Fieldset
Foot, Elbow, Knee? Part 1

6 p.m. Saturday: The patient is 9 months pregnant with twins. She has been having painful contractions since early this morning and she says she has been leaking fluid. She already has five living children at home. I place my hand on her abdomen to assess her contractions.

6 p.m. Saturday: The patient is 9 months pregnant with twins. She has been having painful contractions since early this morning and she says she has been leaking fluid. She already has five living children at home. I place my hand on her abdomen to assess her contractions. You can feel her contractions, but her belly is so huge and taut it is difficult to assess their strength. I press firmly with my right hand, just above her pelvis, to feel for the baby's head. There is nothing that feels like the hard ball of a head, in fact I can feel a small little baby part just above her pubis. Heart sink.

The Doppler confirms the presence of a fetal heart. But is it one or two?

I examine her internally. She is about 4 centimeters dilated and her membranes are bulging; the bag of waters tightens up considerably with each contraction like a balloon about to burst. I feel around gingerly to avoid breaking the bag. What I feel confirms my worst fears. It is a small part behind the bag, not the large hard globe of a head, but a small part that feels like a foot. Or even a hand or a knee? I can't tell what it is, but I am sure it is neither a head nor a bottom.

Normally with a head first position the large diameter of the head opens the birth passage for the rest of the baby. Even when the bottom presents first, it is relatively large and round and prepares the way for delivery. But this! This foot/hand/elbow/knee? The baby/babies will get stuck. Or the cord will come down first and choke off the their blood supply. This is an obstetrical disaster waiting to happen. At home I would call the obstetrician for a Caesarean Section and the story would probably have a happy ending. But here!

I get on the phone with the medical coordinator in Loki. There is a plane on Monday that could transport her to Nasir, another MSF project, for a C-section. Monday looks a long way away.