Hand presentation…or is it? (Compound hand-breech presentation)


By Kristine Lauria, CPM, of Médecins Sans Frontières. Kristine is currently working in a refugee camp in South Sudan, serving a population of around 100,000 people. Her clinic takes in all of the complex and/or complicated maternity cases: preterm, breech, multiples, high-risk pregnancies, etc. There is one general surgeon on call to do cesarean sections, otherwise Kristine and the other staff manage all of the births. She blogs at Midwife Without Boundaries: midwifewithoutboundaries.wordpress.com. 

I ended 2021 on a high note in terms of birth experiences. This story is awesome and hilarious all at once. Just when I think I won't run into a scenario I haven't already experienced, I do!

The COVID situation here has exploded just like in the rest of the world with the omicron variant rampantly taking over and taking down staff members left and right, expat and national staff alike. How long we will be able to run a hospital with an ever-shrinking staff, only time will tell. As of now, even the surgeon and anesthesiologist are isolated. Expat midwife: so far, so good.

COVID has also not bypassed the maternity ward, and 3 patients were identified on the same day and sent to the COVID isolation unit. One was preterm, 32 weeks with premature rupture of membranes and no labor; one was 37 weeks with severe anemia that had been transfused twice; and one was post-op (placenta previa), and although she had been discharged, her baby was preterm so she was still inpatient due to his status.

Birth tukul
Birth tukul

A round tukul in COVID isolation was transformed into a maternity area where patients could birth and stay postpartum. In a matter of hours, the team responsible for completing such tasks had gotten the floor completely covered with tarp (for easy clean-up of biohazard), had a sink with cold running water installed, lighting and 2 beds. This was just in time because the patient who had the PPROM had started labor. I knew she would not labor long so I was just biding my time. I also had to go into OT to do a procedure with a patient and I knew by the time I got out, the tukul would be ready and so would the patient. Sure enough, just in time everything had been set up and when I went back to COVID isolation, I found my patient quietly laboring in the tukul. All I needed to do what set up my portion of the supplies and we were good to go.

Once I set everything up, there was not much else to do but sit and wait, and sweat. It is about 100° any given day. In full PPE, it feels like 120°. I could not disrobe and wait elsewhere because there was no one else to monitor the patient and once I disrobed, I had to throw everything away. The waste couldn't be justified. I was completely drenched in sweat within 15 minutes.

I sat quietly next to the mother. It was her 5th birth so I did not check her cervix or do anything unnecessary. She had already had ruptured membranes for over 24 hours and was getting antibiotics for that. Even without language skills, I knew I would be able to communicate with her and certainly I would know when her labor was progressing. I did listen to the baby a few times. She had time to get in 2 rounds of dexamethasone which would help the baby's lung maturity since it was only about 32 weeks. I was expecting the baby to be small but fine.

Birth supplies
Birth supplies

I knew from previously palpating her abdomen that the baby had been in a breech position. I could see the head was still at the fundus and I knew she would not push long once she started pushing because the baby was small, it wasn't her first and it was breech. Again, I wasn't expecting any issues.

I usually encourage breech mothers to be upright for birth as it is optimal and the baby can maneuver the pelvis more easily. But this mother was sick with COVID and in no condition to be anything but horizontal. Thankfully she was not on oxygen, she was just feeling very unwell. The baby was small and likely would not require any maneuvers and if it did, I could do them supine.

Some time passed and I could tell the baby was moving down by the sounds the mother was making. I said nothing and did nothing. She was doing what she needed to do and once she started to open her legs and bear down slightly, I knew it was getting close. It was not long before I could see something small emerging - toes...no, a hand! My reaction internally was one of, how could this be? I KNEW the baby was breech. When did it flip? It didn't look transverse. A cascade of things went through my mind and at the same time, I was saying to the mother, "no, no, no, just let me reposition this!" Of course that did not go over well because she couldn't understand me AND she had an overwhelming urge to push! So just as quickly as I replaced the hand and tried to reposition it and figure out what was going on, she was bearing down against me and the hand emerged and...a shoulder? head? what?

My brain was rapidly trying to catch up with what I was seeing and feeling. The cognitive dissonance this created was overwhelming for just a few seconds and then everything fell into place. After a big push the entire hand came out again a little further up the arm along with another presenting part, which I then saw had a little dab of meconium. It was a butt. As she emerged, I realized what was going on. She had her arm behind her back, palm up, over one butt cheek, something I had never seen in all my years attending births -- a compound presentation of a complete breech with a hand! The baby continued to slip out easily right up to the neck and the little head popped out and I placed her on her mother. She cried immediately. WOW!

I sat there stunned and elated. I could believe what I had just witnessed. I would never even have thought to conjure up this combination in my wildest dreams. All was well. The placenta came out; I got everyone cleaned up, did all the documentation, and weighed the baby -- 1.76kg, not too bad!

I gratefully took off my PPE, left the isolation unit, and headed for maternity. There I was met by a mother who had just arrived pushing. Within minutes a little boy was born face-first into the world. These would be the last births I attended in 2021.