Delivering En Caul on A Call – A Paramedic’s Rare OB Experience

*record scratch*

You may be wondering how I found myself in this position, stopped along the side of a busy highway in the back of a brightly-lit ambulance at just past 4 in the morning. I was straddling the foot end of a stretcher, crouched in a Catcher’s position with one hand hopelessly snarled in an ill-fitting sterile glove and the other trying to paw at the Ovomorph that just had landed between my knees. In front of me was a very concerned young lady who had just delivered her fourth child sans anesthetic. To my left was my very concerned-looking partner Dustin who was witnessing his first field delivery in his 15 years on the job. Me myself? I was giving this whole situation a solid seven on the Weird-Stuff o’meter and silently pondering my life choices.

Y’know, an “ovomorph.” One of these things

I had never witnessed an En Caul Birth before. Heck, I’ll admit that I didn’t even know what an En Caul Delivery was. I’m not really ashamed about it either. None of my EMS and Paramedic education had touched on the super rare occurrence that is an En Caul birth. I had no idea what this squirmy pinkish-yellow water balloon looking thing that had landed between my legs was and all I could think of was how much of a mess it was going to make when I had to rip it open to get the baby out.

Back to the call in question, it had started out like any other OB call we get on the ambulance. We were sent out on a 911 call for a 24-Delta-3 Imminent Delivery at about 4-o’clock in the morning on some random Tuesday. We go to women in labor calls fairly often, and in my decades of doing this I’ve only actually delivered six or so in the field. Dustin, who had 15 years on the job had never delivered one. As sleepy as we were on this particular morning after being ran hard throughout our twenty-four hour shift, we were very much hoping that this call would be like so many of the others and would not be adding another hash-mark next to the stork sticker on our ambulance.

Births are messy. I’d like to say that “ain’t nobody dying or multiplying in the back of my rig” and If that were possible, I’d have that policy in a second. If you’ve never been the pusher or the catcher of a delivery you may not know that while it is a beautiful and miraculous process, the housekeeping staff rarely feels that way after all of the more glory-filled jobs have been taken care of. Births are messy, as I’ve said, and after the debacle I had with Dustin a few weeks prior to this when he didn’t take my advice and spread the impervious plastic yellow sheet on the cot when we had a lady whose water broke during transport, I wasn’t up for the task of spraying the cot and the floor of the ambulance off with a hose again that early in the morning. So while he asked the lady questions and assessed her, being as we run a dual-paramedic truck and it was his turn to be in charge, I made sure to spread out the yellow-sheet and put down a couple of chux.

Oh, how prophetic this was.

It turned out the patient had been sent home from the hospital earlier that day with the diagnosis of Braxton Hicks contractions. It was her fourth pregnancy (G4/P4) and her contractions hadn’t stopped since she’d been discharged. In fact, they were about 3 to 5 minutes apart when we found her, and they were lasting a while… like 45 seconds to a minute. Dustin remained unconvinced that we were going to deliver, but I was considering staying at the house in order to keep the ambulance cleaner. The thing was though, she hadn’t broken her water yet, so I was still leaning towards there being a chance we could make it to her OB hospital of choice 25 minutes away.

So we loaded her up, sitting her on a blanket that covered the chux pad and the impervious yellow blanket, and put her into the ambulance. I asked one of the intrepid members of the Engine Company if they would drive for us so we could both be in the back and as always, the fire guy was happy to oblige. We got going and everything was going well… until it wasn’t.

“It’s burning! It’s burning! Why is it burning!?” the patient exclaimed… and I, knowing exactly why it was burning but hoping I was wrong, took a look at the business end of things to see if anything was coming out.

What I saw confused and startled me.

I went to Paramedic school back in the 1990s. Back when ACLS was still difficult and Medics were supposed to be Medics. Our class was exhaustive, we were told. However, unless I slept through that particular part of class and unless I happened to subsequently sleep through that part of every bit of OB and Childbirth education I’ve had in the decades since, I had never been prepared for what I saw coming out of this lady.

Instead of a hairy top of a newborn head, I saw this off-white bubble looking thing. It was like she was blowing a bubble out of… there… I realized that it had to be the amniotic sac, but I had no idea that this was a thing that could be happening to a human. Dustin, and bless him for this, actually did know what this was, and said “Ohhhh it’s coming out En Caul.”

What now? I suppose I could be forgiven for not knowing about something that happens in roughly 1 out of 80,000 births. ( I mean, I still learn every day in this job, but usually I have some idea what I’m looking at when I see it. I read a lot… and to be completely caught off my guard is a novel experience these days.

But in my sleep-deprived brain, Dustin’s next statement was not worthy of being blessed. He had opened the OB kit and handed me a pair of sterile gloves. “You’re supposed to put these on” he said. I was just a little perturbed at the guy for not jumping in and experiencing the miracle of his first field delivery first hand like he should have, and even more perturbed by the fact that this was technically *his* call so I shouldn’t be the one getting my uniform damp, but I digress. I mistakenly grabbed the sterile gloves, took one of my gloves off, and attempted to put the sterile glove on my right hand.

Luckily I had only taken one glove off, because you all know what happened next. There was a loud “schlleurruept” sound and the baby was out, fully encased in the amniotic sac like a squirmy yellowish-pink jelly bean and there I was with one glove on my left hand and my fingers hopelessly snarled up in the glove I had been trying to put on my right hand thus rendering me a one-armed man at a fetal-balloon-popping contest.

I had no idea what to do. Dustin, forever helpful, handed me an umbilical clamp that had a spike on it that he said was meant to rupture the sac. As I sat there fruitlessly pawing at the lump of fluid with my one good hand, this also seemed like a good idea.

It was not.

The spike on the umbilical clamp *did* poke a hole in the amniotic sac. However all this did was to shoot a pressurized stream of amniotic fluid up towards my face from the small hole it made. So now I’ve got the alien birthing pod spraying at me with amniotic fluid, I’ve got my one goofy hand all snarled up in a useless now not sterile glove and I’ve got my other hand so darn slippery it was helpless to do anything.

Thankfully, shortly thereafter the balloon popped and while my uniform pants needed a good washing, the baby was removed and was immediately kicking and crying just like she was supposed to be. We put her up to Mom for some good old-fashioned skin-to-skin contact, and then delivered the placenta like the textbook said we should. After that, everything proceeded according to plan.

Last I heard the mother and the baby are doing fine. I asked her if she would name it after me but I haven’t heard back about that.

And now for some EMS education. Here’s what I learned:

An “en caul” birth, as stated above, is exceedingly rare with only 1 in approximately 80,000 humans being born that way. Most are born via c-section just because they happen to be taken out that way, and a vaginal en caul birth is extremely rare. If there are about 4-million live births in the US each year, about 50 of them would be birthed en caul. To have one in the ambulance on the side of the highway is a moonshot of a chance.

Luckily there are rarely any complications associated with this rare event. It is safer not to use sharp objects to pierce the amniotic sac, but in my personal experience that sac is MUCH tougher to break with just my fingers than I thought it would be, goofy-gloved hand notwithstanding.

Next time Dustin’s going to catch. I’ll be up front driving.


If you’re looking for actual education on en caul births, here’s something from an actual medical journal that’s not just an EMS blog:

“Vaginal Cephalic Delivery En Caul and Subsequent Postpartum Intraventricular Hemorrhage and Respiratory Distress: A Teaching Case”