A foot!

The strangest vaginal exam I’ve ever had so far happened two nights ago, on my first night-shift clinical rotation, when a woman in early labor came to triage. She was full term, she’d had some light spotting, hadn’t felt the baby move as much as normal in the past 24 hours, and was contracting about every 5-10 minutes. I took her history and started my physical exam. We were most concerned about the lack of movement, since this is often an indicator of fetal distress, and the tracing didn’t look that hot. I palpated her abdomen and I had a difficult time figuring out where the baby’s head was, but I assumed it was vertex (head down) because we were auscultating the fetal heart below the woman’s belly button, which is usually a good sign that the head is down. I’m a student and my Leopold’s maneuvers aren’t expert by any means, so I figured it was due to my poor Leopold’s that I wasn’t able to tell for certain where the head was.

We moved on to the vaginal exam. My preceptor checked first per usual, and smiled at me as she pulled her hand out and said “this is going to be a great vaginal exam for you.” I began my exam cautiously, figuring the woman was 2-3 centimeters dilated, and wondering what my preceptor was talking about. I felt the cervix right away, and indeed, she was 2 centimeters dilated and about 80% effaced….but where was the head? I didn’t feel the head anywhere. My preceptor told me to put my fingers inside the cervix and feel the bag of waters….and OMG, what is that???! Not a head at all! Some kind of strange, small, hard little thing bobbing up against the intact bag of waters, clear as day. I almost gasped in surprise (but managed not too, thank goodness!). What in the world is that? My preceptor mouthed the word “foot” to me, and suddenly it all clicked in to place. It was indeed a foot, I could feel the outline clearly, I could tell where the heel was and where the toes were….I was basically tickling the baby’s foot, and she was in a footling breech position. An ultrasound scan quickly confirmed what we’d felt, and the head, rather than being in the fundus (or over the symphysis pubis), was actually way off to one side, almost transverse more than anything else. The woman said the head had been down at her last check-up a few days ago, so I wonder….did the baby flip all of a sudden, and is that why the woman thought the baby wasn’t moving as much as normal, because all of a sudden she wasn’t feeling the usual movements in the usual places?

She was committed to having a vaginal delivery, so we referred her to the physicians on the floor, who offered her an external cephalic version in the operating room. As they were trying to turn the baby, though, the heart rate decelerated, and she ended up giving birth by cesarean. To be honest, the tracing, even in triage, never looked fabulous…there were never any accelerations, and the variability was occassionally flat, and as it turns out, there was a cord wrapped very tightly around the baby’s head. So everything happens for a reason, and I do think that sometimes babies have a mind of their own when it comes to how they want to be born. This little one wanted to come out foot-first!

One of the greatest concerns with a breech delivery is that the cervix will not be open enough to allow the large head to pass through, even though the smaller body might have already been delivered, and then you end up in the dangerous situation of a body fully born with a head entrapped by the cervix. While vaginal deliveries may be possible for other breech presentations, like a frank breech or complete breech, because at least the breech (i.e. the rump) is hard enough and unyielding enough to press against a cervix and help it fully dilate, with a tiny little foot presenting, the chances of the cervix opening fully are very small. Because of this, footling breech presentations are the most dangerous type of breech presentation to deliver vaginally, and I’m really glad this woman came in when she did and was able to give birth via cesarean, expecially once it became clear that a version was impossible and that the baby wasn’t doing that well with her tight nuchal cord. So, here’s to cesareans done for a good reason; they really can be lifesaving when they’re truly indicated. And as for me…I will never forget this vaginal exam for the rest of my life!

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