A BREECH DELIVERY
The time ticked quietly by. The sounds of “Aye, aye, aye, conga” came from below. They went round and round the sitting room, then the noise got louder and louder as the snake of people started coming up the stairs. They were all shouting at the tops of their voices, and stamping in unison. Sister thought the noise might bother Betty, but she said, “No, no, Sister. I likes to hear it. I wouldn’t want this house to be quiet, not on Christmas day, like.”
Sister smiled. The last few contractions had seemed stronger and were closer together. She got up, and examined Betty, and said to me, “I think you had better go and call Dr Turner if you please, nurse.”
It was four o’clock when I rang him, and Dr Turner arrived within a quarter of an hour. I was excited. This was my first breech delivery. Betty was beginning to feel the urge to push.
Sister Bernadette said to her, “You must try very hard not to push at first, dear. Breathe deeply, and try to relax, but not to push.”
We gowned, masked and scrubbed up again. Doctor looked at Sister Bernadette, and said, “You take this delivery, Sister. I’ll be here if you need me.”
He obviously had complete confidence in her.
She nodded, and told Betty that she wanted her to remain on her back, with her buttocks over the end of the bed, and she asked me and Ivy to hold a leg each. I was learning, and so Sister explained everything that she did clearly and carefully.
I could see something coming, as the perineum expanded, but it did not look like a baby’s buttocks. It looked a purplish colour. Sister saw my questioning expression, and told me, “That is the prolapsed cord. It occurs quite commonly in a breech delivery, because the breech is an incomplete sphere, and the cord can easily slip down between the baby’s legs. As long as it is pulsating normally, there is nothing to worry about.”
The perineum continued to distend, and now I saw the baby’s buttocks quite clearly. Sister was kneeling on the floor between Betty’s legs because the bed was too low for her to stand. She was explaining everything in a low voice to me, “This is a left sacro-anterior position, which means the left buttock will be born first, from under the pubic bone.
“Now don’t push, Betty,” she continued, “I want this baby to come slowly. The slower the better.
“The baby’s legs will be curled up. I will want to rotate the baby to ensure the best position for delivery, but also the pull of gravity as the baby’s body hangs from the vulva will help to maintain flexion of the head. This will be important.”
The buttocks were born, and with infinite care Sister inserted a hand and hooked her fingers over the flexed legs.
“Don’t push, Betty, whatever you do,” said Sister Bernadette.
The legs slid out easily. It was a little girl. A long section of cord also slid out. It was pulsating quite vigorously - one could see it, there was no need to feel it.
“The baby is still fully attached to the placenta,” Sister said, “and its life blood is coming through the cord. Even though the body is half born, until the head is born, or, at any rate, until the nose and mouth are clear to breathe, the baby depends upon the placenta and this cord for life.”
I found it spooky that this tortuous, pulsating thing was absolutely essential to life, and said, “Shouldn’t we push it back?”
“Not necessary. Some midwives do, but I really think there is no advantage to be gained.”
Another contraction came, and with it the baby’s body slid out as far as the shoulders.
Towels had been placed over the screen by the fire to warm. Sister asked for one and wrapped it firmly around the baby’s body, saying as she did so, “The purpose of this is two-fold: firstly the baby must not be allowed to get cold. Most of her body is now exposed, and if the shock of cold air makes her gasp, she will inhale amniotic fluid, which could be fatal. Secondly, the towel gives me something to grip hold of. The baby is slippery, and I have to turn her another one quarter circle so that the occiput will be under the pubic bone. I will do this as I deliver the shoulders.”
With the next contraction, the left anterior shoulder impinged upon the pelvic floor, and Sister delivered it by hooking a finger under the arm, and at the same time rotating the body a little clockwise. The right shoulder was delivered in the same manner, and both baby’s arms were out. Only the head remained inside the mother.
“You have a little girl,” Sister said to Betty, “but from the size of her limbs I don’t think she is six weeks premature. I think you got your dates wrong. I want you, Betty, to push now with all your strength and really use every contraction for delivery of the baby’s head. Doctor may have to exert some supra-pubic pressure, but I would prefer it if you could push the head out by yourself.”
