A Breech Birth in the Rohingya Refugee Camp
By Kristine Lauria, CPM of Médecins Sans Frontières
The language of birth is universal. I have had the privilege of working with birthing women all over the world. A good majority of the time I cannot communicate verbally with the women giving birth because their language is not one I speak. At times it can be challenging and even frustrating but it has helped me tune in and listen to the language of birth, which can be very nuanced at times but if you listen closely it is easily understood.
This past week, I was working in the Rohingya refugee camp in Bangladesh; this is my current mission with Médecins Sans Frontières (Doctors Without Borders). We have a maternity service that serves about 50,000 of the 900,000 refugees in the camp. We see over 1800 patients a month and attend approximately 70 to 100 births depending on the month. The refugees speak Rohingya dialect and the midwives speak Bangla. I speak neither.
Breech birth is commonplace here, as it is in most of the developing world. There are no discussions of ECV or cesarean section; it is just a variation of normal that sometimes happens and is nothing to be feared, either by the birthing women or the midwives. That being said, stillbirth and neonatal death are also, sadly, commonplace in this setting. These women are among the highest risk pregnant populations in the world. Malnutrition, anemia, hypertension, high parity, and poor living conditions among other things, all contribute to the morbidity and mortality. Every woman that walks through the maternity door is high risk. A breech presenting baby is not really given a second thought.
Last week a young woman came to the maternity in active labor accompanied by a traditional birth attendant (TBA). This is the norm. The TBA's are also from the Rohingya population and they worked as TBA's in Myanmar before they fled the country in 2017. Here they are volunteers as they are not legally allowed to work. They are our link to the pregnant women in their communities in the camp; we rely on them to get women safely to the maternity.
I could see by the way this woman was walking that she was in active labor although her face betrayed nothing. With a series of hand gestures, I ushered them into the birthing room so I could do an assessment. Fortunately, the TBA knew the drill. We are seriously under staffed with several midwives out due to COVID. Where there would usually be 5 or 6 midwives, there was 1, and me. This particular midwife had very limited English and I hadn't been assigned an interpreter yet, so that day we communicate by me repeating things several ways until she understood what I wanted to know. Along with a lot of pointing and pantomime, eventually I would get my point across.
The TBA asked the woman to get on to the table so I could do an assessment. I was going to check for dilation first because she seemed quite actively in labor but she was very stoic. As she raised her skirt to prepare for the exam, I saw a little foot peeking out. I immediately asked her to get off the table. This was difficult because neither she nor the TBA knew what I wanted her to do. Finally they understood, although they were confused. Fortunately, the midwife who was working with me had seen some of the vertical breech videos I showed the staff just the week prior. She was intrigued. So she knew what my plan was and helped me prepare the mother for an upright birth. She explained all the different positions the mother could choose to be in and told her just to do what she wanted. The woman nodded.
I was able to learn this was her first baby. She was 18 years old. She had no health issues. A quick assessment of fetal heart tones was reassuring. Then she had a contraction. She found standing was her position of choice and she held on to the baby resuscitation table in front of her. The second push revealed more of the foot up to the ankle and I could see a butt cheek. This was a complete breech presentation and what I call compound complete because two different parts presented together. The only way I knew she was having a contraction was when the baby started to descend. She was very quiet although the pushing efforts were great. I could not see her face as I was behind her.
There was a TBA besides her giving her gentle encouragement but I have no idea what she was saying. The baby was emerging LST (left sacrum transverse) which is completely normal. After a big push, the entire leg came out and the baby was birthed to the hips. Now the baby was doing the splits and had started to rotate to the anterior, which is what we want. After another contraction the other leg came down and the baby was down to just past the umbilicus and had completely rotated to anterior, the perfect position. The cord was visible and looked good.
Each time a contraction began, the baby did a tummy crunch. This was my indication there was a contraction since I could not tell from the mother. The baby was in great condition with excellent tone and color. I was pleased and unconcerned. At this point, everything was textbook. I was able to point out to the midwife how the baby was helping itself be born by doing the tummy crunches; she was just amazed. It was so much better than a video! Between contractions the baby seemed to rest, being half out now. By this time, a few other TBA's had gathered in the room behind me. Word had gotten out of my antics and they wanted to see.
By this time, 20 minutes had passed from when she first arrived. The baby did another tummy crunch and I knew there was a contraction. Even if I could have spoken her language, she did not need any direction at all. She completely gave herself over to what her body was doing. She needed no words. As she pushed, I could see chest cleavage, a very good sign, and then one arm came down and then the other. At this time, the TBA was doing a butt lift on the mother, although it was not needed. I didn't know how to tell her to stop. I did ask her to but of course she had no idea what I was saying.
The baby was now born to the head and still had great tone. The perineum was 'hollow,' which indicated to me the head was not flexed. I waited for a contraction and it remained like this. I was not concerned. I knew the head was not trapped; it was just not flexed and this could be easily remedied. On the next contraction I did a shoulder press. Nothing. But as I pressed, I could also feel the baby's heartbeat; it was a good rate and this was reassuring. I moved next to the rock and roll technique, which was also not getting the job done. Keep in mind, I also could not communicate with the mother to ask her to push and I had no idea what anyone else was saying to her. The baby could no longer really help because the entire body was out. Still, there was time and I was not worried because we still had good color, tone and heart rate. I wanted it to stay that way.
The next maneuver I did was modified MSV (Mauriceau-Smellie-Veit). The baby's neck was completely exposed so I knew the head would come with a little help with flexion. This maneuver consists of sliding my fingers up the baby's back to the nape of the neck and with my middle finger (the longest) I apply pressure, which helps flex the head forward. Simultaneously with my other hand, I slide my pointer finger under the perineum to the baby's chin and up to the mouth. I put my finger in the mouth. Usually when the baby is in good condition, it actually starts to suck on my finger. This baby clamped down and started sucking! As I applied pressure on the nape of the neck, I gently applied pressure down in the baby's mouth, slowly flexing the head. There is no pulling involved in this and it is done in a gentle fashion. I only needed to flex the head; it was not stuck.
As soon as the baby's chin and mouth were present from under the perineum, I slid my finger out and applied a gentle shoulder press and the head released. The baby cried vigorously as I passed him through his mother's legs to her arms. He pinked up quickly, his heart rate and muscle tone were great and all of this earned him an Apgar of 10 at 1 minute.
In all, it was 25 minutes from the time the mother walked into the maternity to when the baby was out. The placenta came just as easily. The perineum was intact. Everyone was healthy. The baby weighed 2.73kg, which is about average weight for babies here. In retrospect, I think the baby's head would have been flexed if the TBA had not done a butt lift at the time the baby's shoulders were emerging. This is only a guess on my part. But in my experience, when everything has been textbook; the head is usually flexed and comes out without maneuvers. This speaks volumes to keeping your hands off unless there is a true indication. I touched nothing through the entire process until I went to flex the head. Of course we will never know for sure if that little bit of good intention from the TBA interfered with the process, but I will not allow it to happen again.
After the birth when the mother and baby were resting in postpartum, with the midwife interpreting, I told her what a great job she did and had the midwife explain that babies don't usually come out like that and she should be proud of herself. She allowed me to take a photograph of her with her son. Her family said they hoped Allah would bless me. I have attended a lot of breech births in my midwifery career, but I will always remember this breech in the Rohingya camp with this beautiful first time mother.
Originally posted at Midwife Without Boundaries and reposted with permission.