|Jen, Beth, Beth, Tara (a few others were also in the room at this time)|
Our team at the Maternity Center varies from time to time, but as of last week the group that will be in place for the next six or seven months all found their way back to Haiti after short and long breaks. Dr. Jen was the bonus player in house.
At each birth we generally take turns playing different roles. We all have a turn assisting, we all get to be the primary, we rotate spots and try to know how to do everything, should we ever find ourselves alone to deliver a baby. Our entire team knows how to act as a team and knows how to play varying roles.
Because I am so near finished with my clinical requirements, I was being supervised by Beth Johnson (my official preceptor and an experienced midwife) and was ready to catch Stephanie's baby. Stephanie leaned on the side of the bed with her knees on the floor. We watched and encouraged as she pushed. Jen popped in and out to see how the pushing was going.
I debated writing this story for the other midwives, using all the jargon and asking the wiser ones to edit me and make me sound smarter. In the end I decided everyone can enjoy this story if I write it for everyone, (less gore, detail, and official vernacular) and leave the sounding smart part to the very smartest people.
Stephanie wanted to be where she was, at the side of the bed. She continued pushing and pushed for about 30 minutes. As each contraction subsided, she rested. Everything was going beautifully, even with the IV lines she was forced to deal with due to her blood pressure and signs of preeclampsia, and even in spite of her fatigue from 24 hours of labor. Her baby's heart rate remained strong and steady.
A few minutes after 5pm Stephanie pushed her baby's head out. I felt a hand up near the baby's neck and called out that we had a nuchal hand but no cord around the neck. As it turned out the baby had her right hand up next to her left ear. (Take your right hand, put your arm on your chest and rest your right hand so it is touching your left earlobe. That's your visual.)
Because of the position of that right arm and hand, we had about a 90 second delay between the delivery of the baby's head and completion of delivery of the body. Beth J. was great at coaching and telling me how to proceed and allowing me to learn and do the delivery.
Helping a woman deliver is technically a plyometrics workout. We did our workout and a shoulder and then an entire baby emerged. Once the baby was out we passed her through so she was on the front side of Stephanie and we had Stephanie turn around and lie down on her back on the edge of the bed to deliver her placenta. Her baby had a very short cord, making that a little bit interesting, but the flip happened (this is where Bruce Lee and some fancy-pants moves come in handy.)
Wini and Beth M and Dr. Jen and Jenny, the photographer that caught this excitement on camera, were all in the room helping and playing their roles. (There are people with towels ready to dry baby, there are people with pitocin ready to stop a large hemorrhage. There are people handing supplies to the primary. There are people charting the time and vitals.)
|L to R - Wini, Beth M., Tara, Beth J.|
Beth J. asked me if I was comfortable going in for the placenta. I basically said, "No, but I'll do it." (Beth McHoul cheers out loud for you when you do and say things like this. Who doesn't love a good cheer from Madame John?) I put on new sterile gloves and reached in to try to manually remove the placenta. Below you will see the face a person makes when a placenta feels like a fluid filled sac with a thing that is not placenta-like inside. I pulled my hand out and said it doesn't feel like a placenta. Later I added, it felt more like little bones. Wini tossed the doppler back onto Stephanie's uterus to listen for another heartbeat. It was sort of a moment of the entire room adding up the puzzle pieces from Thursday and Friday and a collective, "YIKES" was screaming from our souls.
At that point so much happened so fast that I know each one of us would recall different parts of the story. Beth J put on new gloves to confirm the second baby herself. I think Wini went to get the ultrasound machine. I think Jen cut and clamped and took the first baby out of the picture. I think Beth M. abandoned her charting job and get in on the action. I think Jen put the ultrasound probe onto Stephanie and said, "that looks like a butt first". I think I pooped my pants. I think Beth J, the most experienced in the room, turned into a ninja midwife warrior. I think Beth McHoul hurriedly called Troy from two blocks away to ask him to high-tail it over to the ambulance and be ready with whatever his mid-husband duties required of him. I think Wini put the oxygen on Stephanie.
We talked to Stephanie. "Stephanie, nou gen lot baby. W' gen marasa." (Stephanie, we have another baby. You have twins.) I am still very amused at how Stephanie handled this announcement. If anything, she seemed kind of entertained by this news. She smirked and said, "I have two?" Later I asked her about twins in her family. She said yes, her mother, no longer alive, had been a twin.
Twin B's heart rate was sketchy. (Fancy medical terminology here, try to stick with me.) It had dropped to 60 beats per minute. A decision was made to break the amniotic sac and try to get the baby delivered as quickly as a breech position would allow. I held the baby from the outside with my hands as Beth Johnson broke the sac and touched the baby from the inside. Beth J. had Stephanie flip back to her hands and knees.
She was near the edge of the bed so three of us sort of supported her and gave her help by pushing back on her as her feet pushed into our legs while we stood at the bedside. We figured another plyometric workout was in order. After-all, it had been six or seven minutes since we last worked out.
Stephanie followed instructions like delivering surprise twins - one breech - was a thing she had been practicing doing for decades. She pushed hard when asked.
