34 week posterior breech with cord prolapse and cervical head entrapment

by Kristine Lauria, CPM, of Médecins Sans Frontières in the Rohingya Refugee Camp, Bangladesh.

Some people are just meant to be here. I walked into maternity this morning and heard noises from the birth room. I popped my head in just to say I was here and to ask if they needed anything. I was greeted back with, "Cord prolapse, breech." 

I stormed into the room, threw my backpack down at lightning speed and went to the side of the midwife to see a baby hanging from about mid-chest, with arms still up inside. The mother was on the delivery table and the baby was facing almost completely posterior. (I'm giving details for all the birthy people out there but in enough lay terms that everybody can understand, so if both camps could please forgive me that would be great.) 

I quickly started asking questions--keep in mind my interpreter is not in yet-- How long has the baby been like this? Just now. I look at the clock: 7:26. I looked at the cord, it was blue, like it should be. Baby looked white and floppy. I watch the midwife and she's doing nothing but yelling at the mother to push. The hands-off approach is always best with breech unless you have an issue. 

I said to her, "First you need to rotate the baby." The problem was the baby was almost completely posterior and was not going to come down any further in that position; his arms would be hung up on the pubic bone. I could see she didn't understand me so I got gloves on. This was a race against the clock. 

I gently grasped the baby with my hands in a prayer position, one hand on the chest and belly and the other hand on the back, and I said to her, "First disimpact (which is pushing the baby gently back up just a bit) and then rotate." And I slowly and very easily rotated the baby to the anterior position, at which time it came down to its armpits. Unfortunately the maneuver didn't release the arms as it sometimes can, but at least now we had the baby in the proper position. 

Because I walked in on this drama and my assessment was that the baby needed to come out immediately, I then showed the midwife how to go up with a finger and sweep down the arm, then rotate and do the other arm (Suzor's maneuver), verbalizing everything for her. 

Then I saw the head was still quite high up and immediately saw the reason--the cervix. She was not fully dilated and the head brought the cervix down, so it was trapped like a tight reverse turtleneck. I was not happy. The only thing to do was go up and get the trapped head. It was difficult to get in around the cervix with my fingers, but I managed to get up to the mouth to flex the chin down all while the midwife was giving suprapubic pressure. I had my first and third fingers on the baby's shoulders on either side of his head doing a downward press while the middle finger flexed the head forward. 

The baby was lifeless and I had no hope of getting it out alive, but it had to come out. Then he took a breath! My finger inside kept enough of a space for him to be able to take another breath. It took gentle rocking to bring the head down far enough and past the cervix where I could then gently lift the body and it popped out. 

I looked at the clock: 7:30. We cut the cord immediately; it was looking pretty anemic by then. As I brought the baby to the resuscitation table, where the second midwife was waiting hopefully with the ambu bag, I said, "He's not going to survive." She said, "The heart rate is low," as she listened. I couldn't feel a pulse at the umbilicus. I started chest compressions. Just mere seconds brought the heart rate over 100. I suctioned the nose and mouth and then started bagging the baby. His lungs filled with air several times, his color improved. 

Then I turned him on his side and rubbed his back vigorously, and his eyes popped open and he let out the most beautiful wail. He was completely pink in an instant but not moving his arms or legs. We did all of our midwife things like weigh him (2kg), give eye drops and vitamin K. Soon his little arms and legs were all working symmetrically. 

Later when I asked to take a photo, he smiled at me. As I held down his blanket for the pic, he grabbed out and met my finger and grasped it. All day long I was just in utter shock that not only was I able to get the baby out but that he survived against all odds. And although I'm not an expert, I would say this baby was as healthy as any baby could be. He cried, nursed, looked around. I estimate his gestation at about 34 weeks. 

I did apologize to him for saying I thought he wouldn't survive right after he came out. At the time it was more about my faith (or lack thereof) in my abilities and I didn't really factor in his will to live, which obviously I greatly underestimated. 

After the birth I got the back story of what had happened before I got there. The mother had come in at 6:00 a.m. with a cord prolapse. They found her to be 4cm dilated. They called a referral hospital who, long story short, just gave them the runaround. In the meantime, time went on and suddenly there were feet and then the legs and the body and then I walked in. Up until that time the heart tones had been good and the cord had been fat and blue. 

A cord prolapse is not always necessarily an emergency, particularly when you have a breech. The cord can easily slip down between the legs as the cervix dilates. It isn't being compressed, so it isn't causing any harm to the baby. But it is a little disconcerting to see a cord hanging out of someone when you know it's not supposed to. And because this baby was premature, the cervix did not dilate completely but the baby started to come anyway. I estimate the cervix was dilated to about 6 or 7cm at the most. 

It was really interesting getting that head out from the trapped cervix. It was a very different maneuver than trying to get the head out of a bony pelvis. It required a sort of rocking motion.  

I told his mother to come back in 7 days when he has a name and tell me what it is. The mother was so happy, all day long she kept saying how the baby looked like me, because we both had no hair! What could have ended up as an incredibly disastrous and horrible Monday ended up to be one of the best days here so far. There are so many limitations, tragedies, and ways to feel inept and ineffective day in day out here, it feels really good to actually help someone. Monday was a good day.