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Entries in face presentation (1)

Friday
Dec072007

Face Presentation Birth

My 3rd time client went into labor at 7am yesterday and was quickly complete and pushing by 10am. Her last baby was 10 pounds 6 ounces and she pushed for a little over an hour.

I didn't do a vaginal exam on her until she felt there was no forward movement for about an hour. I'd done an exam, at her request, a week earlier and she was 5cm; not unusual for her since she started labor at 7cm last time.

This labor was easy for her (her words) because she had great breaks inbetween contractions, talked happily, laughed and really had a great time.

Until pushing wasn't bringing her her baby.

When I felt the baby's head, I felt a hand (what I thought was a hand) towards my left (her right) side, about 10:00 (if we are looking at a clock face).

She pushed mightily and she kept saying nothing was happening. Not in a discouraging way, like she was tired of pushing, but in a "something is wrong" sort of way.

I helped her push while putting pressure in her vagina, then I left her vagina alone for awhile and then went and felt where that hand might be again. Right at 2 hours of pushing, I felt again and was unhappily surprised by a bevy of ridged prominences... it felt bumpy, ridged - but not like when the skull crosses over itself and the scalp feels all bumpy. This felt different because the ridges were raised and I thought, "What IS this?" I gently explored and the ridged area was on my left; the head, on the right... split almost from midnight and 6. It didn't take but a few moments before I realized it was probably the face I was feeling.

Because she'd been pushing for 2 hours with virtually no forward movement (the baby was still at a +1... +2 while pushing), I quickly decided we needed to move to the hospital. We were out of the house in less than 10 minutes. Not frantic, but mom was in so much pain by this time - and women tend to be in a LOT of physical pain when the decision to move to the hospital is made - the car ride was excruciating for her even though the hospital is only 6-7 minutes from their house.

Blessedly, she'd seen Dr. Wonderful during her pregnancy and when I called his office, he was already at the hospital doing a cesarean. I called the hospital to give them a head's up, too.

When we got there, mom had a huge contraction in the lobby and when we got through the armed doors of the maternity ward, we were led into... the storage room?

Apparently, the hospital was full. Had my mom been earlier in labor, they would have sent her to the horrid hospital from last year. I would have taken her to a different hospital 40 miles away before I would have gone to the overflow hospital.

Despite being ushered into a room that had been set up for a meeting earlier in the day, a nurse shoving a bed into the space, other nurses hauling a computer, an isolette and supplies in, mom was thrilled we were in the hospital and immediately began asking for pain medication. Later, she said she didn't even know those words existed in her vocabulary, but all she could think of was getting out of pain. I told her I totally understood what she needed and we would get her help as soon as Dr. Wonderful came in to assess what was going on.

On the ride over, I told my apprentice I was worried if I was wrong about feeling the face... would this mom be mad at me? Knowing them through three pregnancies and two births, I was reassured they would never be angry in that I-Hate-You sort of way. They would be very disappointed, but anger wouldn't be their reaction. While I would rather the doctor not have found a face and I would have been wrong, I also hoped he would find the face and I would be correct in my assessment.

Dr. Wonderful came flowing in and lovingly spoke to mom before doing a vaginal exam and, indeed, finding the baby's face. He also diagnosed that the mentum (chin) was in the posterior position... by mom's sacrum (towards her butt, not her belly button). Most doctors would have brought her in for a cesarean right then.

Instead, Dr. Wonderful ordered a hefty epidural, which mom got pretty quickly after the doctor went in search for (the) anesthesia (doc). Dr. Wonderful held my client as she got the epidural, speaking softly in her ears, helping her through contractions, holding her warmly and lovingly. I didn't have my camera then (had to have it brought to me); but know that the image was tender and touching. The anesthesiologist dosed the epidural slowly to make sure her blood pressure didn't go down quickly - the baby's heart rate was going down with contractions and he didn't want anything more to happen - but she was completely out of pain by the time we got in a room, about 30 minutes after going into the hospital.

