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.”

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.