There had been no contractions for a full three minutes, and I was beginning to feel tense and anxious, but Sister was relaxed. The baby was supported by her hands, and then she let go completely, so that it was hanging quite unsupported. I gasped in horror.
“This is the correct thing to do,” Sister explained. “The weight of the baby’s body will gently pull the head down a little, and will increase the flexion of the head, which is what I want. About thirty seconds like this will be enough. It will not hurt the baby.”
Then she took hold of the baby again. I must say I felt relieved. A contraction came on.
“Now push, Betty, as hard as possible.”
Betty did, but the head did not descend any more. Sister and Dr Turner agreed that with the next contraction he would exert suprapubic pressure, and if that did not prove effective, a low forceps delivery of the head would be necessary.
Sister explained to me, “That is because the cord will be compressed between the head and the sacral bones. The baby is all right at the moment, but if it goes on for too long, that is more than a few minutes, there is a definite risk of asphyxia.”
I clenched my fingers with shock and anxiety, but Sister remained completely calm. Another contraction came, and the doctor placed his hands on Betty’s abdomen just above the pubic bone and pressed down firmly. Betty groaned with pain, but there was a definite movement of the head.
“I am going to use the Mauriceau-Smellie-Veit method of extraction of the head,” Sister explained to me. She was allowing the baby to hang unsupported again, and my heart was in my mouth.
“With the next contraction, all being well, we will have the airways clear, and the baby will be able to breathe. I will want my Sim’s vaginal speculum, so be ready to pass it when I need it.”
I looked to see where the Sim’s was on her delivery tray. My hands were trembling so much that for a ghastly moment I imagined I would knock the whole tray over, or pick up the Sim’s only to drop it on the floor.
Another contraction came on, and the doctor exerted the same pressure on Betty’s abdomen. Sister placed her right hand over the shoulders of the baby and the fingers of her left hand into the vagina. I could see her gently moving her fingers and feeling for something. The baby was resting on her forearm.
“I am trying to hook my index finger into the mouth of the baby, in order to maintain flexion of the head, so that the mouth and nose will be the first part of the head to encounter the air. It is
not
to exert pressure by pulling. If you ever use this method of delivery, nurse, remember that. If you try pulling, you risk dislocating the jaw.”
I felt sick with fear, and just hoped to God that I would never have to deliver a breech. I could see that she was manipulating the back of the skull with her right hand. She explained, “I am simply pushing upwards on the occipital protuberance of the skull to increase flexion. A little more pressure, please doctor, if you can, and I think I shall have the airways clear. That’s it. The Sim’s now, nurse, please.”
I had to grip my wrist with my other hand to stop it trembling. All I could think was, I mustn’t drop it, I mustn’t drop it. My relief when I handed it over was so great that I almost laughed.
But there was more to see.
The chin of the baby was now on the perineum and Sister carefully inserted the speculum into the vagina, pushing the posterior wall backwards, rather like using a shoe-horn, so that the baby’s nose and mouth were exposed. She asked for a swab, which I handed to her, and she wiped the baby’s nose and mouth free of mucus.
“Now she will be able to breath, and will no longer be dependent upon the placental blood supply.”
It was astonishing to hear a gasp, followed by a tiny cry. The baby’s face could not be seen, yet her voice could be heard.
“That’s what I like to hear,” said Sister. “Did you hear that, Betty?”
“Not ’alf. Is she all right, poor little thing? I reckons as how she’s goin’ through it as much as what I am.”
“Yes. Your baby’s quite safe now, and with the next contraction she will be born, I assure you. I think you have a torn perineum, but I can’t see it because it’s behind the speculum, nor can I do anything about it, because if I remove the speculum your baby will not be able to breathe.”
Another contraction was coming. ‘This is it,’ I thought with some relief. Delivery of the head had so far taken only twelve minutes, but it had seemed like an eternity to me.
