While J. was sitting with the mama I was trying to decide if I had the guts to deliver this baby in a mud hut with no supplies but gloves and a pair of scissors, and no system at all for emergency backup. We are just now getting the registration for the hospital in order with the government. There are a few things in the hospital, but as yet they are all in boxes because we have not yet had time to build shelving. There is no electrical power, no operating room lights if there were, no drugs to speak of, and very little in the way of surgical instruments.
“I don't want to be in the position to be doing a C-section in mud hut with a flashlight and no proper instruments,” I muttered. I don't think he heard me, but he read my hesitancy.
“It's not her first baby, everything will be fine,” he advised.
“You're probably right. The chances of something going wrong are probably only about 1%,” I consoled myself. If I had known then what I know now, I would have estimated the odds differently. I had been told that her pregnancy was totally uncomplicated. Later I found out otherwise. I thought the baby seemed on the small size, and by dates (which were not at all definitive in this case) she was only about 35 week pregnant (two weeks to go still to be considered full term). That is not so good all by itself, but the date of conception was very vague. The baby seemed consistent with 35 weeks, but guessing gestational age (or size for that matter) based on how big a uterus feels in an inexact science at best.
“Oh we'd better just send her to the hospital,” I thought. “We don't need a premature baby born in a mud hut.” But I hated to do it—the expense, the hassle, the expectations of the villagers. Reluctantly I woke Baba from his Sunday afternoon nap and made arrangements to take her in the van. After last week's escapade with the authorities, I'm not about to drive without a driver's license. I could ride along in case things moved too fast and she started to deliver in the van. I gathered a few simple supplies, made arrangements for my kids, and climbed into the front seat alongside Baba.
As we pulled up to the hut (as close as we could get the van) J. came out looking worried. “I don't think we have time to get there,” she reported. “She's pushing and they [the contractions] are getting closer together.”
“Well, I'll check her,” I responded. Frankly, I was a little worried about how I was going to broach the subject of an internal exam with Ahadi. Believe me, it's just different when you are in someone's home, and you know them personally, and you're also in a very conservative culture that is not your own.
The hut I entered was totally different from the one I had left thirty minutes before. One sure way to tell if a woman is truly in labor is: if she doesn't care at all about who sees her naked, then she's definitely in labor. At least that's true in this very conservative culture. Ahadi had been understandably shy thirty minutes ago, but no longer. Now it was easy to see that she didn't care what I saw. So I examined her. Between contractions she breathed, “T, am I going to be all right?”
“Sure you are. Everything will be fine. In Jesus' name.”
The exam felt weird. And I haven't done obstetrics in five years. She was fully dilated, but, “What is this big blob?” I wondered, being sure to keep my face totally composed. A large homogenous mass was palpable. “[Oh, no] is this placenta?” I think I may have mistakenly actually said this out loud. Having the placenta come out before the baby is very, very dangerous—almost universally fatal without very fast and drastic intervention (a C-section in under five minutes). The baby needs to “breath” through the placenta or through it's lungs—these are the only two options. If the placenta comes out first, it's no longer getting mother's oxygenated blood and passing it to the baby. And obviously a baby still inside cannot breath air. I squeezed the mass. “No, it's just the bag of water,” I concluded. The bag of water preceding the baby in the birth canal was huge, totally obscuring further examination of the baby behind it. It was actually starting to protrude; I even could see it bulging between contractions. Usually these amniotic sacs burst well before this point, but not always. This one couldn't hold much longer; as I said it was already to the point of external visibility.
I examined her belly again. The baby seemed head down, but it was hard to say. It could have still been breech. Mostly the fetus just seemed small. Her contractions were coming quite strongly and quickly now. “What do I do?” I wondered. I agreed that we were very unlikely to make it the hospital an hour away if things kept going the way they were going. The baby's heart rate seemed OK (a sign of vitality), but I didn't have my preferred equipment for listening. I couldn't be sure. In fact I had just three days ago pulled the donated ultrasound machine out of the shipping container and started trying to get it running. That endeavor was unsuccessful, though it does come on and boot up when provided with power (from the solar panels on the roof). I don't know if it's missing a part or the problem is just that I can read neither the machine nor the manual. They are both in German. I need to get an English manual. Again I wished that I had the ultrasound machine working and at hand. It's sitting useless in our apartment, one of the few places with solar power.
She was fully dilated. The bag of water was protruding. She was contracting quickly and they were strong. Certainly there was no turning back, labor could not be stopped. Even if I was sure this baby was premature, there was not a thing that could be done to forestall the birth now. And I agreed that it seemed unlikely that we could make it to the hospital before he came. “Even a mud hut is better than a van on the side of a remote dirt road,” I thought.
“Alright, let's do it here,” I said. Ahadi was relieved. She didn't want to go to the hospital. Since it was going to rupture any minute anyway, and because it was in the way of a proper exam, I ruptured the bag of water. It was so far out I didn't even have to do it internally. I just snipped it a bit with my dissecting scissors (one of I think five surgical instruments I brought with me). The amniotic fluid gushed out onto my arm, feet, and pants. And made a mud puddle where I was kneeling.
