you do to ease the suffering of so many. God bless you!

  18. I’m a medic on a rural island off the coast of Washington state. I love my job but there are times when a call takes a little piece of me. You saved the mother’s life! Grief for her baby, yes, you were too late for the baby. But you did save the mother of five children. You made a difference in all of their lives. Be kind to yourself today.

  19. Susan says:

    May you and your patients be blessed with strength.

  20. Caitlin says:

    Thank you for your dedication to this program and to helping others in the way that you do.

  21. Daisy May says:

    A desperately sad story and one that also shows the range of human emotions we health care professionals go through during and after emergencies. Perhaps it may have been helpful to flip the woman on to all fours earlier? We do it a lot in the UK and it definitely flexes the head as the baby’s body descends and then hangs………

  22. Shanna Wade says:

    Your story was really gripping. Thank you for the work you do. Its because of self-sacrificing people like yourselves that mean the difference between life and death for millions of poor people around the world. Man do we have it soft here in the states!

  23. Emily says:

    Thank you for your service and for bearing witness to what we know is so hard.

  24. Amy Merideth says:

    Thank you for blogging. Your writing really evokes a strong response in me, I almost feel like I am there. Thanks for what you do.