As A Doctor, What Was The Most Unorthodox Procedure You Ever Had To Perform On A Patient?

This question was originally posted on Quora.com and was answered by Lacy Windham, studied at University of Tennessee Health Science Center



A few years ago I was called to see a patient in labor and delivery.

She had been planning on a home delivery with her lay midwife. After 4 hours of pushing, she was no closer to delivery and was brought to the hospital.

The baby was in occiput posterior position. This means that the baby is trying to come out looking up at the sky instead of down toward the floor. It certainly is not impossible to deliver vaginally in this circumstance, but it’s harder, it takes longer, and is more likely to result in a severe tear in the mother or shoulder dystocia in the baby.

I very briefly considered attempting an operative vaginal delivery with a vacuum or forceps, and then quickly discarded that option.

In my professional opinion, this was a big-ass baby.

I ultimately recommended a cesarean, and the patient agreed.

A primary-scheduled C-section prior to the onset of labor is usually not a terribly difficult procedure.

A C-section when a patient has been completely dilated and pushing is an entirely different animal. It is actually one of the most morbid procedures we can perform.

I was taught in residency when making a uterine incision in these cases, to pick where I wanted to cut and then to actually cut several centimeters higher. What you think is the uterus is actually the cervix when a patient is completely dilated.

These C-sections have a very high rate of cervical extensions or tears, injury to the uterine artery, or even injury to the fetus. The blood loss is typically higher, and the surgery is usually more difficult.

She received a quick spinal anesthetic and soon we were ready to begin. A few minutes after starting I was looking at her uterus. I dutifully made my incision higher than I normally would choose.

Suddenly I was looking at the upper arm of the baby. This was not a good sign. Usually you see the baby’s head after making the incision. Sometimes you see the shoulder. The ‘shoulder sign’ is a hint that this delivery is about to get interesting.

I was looking at the upper arm. This baby was deep in the pelvis.

I put my hand under the pubic bone and attempted to reach under the baby’s head. If we can disengage the head from the pelvis, the baby is easily delivered.

This baby was wedged tightly in a narrow pelvis. I couldn’t get my hand under the head. Sometimes, in this circumstance, we ask a nurse to ‘go below’.

The nurse in these cases places a hand into the vagina and pushes upward on the baby’s head until the surgeon can get her hand under.



Unfortunately, it was the middle of the night and my circulating nurse was a new hire and relatively inexperienced. She had never performed this procedure. I would have to ask my scrub nurse to break scrub to do this.

Whether it is a difficult cesarean or a shoulder dystocia in a vaginal delivery, it is not a fun feeling when you are struggling to deliver a baby.

Here’s the weird part of the story. Not even two weeks earlier I had read an article describing a ‘reverse breech extraction’. The example listed in the article was of a patient attempting a home-birth with an occiput posterior baby and several hours of pushing!

I thought for a moment about the description of this procedure, then I reached up into the uterus as high as I could until I found a foot. I pulled.

First one foot appeared followed by a leg. Then the second foot and leg and finally the hips and torso. I was able to disengage the baby’s head at this point with gentle traction.



I was amazed. I didn’t even have an extension into a uterine artery, as often occurs during these deliveries.

I haven’t had to use this technique again, but I’m definitely keeping it in my toolbox.

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