The contraction was strong, and doctor was exerting considerable pressure. Sister drew the baby’s body downwards until the nose was level with the perineum, and then swiftly upwards over the mother’s abdomen. The movement took no more than twenty seconds, and the head was delivered. I nearly sobbed with relief.
The baby was blue.
Sister held her upside down by the ankles.
“This blue tinge is not serious,” she said. “It is to be expected. I must make quite sure that the airways are clear. When she starts to breathe strongly and regularly the colour will improve. Pass me the mucus catheter, will you, please?”
I was not trembling any more, so was able to do this without fear of dropping it.
Sister inverted the baby, and held her in her left arm. She then inserted the catheter into the baby’s mouth and sucked very gently at the other end to draw any fluid or mucus away. One could hear a bubbling sound as fluid entered the catheter. She then cleared each nostril in the same way. The baby gave two or three big gasps, and coughed, then cried. In fact she let out a tremendous scream. Her colour rapidly changed to pink.
“That’s a lovely noise,” observed Sister. “A few more screams like that will make me happy.”
The baby obliged, and screamed lustily.
The cord was clamped and cut, and the baby wrapped in warm dry towels and handed to Betty.
“Oh she’s lovely,” exclaimed Betty, “bless ’er li’l heart. She’s worth all the pain in the world.”
It’s a miracle, I thought. The mother literally forgets the agony she has been through the moment she holds her baby.
“It’s Christmas Day,” remarked Betty. “We must call her Carol.”
“That’s a lovely name,” said Sister. “Now we must get the placenta out, and I think you had better stay where you are because there is a tear, as I thought, and it will be easier for the doctor to stitch you up in this position.”
Doctor was drawing up a syringe and said to Sister: “I am going to give ergometrine now, to promote the expulsion of the placenta.”
She nodded.
I did not ask why. It was not normal practice to give ergometrine in those days, unless there was undue delay of the third stage, or severe bleeding, or an incomplete placenta. As I noted earlier, oxytocic drugs may be given routinely today, immediately after delivery of the baby.
Within a couple of minutes a contraction came on, and the placenta plopped out into the kidney dish held by the Sister.
“Right, I’ll hand over to you, doctor.” she said. You can take my place, now.”
This was easier said than done though. Sister tried to get up, but couldn’t. She gave a gasp of pain.
“My legs! I can’t feel them. I’ve got pins and needles.”
Not surprising, poor thing! She had been kneeling on the floor for over half an hour, in the same position, concentrating wholly on the work she was doing.
“I can’t move. You’ll have to help me, my legs have completely gone to sleep.”
The gallant doctor put his arms round her and pulled. She must have been a dead weight, because he made no impression. Ivy and I joined in, pushing and pulling. We were all laughing. Eventually we hoisted Sister to her feet, and got her stamping and moving her legs. Bit by bit the circulation and the nerve supply restored the function, and she was able to stand without help.
The doctor opened his suture case and scrubbed up again. He asked me to hold his torch, so that he had a direct light on to the tear. He anaesthetised the area with a local, and then examined it thoroughly.
“It’s not too bad, Betty,” he said. “I’ll soon have you stitched up, and it will have healed within a couple of weeks. I want to examine you internally, though, to make sure that the cervix is not torn also, because this can sometimes happen in a breech delivery.”
He inserted two fingers into the vagina and felt all around. He explained to me, “The breech is smaller in diameter than the head. Therefore the cervix may be sufficiently dilated to allow the passage of the breech, but not relatively open enough to allow the free passage of the head. This will obviously be one of the occasions when the cervix may tear. If that occurs, the mother will have to be transferred to hospital, because I do not have the facilities here to repair a cervix. However,” he continued in a confident voice, “you are lucky, Betty, there is nothing torn inside you. I just have to put a few stitches on the outside.” He selected his catgut and needle. He pulled the muscle together with forceps, and with a few circular movements of the wrist had made a neat repair. It only took a few minutes.
“There we are. That’s that. Now let’s get you back into bed, so you will be more comfortable.”