twins

Twins are considered suitable for vaginal delivery but that doesn't help me relax. It's better if they are both presenting by the head but the second baby can be breech, as in this case. In the absence of spontaneous labour an induction was  booked for thirty-eight weeks gestation.
Even off-duty over the weekend, I found myself thinking about the twins every spare minute, especially the breech, which I knew was larger. I dreamed that the head became stuck. On Monday morning she came in for induction of labour. An oxytocin infusion led into good labour and by mid-afternoon I was called from my clinic for the delivery.
There was quite a crowd in the labour room - patient, partner, three midwives, two obstetric resident doctors, two medical students, two paediatricians and me. My patient, always positive, greeted me cheerfully. I went about my routine, checking all the nursing observations and foetal heart rates then setting up a delivery trolley while chatting a little to the mother about the birth. An ultrasound machine was placed by the side of the bed. Her legs were put in stirrups for better access and this revealed that the first baby was nearly out. It was soon delivered with minimal fuss. Then, while the vagina was still distended, I put my whole hand into the vagina to identify and guide the breech into the pelvis. It disappeared nearly up to the elbow, finding only the baby's hand reaching down into the vagina, threatening to become an undeliverable shoulder presentation if allowed to progress for a few more seconds. I thought perhaps the head was trying to deliver first but a quick ultrasound scan showed that it  was still furthest from the birth canal. However the breech was also fairly high up and would not be encouraged to come down. By this time, still only a minute or so after the first delivery, the second sac had ruptured, the amniotic fluid was rapidly draining away, and there was a serious risk that the baby would become entrapped by the contracting uterus. I had to pull down a leg and do a breech extraction, only by touch. If I pulled down an arm she would need a Caesarian section.Twice I grabbed a hand but managed to push it back. Eventually I found one of the feet and pulled down until the breech started to deliver, first a foot appearing, then the leg, buttocks and back. When the first scapula appeared it seemed that something was blocking further descent. But if the baby wasn't born soon it would rapidly lack oxygen. As I pulled down further a nuchal arm was revealed.
The left arm had become locked behind the head, blocking any further descent like a wedge beneath a door. I pulled the head down as firmly as I could without injuring the neck. It would come no further. I tried to deliver the arm around the back of the head without success; tried to push the head back up the birth canal to free the arm but there was too much resistance; rotated the shoulders one way then the other -   this failed but it seemed closer to the desired result.
The baby's muscle tone was nearly gone. Initially wriggling vigorously, it was now floppy from lack of oxygen. Yet I stopped and gathered my thoughts for the last attempt before it would be too late. Most of the people in the room were talking, mainly about the baby already born, unaware of the increasing drama. I momentarily envied their lack of responsibility and then tried to think. It seemed that the arm was closest to coming free when the head rotated to face the front but that is a position that is usually actively avoided in breech deliveries so I had been stopping the rotation before it proceeded too far. I decided to take it as far as it would go since all other attempts at delivery had failed. The next step would be to deliberately break the arm although I was not certain that would be effective either.
I started again, turning the body around so that the shoulders and head would face towards the front while trying to apply pressure to the inside of the elbow in the hope that it would bend and come out. It worked, then once one arm was out the other was also locking the head. This time I made the correct manoeuvre at once and suddenly the flaccid baby was delivered and handed to the waiting paediatrician. He recovered rapidly but I didn't know if the arm was damaged. No one seemed concerned except for a student midwife who started to faint and had to leave the room.
The mother was happy and excited. Everyone was smiling. I returned to the clinic, shaken by the near miss, disconcerted by how quickly things can deteriorate in obstetrics; how a life can so nearly be lost or permanently damaged. Still trembling, I resumed the mundane repetition of antenatal care. Later I found out that the arm was moving normally. Both twins were well but I wasn't so sure about myself.