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Denise Punger MD FAAFP IBCLC
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By Lori Nelson LM

Labor had been going very well. Blood pressures were normal and fetal heart tones were good through uterine contractions without decelerations. We were all relaxed and confident. At Denises request, I had not done any vaginal exams but the emotional and physical signposts were unmistakable. Denise arched her back and moaned with a deep guttural sound. At the peak of the contraction was a subtle catch in her voice, she was almost ready to push. I put on my gloves and waited. The next contraction swelled and with it came the moment we had been waiting for all day long: stage two, pushing. The baby was almost here. We were all encircled at the foot of the bed, excitedly watching her perineum, waiting for the door to open like family and friends waiting in the darkness at a surprise party only we were the ones to be surprised.

"Somethings coming out," Denise moaned, as she tilted her pelvis forward. I dipped my fingers in the oil, ready to perform the familiar perineal massage, that eased the babys head out without tears, but as the door opened I did not see the dark curly hair that we all anticipated. What came instead were two purple feet with ten perfect little toes. My eyes opened wide as adrenaline surged through my system. I did not speak immediately intending to keep the family calm, but William, Denises watchful six-year old son cried out "Its toes!" About a hundred things ran through my mind at once. How could this have been missed? I had my hands on her belly all that day. Well this makes sense now; heart tones had been difficult to get throughout the day. I had thought, "How could this baby still be shifting from one side of the uterus to the other so frequently?" I immediately assessed the situation and mentally ran through her history: the size of her other babies, how long had she pushed, previous complications (especially shoulder dystocia). I knew that her last baby, a nine pound baby came quickly. She had a good history.

I delivered plenty of breeches, but I knew ahead of time if the baby was Complete or Frank. After all, I had access to technology. Ultrasounds were a must, if I was unsure of a babys position. As homebirth midwives, we always had to be ready for the unexpected. I had said that very day to Denise and her doulas that I would not deliver a planned footling breech. Just too many risks both medically and politically. I guess God had other plans and traveled me 600 miles to learn another humbling lesson. Thank God, I had two wonderful and experienced doulas at my side.

With the tiny feets emergence, I took a breath, centered my mind and heart and prayed. My hands knew the way. I could feel the tension behind me. I attempted to set this two-physician family at ease. "Look," I exclaimed, as I waited for another contraction, "The baby is ticklish!" I ran my finger down his foot. He wiggled his little toes. William standing at my side, with his camera in hand grinned and touched the babys foot and then took a picture of the tiny purple feet.

I knew all of the risks at hand, but management of this footling went perfectly. I went into autopilot. There was no prolapse of the cord (one of the fatal complications of a footling breech); fetal heart tones were perfect in the 150's. Next, the baby came to the knees and then the thighs. I could finally reach inside and feel the cervix. It had to be fully dilated to continue. I felt around the top, and then the back. The cervix was out of the way. With the next contraction, the baby delivered to the chest and I eased the cord down. The arms were up over the babys head. I rotated the baby, first to the right and then to the left, as I brought one arm and then the other across the chest and over the perineum. Only the head was still inside and it was deflexed and the mouth out-of-reach. I had to move quickly. The two doulas brought Denise closer to the edge of the bed. Supportively, I dangled the baby down and the occiput came under the pubic bone. I then put my finger in Davids mouth to flex the head and then lifted. His face delivered over the intact perineum. David was limp, but I knew this was common with breeches. I quickly brought his tiny mouth to mine, and filled his lungs with three puffs of my air. I felt him tense in my hands. I looked down, he sputtered arched his back, let out a welcome cry and up to mommys tummy he went. Everyone responded with the typical oohs, ahhs, applause, and tears of any birth I had attended. I breathed a sigh of relief and a prayer of thanks. "Welcome sweetie, that was quite a performance," I cooed as I witnessed the naked little boy blush pink.

I remember when my mother, her sisters, and my grandmothers used to talk about breech births. Three of my aunts had had them, and three out of my grandmothers eight children, were breech. They were considered normal then; just a variation of normal. As the days have passed, I am awed at Davids journey. I will hang, in my office, the picture of the tiny purple feet standing outside of his warm wet world like a trophy. I am honored that God would bring me 600 miles to 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 a womans perineum, instead of the anticipated dark curly hair.

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Surprise Footling Breech in The Hospital

 
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Denise Punger MD FAAFP IBCLC
4640 S. 25th Street
Ft. Pierce, Florida, 34981
772-466-8884
Copyright 2005