A couple of other vaginal exams over the next two hours showed that the baby was still in the mentum posterior position. Dr. Wonderful brought in pictures so mom could see what position the baby was in and explained that he wanted the epidural to allow the baby less pressure to find his own way to a mentum anterior position. He explained that babies cannot be born vaginally in the position the baby was in now, so we all set to visualizing the baby rotating to the position he needed to be in for a safe, vaginal birth.

About 90 minutes into this epidural'd second stage, the baby's heart rate started going funky. While he'd previously had head compression during contractions - his heart rate going down with the contraction - now, his heart rate was going down after the contraction - late decel(eration)s.

By the two hour point, Dr. Wonderful was concerned about the baby and the last vaginal exam found the baby still in the mentum posterior position, the decision was made to do a cesarean.

During the time in the hospital, we'd talked with each other about how things were unfolding and mom cried off and on about her lost homebirth. After two wonderful homebirths, it was very painful for her to be in the hospital, walking towards a cesarean. When she found herself at the operating room doors (figuritively), she broke down completely. We sat holding her, letting her feel the utter disappointment and sadness at now needing a cesarean. She looked at me and asked, "Did I do everything I could to have him vaginally?" And I told her, "Absolutely." She shook off the sadness and said, "I'm ready."

After the usual preparation, she was wheeled off into the OR - I was not allowed to go in to photograph the birth because of a nasty nurse who didn't like me at all, so my apprentice and I waited in the room for them.

This being a Baby-Friendly Hospital - one of two in San Diego - dad came in with the baby and mom followed quickly behind. She was groggy, but doing well.

Dad, when he was done showing us his precious son, began crying and telling us that the baby came out not breathing and that they had to do chest compressions on him. He also told us that whomever was working the ambu-bag couldn't get it to function correctly and they tweaked with it for far too long before someone walked over and turned the oxygen on. He said the ambu-bag didn't inflate properly until the knob was turned and then his baby began to cough and breathe. I can't imagine how horrible it must have been to watch and wait for them to get it together before his son was able to breathe. Later, the nasty, territorial nurse defended the operating room experience, saying how resuscitation can be done with room air, that someone had checked the ambu bag twice and she didn't know who it was that came and turned on the oxygen, but it wasn't Dr. Wonderful. We were told later there was a lava flow of meconium at the birth, so the baby also had to be suctioned several times to get the mec out of his mouth. I will mention to mom and dad today that it was a wonderful thing their son came out not breathing so he didn't have any chance to inhale meconium.

Below, I have two pictures of this beautiful new baby. He went through a lot, didn't he? See his right black eye? The abrasions on his cheeks are from his slide through the pelvis as he went from occiput to mentum presentation. The poor dear! And look at his fat lip! His upper lip is about 5 times the normal size.

In this second picture, you can get a sense of the elongation that occurs with face presentations.

 

I found some really good sites for my apprentices to learn and try and "see" what a face presentation looks like from the inside. One of the best I found was here. Another good site can be found here.

This sweet baby boy weighed in at 9 pounds 2 ounces - a full pound and 4 ounces less than his brother that came before him. Mom's vegetarian diet was meticulous this time; I'm so proud of her! I told her it was her diet that sustained this baby so beautifully during his stress.

I left after a couple hours postpartum, after getting the baby to nurse terrifically, after annoying the nurse tremendously because the parents didn't want Erythromycin, pokes to check the baby's blood sugar or a bath and I verbally supported them in their decisions. She was amazingly manipulative, but my clients were wonderful in their convictions; the nurse took out her snottiness on me. The family did decide Vitamin K was important (I agree!) considering the amount of bruising he already had. When I left, the bruising had grown to much of the face.

I'll be back to see them in a couple of hours... I talked to them twice last night, but haven't heard anything from them during the night. I look forward to taking more pictures and will share the here again later.

sigh

 

I am certainly sad about the cesarean, but am infinitely grateful it was there to -really- save this baby's life. He was suffering in there and was going so quickly downhill, mom got a shot of terbutaline to stop the contractions so the baby could "breathe" before the cesarean. It was apparent that the birth happened at exactly the moment it was meant to.

As mom was being wheeled out of the room, Dr. Wonderful said, "We're going to have a birth... not just surgery." I loved him so much for saying that.

What a day.