Troy came into the delivery room and said the ambulance was ready and available. We started bossing him around. Beth McHoul asked him to move a few things in the room. He was given the camera. (Those photos are amazingly beautiful but far too personal for the Internet.) In the minutes that felt like hours, Stephanie delivered one foot, then the butt, then the second leg came, then the torso of her second daughter. Beth McHoul wrapped towels around the baby to keep it warm and hopefully prevent it from taking a breath before the head was delivered. The fan in the room was turned off.
We were all sweating bullets of nervousness. I dripped on the people around me. I wish we had audio on these moments, people just kept praying out loud as needed. Jesus was asked to protect, guide, and direct. (Multiple times by multiple people.)
At 5:34pm the limp little baby's head slowly emerged, in fact we saw the chin pop out, and then a little pink tongue. We could feel the heart beating as the baby hung mostly outside of her mother. "Baby is alive" was announced. Once the head was fully delivered, we cut and clamped quickly and Dr. Jen (trained in Emergency Pediatrics) went to work on baby B while Jenny held baby A and the rest of us (Wini, the two Beths and Tara) focused on Stephanie. The amount of blood and fluid was abundant. We had it up our arms and splattered all over our feet.
Troy told me late that night, "I really wanted to cry at what I was seeing but I looked around the room full of women doing their jobs without melting down and decided I best not do that."
Instead of crying, Troy captured many beautiful images...
At that point, we were finally in a position to actually deliver a placenta.
Back in the day, surprise twins were a thing. It happened. Technology has meant that it is not typically a surprise anymore, especially in the developed world. We are not in the developed world and we don't routinely do ultrasounds; obviously we hadn't ever done an early ultrasound on Stephanie. The babies were positioned in a way that made it really difficult to detect. We certainly did not see twins at the Thursday ultrasound.
Delivering a breech baby is a lost art. There are many newer, younger docs and nurses that won't ever see it because C-Section has become the answer for a breech baby. The reality is, knowing what to do when a C/S is not an option is a really wonderful thing. We are 20 minutes from the hospital in the best conditions and you don't even want to know what the worst traffic conditions could mean. We need to have plan A and B. Midwives learn about breech deliveries, they read birth guru, Ina May Gaskin, and they hear older midwives tell their stories and while they may never see it, they know what to do. Thank the good Lord, Beth Johnson took charge of the situation and those of us around her knew how to support her and we did what we have been trained to do.
Without being uber dramatic and self-congratulatory, we do want to acknowledge that had Stephanie not been in our program and had she chosen to deliver at home, two and possibly three people wouldn't have lived. The first baby was not an uncomplicated delivery, the second was the opposite of uncomplicated and many measures were taken to stop bleeding. Giving birth at home without help is risky business in Haiti. Most women do it because they don't have access to better options.
We quickly took turns getting showered and changed. Nirva (nurse on staff) arrived. She and Jenny helped feed the twins a breast milk snack while Stephanie underwent some pretty major repair work. Wini started the repair, and Nirva and Dr. Jen jumped in to help. Beth and I began charting the insanity of the previous hour and we all collectively sighed our "thank you Jesus" prayers.
Within a few minutes of starting the repair, Stephanie began to bleed very heavily again. That took us back into adrenaline mode. Orders were shouted to those in a position to help and many measures and maneuvers to stop the bleeding were done.
After a lot of investigation and repair, it turned out that poor Stephanie also had a cervical laceration. At this point, the bleeding was under control but we always want every woman to be given the treatment we would want. Because the cervical tear was of questionable severity it was decided that we should try to see if we could get a second opinion. We called the hospital and they said to come. Troy fired up the ambulance and we transported Stephanie to another hospital with OB doctors on staff. The hospital staff and OB doctor looked at it and agreed it was torn but said they felt that repairing it could potentially worsen the bleeding (which had since slowed considerably) and cause more damage. We took Stephanie back to Heartline and got her settled in for the night. Her bleeding continued to improve overnight.
|Nirva, Jenny and important nutrition while Momma is off in the ambulance|
|Twin B (left) 4lbs 13 ounces - Twin A 5lbs 13 ounces|
|the face you make when you see a miracle|
|the face you make when you are in love|
At this hour the baby-girl-twins and their Mama, Stephanie, are resting in the post-partum area. Help will be given for days, maybe weeks, as Stephanie is cared for, encouraged, and helped to breastfeed twins.
They have been joined in post-partum by Lonecia, who delivered her baby girl into Nirva's hands - sans drama - Saturday morning. That makes two births, three babies for 2014.
We were grateful that many had said they were praying for Stephanie's birth. It takes a team to do this work, and we consider you a part of that team. We know that statistically-speaking things as complicated as this don't always have such a happy ending. During the labor portion of this many hour event, I had turned to Stephanie's aunt and asked where her children were born. She said, "both at home", then she added "all normal". At the end of the birth the aunt's eyes were doubled in size and she knew she'd seen some not so normal things.
This experience may very well be a once in a life-time for all of us. We're aware we witnessed something unusual and miraculous.
How blessed are we to get to be there when God shows up?
Photos courtesy of: Jenny Duhm, Troy Livesay, Beth McHoul
LINKS TO OTHERS THAT WROTE ABOUT THIS:
Troy Livesay's Post
Beth Johnson's Post