Feet First

It’s 8:00PM at the Centro de Salud in San Juan and a few students, including myself, are beginning a 12 hour call– my second here in Guatemala. We sit in the common room, making dinner, chatting about the day’s events – me mostly trying to understand Spanish - when one of the nurses briskly walks in and tells us a woman with strong labor pains has just been brought in by a pick-up truck – a common mode of transportation here in Guatemala.

As this is a fairly frequent occurrence, we gather our equipment and promptly make our way down to our observation room. An initial survey reveals a woman in her mid 20’s, breathing rapidly, sweating, in visible pain with each contraction. One of the students quickly gloves his hands and performs a tactile exam – used to determine the cervical dilation, effacement (or thinning), and the position of the baby. Simultaneously, another student searches for the fetal heart rate using one of our handheld Doppler devices.

I work with the nurses to obtain a bit of history. Second pregnancy – no prenatal care – her last period was approximately 8 months prior – she had been laboring in her home with the help of a local comodrona – midwife – for the past 5-6 hours, but the midwife felt there was something strange about the babies position and so they came in.

It is the student performing the tactile who first notices the problem. Normally, when performing a tactile, you encounter the cervix with a variable dilation, followed by the circular, formed, top of the babies head. However, rather than a head, he immediately felt an object just behind the opening of the vagina – small, moveable – he worked his fingers up and the object continued to grow - he realized instantly – it was the baby’s foot.

Normal delivery of a baby through the pelvis is a tricky manipulation of space. The babies head is naturally larger than the opening of a normal pelvis – if one was to just try to pull a baby through, it would cause severe damage to the baby, and, most likely, would not work. However, nature has adapted to this space discrepancy – first, a babies head is not circular – that is, it does not have the same diameter around all parts. In fact, depending on how you position the head, the overall diameter – width – decreases. Additionally, nature has not yet fused the bones of the skull together, allowing them to overlap and further minimize space – we know it as the soft spots on the babies head. However, in order to take advantage of these benefits, the baby, inside the uterus, must, during labor, turn and move in specific orientations to fit through the pelvis – otherwise it is like fitting a square peg through a circular hole. Nature has adapted for this difficult process – when the baby is head down in the uterus (cephalic), the shape of the pelvis and force of contractions naturally turn the baby in the correct manner. When this occurs, delivery of a baby is a rather uncomplicated process – the job of the physician then primarily focuses on catching the baby (of course I simplify – but it can be quite tricky to catch wet, slippery babies)

However, the physics and beauty of nature goes out the window during a breach presentation (when the baby presents feet down). First, the smallest part of the baby – everything below the shoulders – is delivered first, usually quickly. This leaves the largest parts of the baby, shoulders and head, stuck behind the pelvis. The normal head movements are more difficult, because the babies head is starting from the wrong position, and a human head can only move so many ways. Additionally, and most dangerous – the umbilical cord partially comes out with the lower torso of the baby – while this itself is not dangerous, there is a high risk of pinching the cord when the baby tries to squeeze its shoulders and head through – cutting off the oxygen supply to the baby.

As you can imagine, this is an emergency – in almost any hospital in the US, this mom would have immediately had a cesarean section, which bypasses the pelvis entirely and simply takes the baby directly from the uterus (I have firsthand knowledge of this, being one of those babies who wanted to enter the world feet first).

However, here in the Centro de Salud, we don’t have the resources or personnel for a cesarean. In fact, on call during the night, the closest attending doctor, a pediatrician, is approximately 30 minutes away by car. Additionally, the nearest hospital to have a cesarean is a 1.5 hour ambulance ride away – too much time.

We bring the woman into the delivery room, and the Guatemalan students act masterfully. Their training in medical school has focused more on practical technique, to meet the demands of the overburdened hospitals. This has not only given them more clinical skill, but has also instilled a sense of confidence, of focus. We all realize the gravity of the situation, but, while I am thinking of options, their minds are already made up – they know what must be done.

Using specific maneuvers, they insert their fingers past the pelvis to the babies head, one hand on the back of the head for support, pushing down, the other on the face, causing the babies head to flex to its chest, they then turn their hands 90 degrees up, pulling the feet toward the ceiling, delivering the face first. Of course, this procedure is difficult due to a lack of space, and takes what feels like an eternity to work. But, the students stay focused and the baby is ultimately delivered.

We cut the cord, bring the baby over for possible recusitation, although somewhat blue and not crying in the first few seconds, after we warm, dry and give a bit of oxygen, the baby pinks up and starts crying.

Looking back, I am still in awe of the students I worked with. Although we are technically the same level in medical school, their situation, their experiences have focused on practical clinical skills, while, in the states, we focus more on theory, understanding of underlying principles.

It is not to say that their education is superior – it is just that each of our educations have been optimized for our environments. In the US, students are always supervised and the clinical education focuses on exposure rather than mastery. The reason is simple, especially in Boston – there are an abundance of doctors to treat patients – therefore, standard of care dictates that doctors and residents should be the primary health providers. Additionally, our system is specialized, therefore, if I decide to go into dermatology, more than likely, I will never attend another birth – as the doctor – for the rest of my career. Therefore, our education focuses on building a foundation of principles, leaving the development of specific clinical skills until after you have decided on a tract in medicine.

Guatemala, however, is different. First, the hospitals are incredibly overburdened – there are just too many sick and not enough doctors. Therefore, the responsibility for patient care transfers down to the level of the intern / medical students. This deficiency is even more pronounced in the rural areas, where it can be many hours to the nearest hospital or clinic. Secondly, many of the graduating Guatemalan students will go on to be general medicine doctors – they will more than likely see all types of patients – pediatrics, obstetric, general adult medicine. Therefore, their education focuses on direct patient care early on, comparable to our residency programs. This not only shapes their clinical knowledge, but also their mentality – they are trained to be resourceful, to rely on themselves, to have confidence in their own skills.

Of course, these systems function well as long as the students in them stay in their respective countries. For me to come to Guatemala, I find that my clinical experience pales in comparison – I had never seen an emergency vaginal breech delivery, and for many good reasons – we have the resources for cesarean, we have adequate screening, access to ultrasound. Therefore, it has been quite the experience to practice medicine with this added responsibility, and without the equipment and procedures I am used to.

At the same time, some of the Guatemalan students have problems in the US system. Because they have been groomed to be decisive, they can come to diagnosis very quickly, and have trouble in a system that values a wide differential diagnosis and has almost unlimited medical resources at their disposal.

While it can be, at times, overwhelming to be here, practicing with these other students, it is also a great opportunity. To be able to practice in this setting, to add some of their clinical skills and, more importantly, some of their strong personality traits to my own character I believe will only serve to help me as I continue my career in medicine.