Good things comes in threes 24.01.2020

This was how my Friday began today at 3am. I was called for a IG 0P at 38+4 who is 154 cm tall and had a baby with an estimated  weight at about 3100g. Not large for European standard but when the average weight of a baby at term here is 2500 g it puts it into perspective. The above partogram is what the midwives use to see the progress of delivery. In the image a line is crossed that suggested a stagnation in the birth process (not what I would consider stagnated but ladies here proceed very quickly so anything taking longer than 4 hours is suspicious) We started with Oxytocin to help along. By 6 am we had 9 cm dilation. The head presenting in anterior asynclitism or naegele obliquity. Using change of position, stopping of oxytocin and rotating the lady on the side the baby had a chance to turn into a more convenient position before restarting oxytocin. Success. Finally a hard delivery and then shoulder dystocia! Gaskin maneuver (patients are extremely mobile) and delivery. The lady did well, APGAR of baby was 7-8-9 born at 6:25. Bilateral labial sutures and second degree tear was my first suture teaching opportunity to my two midwives.

Baby boy Naël 3028g

To understand why a roughly 3 kg baby has a shoulder dystocia (in Germany we usually don't worry about this unless the baby is above 4,5 kg), here is a table of average sizes:

In the afternoon I had was doing routine ultrasound scans and came across a IIG IP at 37+4 weeks pregnancy in transverse position. I had just finished a discussion with Tanja about the topic of external cephalic maneuver. Here it is often done without tocolytics as it is rarely available. Instead the women have a full bladder and seem to have a very relaxed nature with low muscle tension. We discussed the risk of complications she has had and determined it was low, perhaps 1 in 100. As Murphy's law would have it, this was that one. The maneuver was not successful, heart rate during was fine but as we checked the fetal heart rate right after ending the procedure it was only at about 50 bpm. We initiated immediate steps and used our emergency spare of partusisten! After 4 minutes of bradycardia we had a heart rate back around 120 bpm. We kept the patient for observation and were planning further procedure when within the next hour she had a spontaneous rupture of membranes, so off to the operation room we went for my second c-section as baby was in transverse position. All went well, baby Sabrina was born at 17:35.

C- section number 2

Baby girl Sabrina 2428g

Oh and just before we started the cephalic maneuver we had a IIG IP come in near term and deliver in typical malagasy style-standing at 15:34 :) She walked home two hours later (normal).

Baby girl Mikalo 2959g

Summary: One shoulder dystocia, one born standing, one c-section because of a funny position. Team exhausted and happy. Moms and babies all well ❤️