Downward Facing Delivery!

Last weekend’s call started out normal enough. I rounded on the postpartum patients. We met in the resident lounge at 7:00am for sign out. I learned there was a patient in LDR 17 who was fully (dilated) and pushing. She was a multip (had had babies before) with a history of bipolar disorder, had been pushing for some time now, and had not been able to get an epidural. After 8 failed attempts, she was placed on IV pain medications instead. My senior resident asked me if I would go check on her and deliver her if she was close. “Of course!” I replied, with my I’m-almost-a-second-year-resident confidence.

As I approach the room, I hear the screaming. A couple steps later and I find the patient in a most unorthodox birthing position. She is on the bed, on her elbows and knees, face planted in the bed, bum in the air – a modified version of child’s pose for you yoga buffs out there. Upon seeing the confusion on my face, the labor nurse explains. “We’ve been pushing for over an hour, this is the only position she has made any progress in.” I take a quick second to assess the room and figure out what my next step is. The patient is writhing in pain, screaming for us to pull this baby out. The nurses look exhausted, both from trying to coach a very belligerent patient and from trying dozens of birthing positions. I make the decision to proceed as is.

As I don my sterile baby catching suit, a dozen thoughts run through my head, namely, HOW THE HELL AM I GOING TO DO THIS??? The woman is upside down compared to the usual lithotomy position (face up, legs in the air). She keeps dropping her bum to the bed - how is this baby going to have room to come out? Is she going to have a tear beyond all tears from this? And how do I figure this out without letting the room know that I have NEVER delivered a baby in this position? Another huge question is on my mind: what in the world am I going to do if I have a shoulder dystocia*? Remembering that my panic will cause the room to panic, I take a deep breath and remain calm. On the outside, that is.

At this moment, my (favorite) senior resident walks in. I explain the situation. She says to me, “Okay, you can do this. It’s the same maneuvers, just upside down.” She says this so confidently that it makes me believe that I really can do this. Then, as if she is reading my mind, she announces to the room, “Everyone, if we have a shoulder, we will quickly flip the patient on her back, okay?” There, she said it. I breathe a sigh of relief.

I don’t know if I could post a blog long enough to describe the insanity that came next. It really was like delivering a baby upside down. The patient was in pain, not following directions very well. One minute her bum would be in the air and I would have plenty of room to catch the kid. The next minute, her bottom was down on the bed. It was like trying to deliver a baby through a drawbridge that kept opening and closing. My coaching tone changed from my usual soothing voice to my loud command voice.

Finally, after an entire team effort, she delivered the baby. There was no shoulder dystocia. Baby was a little floppy from all the IV drugs, but otherwise fine. Mom was fine. The whole room breathed a sigh of relief. Me, most of all. This was just another moment in residency when I walked away after doing something I didn’t know I could do. I left smiling inside.

* A shoulder dystocia is when the infant’s head delivers, but the shoulder is stuck. It is a dangerous situation and can lead to asphyxiation or nerve plexus injuries of the baby. We have a toolbox of maneuvers to deal with this, but they all revolve around mom being on her BACK!