Another Learning Experience to add to the list of Complicated Births

WARNING: Descriptive birth story with a photo of an abnormal placenta. Only read if you're really interested...

I delivered a baby last night. It happened to be my third of three required continuity patients necessary for the completion of my clinical requirements to become a midwife.

It was a tough delivery and I learned a lot. I want to share the details of my patient in order to illustrate why most of the births we see at Glory Reborn don't end up being considered normal. My patient is just one example of so many other like her that we see every day.

My patient is a 28-year-old G8 P6213, which means this is her 8th pregnancy. Of the previous 7, all but one fetus made it to a viable age. She had 2 premature deliveries, 1 miscarriage, and currently has 3 living children.

The two premature babies she had (one at 5 months, one at 6-7 months) died within a month after birth. Another child died at 18 months from an infection. Thus the 3 living children. Until last night. Now she has four living children, praise God.

Her first 5 deliveries took place at home with a traditional birth attendant (hilot). Hilots are not medically trained. They rely on traditional 'wisdom' and folklore. They don't have B/P cuffs or any method of listening to the heart rate of the baby. Therefore they don't monitor blood pressure in labor or the baby's heart beat. They don't carry pitocin (to prevent/treat a woman from bleeding to death). They don't do prenatal care. They don't suture tears and apparently don't refer women for suturing even when it is essential (as in the case of fourth degree tears). They basically are called in at the last minute to catch the baby and cut the cord. And they get paid for this. Sometimes more than what we charge at Glory. Crazy. I have a whole host of stories about hilots but I think you get the picture.

My patient's previous premature labors likely could have been prevented through routine prenatal care and treatment of common infections or dehydration.

Throughout this pregnancy, my patient was diagnosed with and treated for a severe UTI, and another common infection in pregnancy. She took good vitamins for her mild anemia. She had regular check ups.

The last baby my patient delivered had a midwife for an attendant. Apparently her labor lasted for seven days. When she finally went to the midwifery clinic (not Glory Reborn) they were able to artificially rupture her membranes (AROM) to get her to progress. It worked and within two hours, her baby was born.

This labor started out very similar to the last, according to my patient. She had been having mild to moderate contractions every 10 minutes for days. She came in to Glory Reborn yesterday at 11:00 am at 4 cm dilated, head -3 station (head high in pelvis). We gave her some herbs to help strengthen her contractions, which, for a while made them come every 5-6 minutes but they were still very mild. She progressed to 6 cm after 8 hours.

Thankfully the heart rate of the baby stayed normal enough for us to not need to hurry things up. We would have liked to do AROM but that is contraindicated when the head is not yet engaged in the pelvis because of the risk of cord prolapse.

When we did an IE at 7 pm we found a tiny little hand and fingers up towards the top of the head. This is risky because if her water were to break spontaneously the baby's arm could extend past the head and make vaginal delivery either extremely difficult or impossible. She was still only 6 cm dilated and the head not yet engaged. We called our obstetrician for advice. She said to wait two more hours and see what happens. We tried to move the hand back and out of the way but it didn't work. We let the patient rest and her contractions slowed to every 10 minutes again. Two hours later she was 7 cm dilated, head at -2 station (still not engaged) with compound presentation (still nuchal hand but at least now the hand was at the side of the head instead of the top). We called our Dr. again. She said we could try slow, controlled AROM with an assistant gently guiding the baby's head into the pelvis while the other held the baby's hand back.

This was risky but considering the alternative - hospital transport of a patient with no money and an almost useless public hospital with no such thing as a stat C-section even if it became necessary to save the baby's life - we explained the risks and options to the mother and she discussed it with her husband and they agreed to go ahead with it. We made a hospital transport plan in case we were unsuccessful and the hand slipped through the cervix before the head.

I was able to poke a tiny hole in the amniotic sac and then slipped one finger through it so I could control how fast the water drained, while at the same time pushed upward against the baby's hand with my other fingers, while the other staff gently held the baby low in the pelvis. The AROM immediately resulted in strong, frequent contractions. We also did nipple stimulation and gave her more herbs. After about 30 mins of slow leaking of her water the baby's head began to fill the pelvis and the hand was completely out of the way. Whew! During this time she showed signs of partial separation of the placenta as there was a big clot that came out and also the water was blood-stained. Thankfully the baby's heart rate stayed within normal limits but this had us on-guard.