I examined her again. What I felt was NOT what I was expecting. “What is that?!” I wondered. It didn't feel like the top of a baby's head at all. “Good grief, what have I gotten myself into?” I doubt my face was as composed as I was trying to make it. This is the furrowed expression that J. had picked up on.
Then it registered in my brain. “Those are five little bones,” I realized to myself. “And that thing right next to it is five more little bones. They're either feet or hands, and both of them are there. Any way you slice it, this is a strange presentation—a one in a thousand, or even more rare. So much for my self- assurances of “a one percent chance.”
I can't feel the head at all. And I can feel two extremities—probably both feet or both hands. But they're so far up there I can't tell which they are. They were just tiny nubs palpated with the tips of my fingers.
Now I've never actually seen any of these rare fetal “malpresentations,” as they are called. They are pretty rare—something like one in a thousand. I don't know how many babies I've delivered, but it's nowhere near a thousand. And back home, anything like this gets caught long before this stage and ends up getting solved with a Cesarean section early on—so there is less than a one in a thousand chance of discovering one of these rare cases.
But I had learned about them in training. However it was totally theoretical. I have no practical experience with them at all. I haven't even delivered a breech baby. In America, especially where I got my obstetrical training, almost all breech babies get a Cesarean section at the first sign of labor. And the few breech deliveries I've encountered before in Africa were all in the presence of an experienced midwife whom I trusted. She knew what she was doing—so I let her deliver them.
I thought to myself: “OK, there's breech. And then there's breech with a foot sticking out. And then there's breech with both feet sticking out. I can't remember what those are actually called.” I wished I had a textbook handy. I'm not too proud to work with a textbook open—especially in cases of fairly rare things that I've never dealt with before.
I continued to try to remember lectures from years ago: “And all those breech presentations can be managed with the normal methods of delivery. And there are a couple of maneuver’s you can use to help the baby come out. And I can remember at least two of those. But what if those were not feet but hands? It kind of felt more like hands, but... Can you get both hands at the same time? I don't remember hearing anything about that.” I examined her again to double check. There were definitely two. And I definitely could not feel the head above them.
The rumination continued. I don't know if everyone does this, but I typically work through problems via an internal conversation with myself: “I can remember that you can get a 'hand' presentation with the hands above the head, but I'm not feeling a head there at this point. I wonder if the baby is coming shoulder first? I remember those usually get stuck.”
I have to admit, I wasn't positive what to do. The baby seemed to be doing OK. Mom seemed to be doing OK. So I just encouraged and observed for a while. I sent J. to our house for towels, string, and a baby blanket while continuing observation. Ahadi seemed a little scared at times. At one point I actually sang her a song—and I am NOT a singer. But I offered to sing her the same song I sing my daughter when she is falling asleep. It's actually a bible verse, verbatim, set to music:
“Be on your guard, stand firm in the faith, be men of courage be strong. Do everything in love.”
She seemed to appreciate the song. It's certainly the first time I've sung for a patient. I don't think it's what anybody was expecting, but it seemed appropriate at the time.
After about an hour of contractions, which seemed to be getting less frequent, she really hadn't made any progress. I was waiting to see if the labor would push the head (or butt) down into the pelvis, and thus possibly push the hands (or feet) out of the way. But no luck. There was still no round hard thing (head or butt) palpable at the upper pelvic rim. Just these two little extremities. Actually, it seemed that the past hour of labor had advanced them further down into the pelvis. But they were still pretty far up there. They were nowhere near where I might see them. But I could feel them better. I felt one carefully between the sides of my fingers by rubbing my index and middle fingers together at their tips.
I felt the baby grasp my index finger! It felt just like how a newborn baby grasps your finger if you place it in his palm. (It's a reflex they have.) The sensation was unmistakable. I checked for the other extremity. Yes, it was still there, and it too was a hand. And still there was no round lump palpable above that. Just two arms that were now partially extended!
I've never heard of this kind of fetal presentation, though I suppose it is a variation of the shoulder presentation. To help you imagine it, this baby was trying to take a swan dive through the birth canal. He was coming chest first, with head back and the front of his neck was holding him out of the pelvic brim on one side, and abdomen resting on the upper pelvic rim on the other side. His arms, instead of being extended at his sides like in a true swan dive, were extended in front of him.
“Ahadi,” I said. “I don't think you're baby can come out this way. He is trying to put his arms out instead of his head out. I think we had better take you to the hospital after all. Don't worry, it's not an emergency and you don't need to be scared. I don't want you to be scared.” I was trying not to be scared myself. I knew that the only way this baby could come out alive was via C-section. The problem was that I didn't have the proper equipment to be assured that the baby was still doing OK in the mean time. But then he did grab my finger...
We climbed into the van and sped off toward the hospital. Baba actually used to have an ambition of being a race car driver. He's a fast driver as it is, but he was now in top form. It being Sunday afternoon, the dirt road was crowded with foot and bicycle traffic, with a rare car or truck. Baba weaved through them with... alacrity? Honestly, it was fairly terrifying. We all prayed for Ahadi and the baby. I don't know if I was the only one praying that the rest of us would arrive at the hospital in one piece. But we did—after only one stop—we had no other choice—to buy twenty liters of diesel put into the van from a plastic cooking oil jug.