The halfway point

The most gratifying patient of this third week was a woman who came in with a prolapsed umbilical cord followed by the baby’s arm.

The most gratifying patient of this third week was a woman who came in with a prolapsed umbilical cord followed by the baby’s arm.

It was in the middle of the night and the midwife on call didn’t exactly convey a sense of urgency. Her exact words were, “doctor, could you come in to evaluate a patient?”

When I arrived there was an umbilical cord hanging out between the patient’s legs with a full term sized fetal arm. There was still a pulse in the cord, although it was only about half of what it should have been. I called the anesthestist and notified the operating room (OR) and then placed a catheter in her bladder and filled it full of water to try to elevate the baby off of the cord, although I had already pretty much written the baby off.

According to the history she had been on her way to the hospital, a journey of about an hour for her, when her water broke and the cord and arm prolapsed out. We got her back to the OR and the baby still had a heart rate that you could feel through the umbilical cord, roughly 60 beats/minute when it should have been at least double that. As I said before, our goal here is to avoid surgery on the mother unless it is to save her life even if avoiding the surgery is at the baby’s expense, so we set her up for an internal version, finding one of the baby’s feet in her uterus and then performing a breech delivery.

It was a difficult delivery. The uterus had already clamped down and it was hard to find the baby’s foot but finally I felt a heel and grabbed the foot and held on while pulling down. There was a lot of resistance at first but eventually the foot came down and the arm went up and after that it was a pretty straightforward delivery as a breech.

The baby was floppy and lifeless as I’d pretty much expected. The heart rate was only 50 beats/minute so we started chest compressions and placed the ventilating mask over its face and started breathing for it. I felt that we were just going through the motions and didn’t expect the baby to respond but after about a minute it took a deep gasping breath and started breathing on its own.

Its color changed from a dusky gray to a healthy pinkish gray almost immediately and then it started screaming its head off. I have no idea how that baby tolerated what it went through but it seems to be perfectly healthy. It even went home the next morning with the mother, never had to be put in the neonatal unit.

I think this is the fourth internal version with breech extraction I’ve done since working with MSF but this is the first one where we actually got a live baby. We had already prepared the family and the mother for the fact that the baby probably wouldn’t survive so they were overjoyed when the baby came out looking like a normal baby. The only way you’d ever know the baby had chosen an unusual birth plan is the bruising on the arm that tried to come out first and the bruise around its ankle where I held on pretty tightly.

I’m almost to the halfway point now. Time passes quickly. As Lisa, our pediatrician, says, “The days are long but the weeks are short.”