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"Its Toes!"

by Denise Punger, MD, FAAFP, IBCLC

My midwife recognized my facial expression. "Shes ready to push," she told my doulas. I felt confused as I did have the urge to push, but never recognized going through transition. All of a sudden I had a strange sensation in my vagina. "Somethings coming out," I announced, thinking it was a huge clot, but certain that it was not a head crowning. My midwife and doulas repositioned me to look, and my six-year-old son, William, exclaimed, "Its toes!"

Toes? How could that be? So many sets of hands had been on my abdomen: several midwives, physician friends and doulas. The baby was vertex. There was no doubt. When did this baby flip? Then I recalled stumbling in my bathroom about a week before and being stunned and sore. Could that have turned my baby?

As I thought of different scenarios, I saw my life flash before me. Had this last minute discovery of a double footling breech occurred in a hospital, I would have had an anesthesia mask slapped on my face and been whisked to surgery to have my abdomen and uterus barbarically cut opened. Or had I let my quick labor progress at home unassisted without an experienced midwife present, I might have lost my life, my sons life or both. A double footling breech required skillful maneuvering (posterior rotation and flexion at the neck) to prevent the chin from getting stuck in the pubic ring. This is not something that can be done alone. I sensed the confidence of my midwife to handle the situation. I also noticed she was able to keep my husband, John the doctor, calm. Both of these things gave me the strength I needed. I was determined to push my baby out on the next contraction. I thought I only had a few minutes to give a grand-finale type push with all my might before my baby would be compromised. On the next two successive contractions, I wailed without holding anything back and pushed with every bit of energy I could muster. What a relief it was to feel my babys body slip out and to hear him cry.

It boggles my mind to think how fortunate I was to have had the birth team I did. Lori Nelson, LM, and doulas Dawn and Regena traveled 600 miles to be with me. My husband had taken employment out of state, so we were living far away from "home" during my pregnancy. I kept in contact with my birth friends through e-mail. Early in my pregnancy a few had expressed interest in being present at my birth. I thought, "Right! How is it ever going to work out that you come 600 miles to catch my birth?" As my pregnancy progressed, the doulas still insisted they were coming. I was gaining confidence that I would have at least one of them present to work along side the local midwife on my birth team. It was still hard to imagine, but I figured it would all work out in the end. Then something unexpected happened. I received an e-mail from Dawn stating that Lori wanted to caravan with her to be at my birth. I thought, "I must be dreaming; this is too good to be true." I could have two midwifery teams at my birth! What an incredible time of bonding and camaraderie it would be. I had one last trip back home planned. I met with Lori and my doulas during the visit and sealed the plans for their journey to my new home. They made me feel as if my pregnancy and birth were the most important thing in the worlda feeling all women should experience when pregnant.

As the time neared for my highly coveted birth team to arrive, it began to seem unnecessary to have two teams at the birth. I could just have those I felt most comfortable with around me during labor. What a freeing thought! If I could only hang on until Lori and the others came.

They arrived on September 11th, a week before my due date. What a reliefa midwife and two doulas in my house! We stayed up way too late talking about my pregnancy, my birth plans, my five-and six-year-old sons level of participation, my husbands role and anything related. There was so much to talk about. All this talk got my hormones going. I knew it wouldnt be long.

The next morning Lori noticed that I had the waddle and complexion of someone in prelabor. I didnt even tell her the Braxton Hicks contractions were getting regular! She assessed the heart tones and we went about our day. As the contractions were still regular, we made a belly cast. Lori showed my sons, William and Scott, all of her midwife equipment as she set up and demonstrated on stuffed animals. They thought Lori was the coolest. In fact, I think her attention solidified the two older brothers bond with their baby brother. All the while, we women still discussed birth, babies and breastfeeding. Interestingly, Lori told us several scenarios she hoped never to deliver. A footling breech was one of them.

Throughout the day my doulas questioned if I was even in labor, I seemed so calm and able to laugh at our jokes or what my sons were doing. After the cast was done, the contractions became more convincing. I sat on a birth ball as Dawn massaged my back. After I changed positions to the rocking chair Lori massaged my feet and calves, emphasizing the uterine pressure points. My husband came home from work finally and he questioned if the labor was real. We were all too peaceful. "We do not need a doctor to diagnose labor," Lori told him jokingly. "The signs are unmistakable." (Thus, I declined vaginal exams.)

