DR. SIMION TSINKER

Twins presenting in transverse position can still be delivered normally.

By Alfredo Arango
Medical Editor

When Pamela Rivera found out she was pregnant, she decided to have a midwife deliver her baby. The Honduran mother, who lives in the town of Homestead, south of Miami, hoped she would have a normal delivery, as in the case of her previous three deliveries. However, when the midwife informed her that she was having two babies instead of one, Rivera had to accept the services of a doctor, since the delivery of twins is considered risky and midwives do not manage them.

Things got even more complicated when the sonograms showed that the babies were not descending headfirst as they should be; instead, they were in difficult positions, one in a sitting position in the birth canal, and the other in transverse position across the abdomen. This meant that the delivery was at even great risk. All the doctors that Rivera consulted told her the same thing: delivery would have to be by cesarean section.

Rivera returned to her midwife to ask her for new advice. Was there a doctor who would dare deliver her babies vaginally? The response was affirmative; the midwife told her there was a doctor in Fort Lauderdale whom mothers-to-be who expected complicated deliveries would visit from far away places in Florida, and some even from other countries, because he was famous for having the ability to perform normal deliveries of babies who were already planned to be delivered by cesarean. His name is Dr. Simion Tsinker, vice chairman of the department of obstetrics and gynecology at Plantation General Hospital, in Fort Lauderdale.

“I was quite moved. I wanted to do everything possible to have my babies delivered normally. I did not want to wake up from my delivery with a stomach full of staples, having had surgery. When I was 20 weeks pregnant, I went with my husband to see Dr. Tsinker, and he gave us hope”, says Rivera.

Dr. Tsinker explains that such hope is based on concrete facts.

“If we had been dealing with only one baby in transverse position, cesarean section would have been the only option. When there are two babies and the first is not the one in the transverse position but rather the second one, it is possible to try vaginal delivery, because the baby that is delivered first opens the way for the second one, for whom it is possible to use a maneuver to turn that baby. It is clear that this was an extremely complicated case, because the first baby was not presenting in vertex position, in other words, in the normal, head-first position, in which case the cervix dilates to 10 centimeters, thus making it easy all around; instead, the baby was also in an abnormal position. However, we were not dealing with a first-time mother, but a mother with three prior deliveries, which made for a greater possibility of success. Mrs. Rivera was perfect for confronting such a very complicated delivery”, explains the specialist.

The problem was that the first baby was presenting in a sitting position. This is known as ‘breech presentation’. There are different variations to this position. In the Rivera case, the first baby, who was the male, was practically bent over, with the face between the legs, facing forward in the belly, which position, in English, is known as the “Frank breech”. The obstetrician took his measurements, calculated the possibilities and saw that it would be possible to deliver the baby in that position, and he could turn the second baby, who was the female, so that he could deliver her feet first.

Such a complicated delivery would be very painful; therefore, the expert recommended epidural anesthesia. “If the mother is not in so much pain, she can cooperate and follow instructions better during the delivery”, clarifies the doctor.

Rivera agreed to receive the epidural anesthesia.

“When the baby crowned the buttocks, I did not believe he could be delivered that way. The doctor delivered him with amazing skill”, comments Mario González, Rivera’s husband, who is from Nicaragua.

“In these cases, the baby is delivered bent-over, buttocks first, then the legs, then the arms, and lastly the head”, explains the obstetrician.

As for the female baby, Dr. Tsinker introduced his hand and forearm to move her inside the womb using a maneuver called “internal podalic version”.

“It consists in blindly seeking inside the maternal abdomen for the feet of the baby that is in the transverse position. The bag of waters cannot be broken, because the bag is what keeps the uterine walls apart. If the bag breaks, the walls of the uterus contract and trap the baby even more. One feels around the bag of waters that surrounds and protects the baby. The only things you manage to feel on your fingers are the baby’s heels. Once found, you firmly hold them between the fingers and pull them to the vagina, you hold them there, you break the bag of waters and pull the baby in such a manner as to deliver the feet first, then pull the arms and, last of all, the head”, adds the doctor.

Rivera had the peace of mind that if anything went wrong, the delivery could be turned at any time into a cesarean, so that both she and the babies would be saved. For this reason, such procedures must be performed in a hospital. Babies Daniel and Andria were delivered normally and are now two months old and are healthy.

These maneuvers to turn a baby in order to deliver it are not at all new. The “podalic version” was performed in Hippocrates’ day in ancient Greece. It stopped being performed during the Middle Ages, until the procedure was revived in the 16th century by the Frenchman, Ambroise Paré, who was surgeon to kings and warriors.

“Modern obstetricians should be proficient in the ‘art of obstetrics’, not only in uncomplicated natural deliveries or cesarean sections. Our specialty requires from the doctor to master all these well known and available techniques,” says Dr. Tsinker.

The Riveras expressed that in these days, when the tendency, not only in medicine but in all areas of life, is to perform things as quickly and as easily as possible, a great degree of patience and courage is required on the part of an obstetrician to wait for hours for the complicated babies to be born, and risk doing everything possible to deliver them normally.

“In my opinion, my case illustrates the extreme importance of finding a competent physician when a woman contemplates pregnancy or is already pregnant, because it could make a big difference in the ultimate outcome,” says Rivera.