Double The Fun

I received a call from Mercyline, one of the clinical officers, this morning while I was still at home.

-       “Are you coming to the hospital this morning? We have a woman in labor and we need your help with the ultrasound to tell the fetal lie”.

The delivery room

The woman had come in last night after breaking her bag of water, and was having frequent contractions now. But after palpating the maternal abdomen, they couldn’t tell if the head was down in mom’s pelvis, ready to be born “the normal way”, or if the baby was breech, and planning to meet the world bottom first. I was told that the mother’s cervix was 6 cm dilated. Typically a woman begins her contractions with her cervix closed, or at one or two centimeters of dilation. And then with the strong, repeated contractions of her uterus muscles, along with a cascade of hormones surging through her blood stream, the cervix slowly dilates to a maximum of 10 centimeters. Then it’s show time. The door is open for the baby to be pushed out.

Our portable US machine

When I got to the hospital and walked into the labor room that is about the size of a walk-in closet, I found out more details. She was apparently in preterm labor, since by measuring from her last menstrual period, she was only about 34 weeks pregnant. She had ruptured her bag of water 12 hours ago, and she had been in labor for at least the last 8 hours. Her initial cervical exam showed 2 centimeters of dilation, and her cervical dilation hadn’t been re-checked since midnight.  Chance for infection, including passing HIV to the newborn, increases with time. The clock was ticking, and we seemed to be behind the eight ball. We had to ask the laboring mom to get up and walk to another room once we found an outlet to plug in the ultrasound. One look with the naked eye at mom’s abdomen showed that something inside was probably not right. She had a big lump high up, near her rib cage, and when I put my hands low on her belly to feel for the hard, round, fetal head, I couldn’t feel anything for sure. I gave the ultrasound probe to Patrick, one of the clinical officers that specializes in HIV/TB care, and told him we’d find the head together. On ultrasound, liquid is black in color on the monitor, and harder substances, like bone, show up bright white.  He started high, over the big lump, and a bright white ring filled the screen. Yep, the baby was sitting down in the uterus, and was planning on greeting the world in reverse.  Now the mother had already delivered a few children previously, so she could probably deliver another baby pretty safely, even a baby in breach presentation. But a premature infant tends to have a relatively larger head than body, and this can pose a problem. Sometimes, the body can deliver past a cervix, and then the large head can get stuck at the cervix, leaving 2/3^rds of a baby delivered. If the umbilical cord, which is now outside mom’s body, gets pressed between the baby’s hard head and the edge of the cervix, life sustaining blood and oxygen from mom is cut off and the baby is in a lot of trouble.

I took over with the ultrasound to get a quick lay of the land. Not much fluid left in the uterus, consistent with mom’s story of a broken bag of water.  A good, strong fetal heart beat at 140 beats per minute. But yet something wasn’t right. As I followed the head down, instead of seeing the chest and heart, I kept seeing an abdomen first, then the chest. Now, I might not have aced anatomy lab in med school, but I’m pretty sure the chest should come south of the head and north of the belly. Sure enough, following the line of the baby’s body further down, we came upon a bright white ring, low in mom’s abdomen and pelvis. Another bright white ring. 

Mom was having twins.

And she didn’t have much time to digest this bit of news.  The nurse checked her cervix, and it was now fully dilated. Bingo. Time to have a baby. But at this tiny hospital, they don’t deliver twins. They’re not set up to do cesarean sections, they don’t have any consistent fetal monitoring (the baby’s heart rate was last checked 11 hours before I arrived), there is no oxygen in the delivery room, etc. The first twin was head down, or vertex, so should be able to be delivered easily. But the second twin was lying 90 degrees the wrong way, with the head towards mom’s left side and the feet toward mom’s right side. She needed to be delivered in an operating room, so that in case of any complication, she could have an emergency c-section.

The postpartum ward

The first question to the patient blew my mind,  - was she planning on going by public bus to the government hospital, or could she afford the ambulance fee. I quickly nixed that idea. We went back to the nursing station to discuss the plan and get the government hospital’s ambulance on the way. When we couldn’t find the maternity nurse, we realized it was because she was busy delivering the first twin! The team rushed into the delivery closet and found one baby out and crying, and the other twin still inside. A quick look with the ultrasound showed that the second twin had spontaneously switched from transverse lie to breech, great news for the chance of her delivering a healthy baby. I turned away to put down the ultrasound and turned around to find that mom had pushed out the legs, butt, and part of the torso of twin B. Things were going a bit crazy. The closet and doorway were full of people, including the front desk clerk (maybe that's why they have the sign above regarding strictly no admission). I was asking for blankets and gloves and was wondering where all the neonatal resuscitation equipment was.  Benard, the other CO, quickly threw on a pair of sterile gloves. As I watched him do a little tugging, I realized that the head wasn’t coming. Before I could put on my pair of gloves, Benard and the nurse, Maximilla, had successfully delivered a quiet, purple faced baby. Thankfully, with a little rubbing of the baby, he started to breathe and even cry on his own. Two baby boys had been born, and both were looking alright. These little guys, tentatively called Jeff and Benard :), were the first twins born at Sagam for as long as anyone could remember. With some more luck (as we had plenty of it today), and if she diligently takes her medicine, her twins will be free of infection and healthy. 

Two boys in a tree

It hadn't hit me that it was 9/11 until late today. On the day that so many Americans were affected when the Twin Towers were attacked, it's a small but moving coincidence to have been involved in this uplifting twin delivery. On the way home, as the evening storm was rolling in, two boys playing in a tree asked me to take their picture. Hopefully the new twins will have many such happy, carefree times ahead of them as well.  I hope we all do.

Thanks for reading,

Jeff