After the foot massage, I tried lying in bed just to get some rest. At a certain point, I did what seemed natural and sat on the side of the bed with my feet propped on a stool with the doulas on either side of me, providing comforting touch. This intuitive position turned out to be critical, as Lori would need me on my back with my bottom at the edge of the bed to safely deliver my son. I kept listening for signs that my body was reaching transition. (I see now that I wasnt going to experience this phase.) I visualized the babys head coming down, my cervix opening and the kind of sensations I would have in my perineum. I didnt have that familiar feeling from my previous pregnancies. I felt like reaching down to see if I could feel the babys head, but I didnt do it. I also wanted to ask if my team if they saw a head, but thought it would be discouraging if they said no. Instead, I kept visualizing the head crowning. Thats when we discovered David was a footling breech.

Lori remained in total control as she adjusted her plan and safely delivered my son. She observed his black and blue legs. Not sure if it was cyanosis (discoloration of the skin caused by deficient blood oxygenation), she immediately gave him three puffs of mouth-to-mouth resuscitation as a precaution. He pinked and Lori placed him on my chest. The first things I looked for were his ears and spine to eliminate any concern over Down syndrome and spina bifida. I had had an abnormal triple screen earlier in my pregnancy. I opted not to have an ultrasound or alpha fetal protein, knowing I wanted this baby no matter what. Seeing he was healthy, I felt major relief, and I am not sure I had yet processed how close to death this little one had been. I assume few midwives or physicians could skillfully deliver a footling breech without complications: cord compression or prolapse, broken arm, palsy, still born. All we had were two bruised legs and a cephalohematoma (a blood-filled tumor or swelling beneath the scalp, generally caused by birth trauma). I did discover an unexpected advantage of breech birth: we saw two curious, wide-open, brown eyes greet us. Davids eyes werent swollen shut like my other babies, and he was just as curious to meet us as we were to meet him.

Lori thoughtfully delayed examining my perineum, while we celebrated. Years ago, in my residency training, we examined the cervix and perineum right away. The thinking was: "While the mothers are admiring their babies, they wont notice the cervix exam as much." What a way to foster bonding and initiate nursing! Having now experienced three vaginal deliveries, I can say the exam was almost the worst part of giving birth. John got to cut the cord. Lori weighed David. (He weighed nine pounds even, exactly what William and Scott had both weighed.) After all this, Lori checked my perineum. It was intact. No stitches required.

My older boys were totally engrossed in the miracle of birth, which I also attribute to my birth team. In fact, William took my favorite photograph of my labor: Davids feet emerging from me. All the other cameras missed this shot. His four-foot stature gave him the perfect view. At only six years old, he had the common sense to capture this once-in-a-lifetime photo opportunity. I cant picture any other birth practitioner letting a young boy be so involved as Lori did. Both older brothers couldnt wait to hold David. William especially treated him like he was his own baby; what a joy to me as a mother. What an experience to have my family and friends in my own home to share this special birth and bonding time. This birth would never have occurred if any of the circumstances were even slightly different. I credit the success of my unplanned double footling breech delivery to my birth team. They were not only confident, but also able to read body language (mine and each others) with minimal verbal exchange. I was so lucky to have had three birth practitioners in my home for so long to focus on me. It was amazing that their schedules all worked out, their other clients delivered early and their families allowed them to come. They stayed with me for three days after the birth. I had never heard of a midwife willing to travel so far and sleep in a childs top bunk, not even knowing when labor might occur. These five days were like a modern day "red tent," a place where women celebrate the cycles of life while sharing secrets and friendship.* I doubt that I could have labored so uninhibitedly if the spiritual connection had not been present among all of us.

Lori has since said that the birth was quite an experience for her as a midwife. "As the days have passed, I am awed at Davids journey. I will hang in my office, like a trophy, the picture of his tiny purple feet standing outside of his warm wet world," she said. "I am honored that God would gift me with this awesome experience. But, I am also saddened that so few practitioners will ever stand at the foot of a womans bed and watch with surprise as two tiny feet emerge over the perineum."

I am proud to have delivered my double footling breech baby in the safety of my own bed on September 12, 2003 around 11:10 p.m., and I am entitled to all the bragging rights that go with it. May my son David go through life always landing on his feet first.

*See Anita Diamants book, The Red Tent.

Denise Punger, MD, FAAFP, IBCLC, and her husband, John Coquelet, consider Florida to be home. Denise is taking a leave from her practice to nurture their three boys. She is medical editor for Mother to Mother, a quarterly newsletter for expectant and new parents published by Gentle Spirit Doulas, Inc. For comments or subscription information, e-mail or visit her Web site at






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Denise Punger MD FAAFP IBCLC
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Copyright 2005