The contractions were coming frequently and the baby's head started to descend and it was finally at 0 station (engaged, fully filling the pelvis). Then the baby's heart rate dipped down so slow to 60 beats per minute during a contraction. This was way too low! Normal head compression would cause the heart rate to dip down to 100 but not 60. This was a sign of either the beginning of placental separation or cord compression. We connected the mom to oxygen and stimulated the baby's head. After the contraction the heart rate went back to normal. She was still 9cm but she had to push that baby out! As with other women who have had so many of babies, the cervix is very soft and stretchy and usually will just move out of the way when the baby's head moves down. But our patient didn't push well during the contraction that caused the baby's heart to slow and so the baby's head stayed where it was. With the next contraction the heart rate dipped again. The last time I heard a heart rate that low was when we transported a patient with cord prolapse and the baby died because the public hospital would not do a stat C-section. So this was now a real emergency.

Hilary stepped in and put hard pressure on the posterior vaginal wall to stimulate the right kind of push from the mom and we all demanded that she Push. Now. Hard! Hilary alerted the staff to get ready for resuscitation. The patient did exactly what we demanded and the baby's head was suddenly visible, then crowning. We told her to keep pushing. Then the head was out. It rotated normally but the cord of the baby was wrapped tightly around it shoulders. I slipped my hands beneath the cord and slipped if over the shoulders and applied traction to deliver the baby immediately. Thank God the baby cried immediately and resuscitation was not necessary. Thank you God. We were all praying like crazy!

Also because our patient was G8 and anemic and had possible partial separation of her placenta, we prepared for hemorrhage. We infused her IV with pitocin after the baby was born (we usually always wait till after the placenta is delivered but this was a unique case). Thankfully the placenta was delivered within 5 minutes and it was intact. She didn't hemorrhage. And there was no tear. Praise God.

Her placenta had an abnormal shape. It was a circumvallate placenta, which is associated with prenatal bleeding especially during the 2nd trimester, placental abruption (separation of placenta in utero), multigravity (more than 4 pregnancies) and placental insufficiency, which can lead to intrauterine growth restriction (IUGR). IUGR is associated with malnutrition. My patient's husband is a smoker and has no job. She sells fruit when she can but mainly they depend on family for food and they commonly do not have enough to eat. She also had some bleeding in her second trimester. So interesting.

Here's a photo of a circumvallate placenta. My patient's looks so similar to this, expect smaller and with a very thin cord.


Within 20 minutes the baby was breast feeding and mom was smiling. Baby Lenzy weighed 2,550 grams (5 pounds 10 ounces). I'm so thankful everything turned out okay. Hilary was so fantastic at staying calm and instructing me and the rest of the team. I have to admit I started to panic at one point. Not majorly but I did say, "Oh God, Oh God" when I thought the placenta was separating. I'm embarrassed about that now but I'm thankful that Hilary was there to tell me, "Don't panic. Stay calm."

It's experiences like these that I wonder if I can do this. Be a midwife. I'm still not to the point where I am 100% managing the birth by myself (unless it's normal or a slight variation of normal). But that must come with time, right? I know I am getting great experience and I feel fairly confident in handling some complications, like hemorrhage but it's hard to know how I will react and handle other emergencies when they happen. It's a big, scary unknown. So far, I've always had someone with me, which of course is the way it should be as I am still a student, but in those times of emergencies there isn't time for my supervisor to ask me, "ok, what are you going to do or what do you think we should do." No, there is just only time for the supervisor to tell me directly what to do, so I have no idea what I would have done.

In fact, I meant to blog about a couple of other emergencies that I had last month during deliveries. I learned a lot from those too. I got to deliver a posterior shoulder because the baby's body wouldn't deliver spontaneously after the head was born and needed assistance (it was almost shoulder dystocia but not really a true case). Another time I attempted to manually remove a placenta as it was abnormally attached, possible due to previous uterine scarring and/or the abnormal shape of her uterus. It was scary because she was really bleeding. In both cases, my supervisor was excellent at calmly instructing me what to do and I was able to do it. Well, I wasn't successful at removing the placenta but I did get in there and try and now feel confident that I know what to do next time. It was my first time after all!

I just needed to process that birth, so thanks for reading if you made it to the end! When I read about these beautiful, natural, water births at home with midwives with healthy, empowered, educated women I feel I am living in a parallel universe. Then I remind myself that the maternal mortality ratio (MMR) and the infant mortalitie rate (IMR) in the Philippines, especially among the urban poor, are much worse than that of the U.S. and Canada. That has to count for something!