Preterm delivery occurs when a birth is before 37 completed weeks of gestation. It is a complication of pregnancy that affects just over 10 % of all births. It is associated with a disproportionate risk of neonatal harm that may persist for as much as five years postpartum [8]. Adverse outcomes are invariably related to functional immaturity of the lungs and other major organs, including the central nervous system. These sequelae become more catastrophic as gestational age and birth weight decrease.

A baby's presentation describes the part leading towards the maternal pelvis in a longitudinal or vertical lie. At term, nearly 97% of babies will present as cephalic, which means the head will be the lowermost at the level of the pelvic brim. In contrast, a breech presentation occurs when the baby’s bottom (breech) or feet (footling) are leading [9]. It is rare to find this at term; however, it becomes more likely at earlier gestations due in part to the smaller size of the baby allowing greater relative mobility within the uterus [10]. The way a baby presents may thus vary, particularly at lower gestational ages. This is significant because if labour occurs while the baby is in a breech position, there is a higher risk of complications. These are varied but may be explained by the mechanics of foetal movement as the baby descends against the soft tissue resistance of the cervix and vagina. A cephalic birth tends to flex the head towards the chest, thus presenting the smallest possible surface area – the vertex - during descent. In contrast, during breech delivery, particularly when external traction is used as an adjunct to pull the baby out, the head trailing behind will tend to extend so that the diameters it presents to the pelvis are larger. This makes it more likely to obstruct and become trapped above the symphysis when the body has delivered. This is an acute obstetric emergency, and this scenario is what confronted the Obstetrician when he first saw the patient described in this case report.

The Term Breech Trail of Hannah et al. in 2000 advocated elective caesarean section delivery to reduce the neonatal risk for babies presenting as breech at term [10]. Whilst these findings are now less resolute, a systematic review of preterm breech delivery shows indisputable benefits for babies born by elective caesarean compared to vaginal delivery: 3.8% mortality versus 11.5% [11]. There are many reasons why this is so. The preterm baby's head is relatively larger than its body and may become trapped if the latter slips through an undilated cervix. Additionally, the breech fits less snugly within the cervix, increasing the risk of cord prolapsed [12] was partially delivered with likely head entrapment. It was a dire set of circumstances. We may reflect on the reasons that may have led to the mother's late arrival. She lived in a remote community with limited access to obstetric or midwifery care. Primary health providers were available but without the province of specialist training. When we reflect, we might posit that reasonable medical care should always be on-site, but we know this is not always possible. Alternatively, we might argue that we should move patients with imminent need to centers where we can provide care before the realization of critical risk. This is prudent, but again, not always practical nor indeed desired. Risks are not always as we see them; when they are, their impact may not be enough to balance the cost of moving a person from home and family. Indigenous Australians are connected to the land. It is the home of ancestors and culture and is woven into the fabric of life and the lives of the children they nurture and carry. Moving away and separating a pregnant mother from her home, family, land, and country may affect her and the future of the baby she is about to birth. She will hide or resist regardless of the risk to protect that right. For these and no doubt many other reasons vital to her, our patient presented when she had to, late in labour, and without having had any formal care till then. To us, this seems wrong, and we agitate that there has been a disinclination to accept the care we offer, but we forget to see it through her eyes; we forget to ask why this might be so. It does not mean we stop trying; it just means there are reasons why we might not always succeed.

Few of us would be brave enough to imagine that had these events occurred in a metropolitan birthing centre, the apprehension of a seemingly irresolvable crisis would have been any less confronting. The difference, of course, is that had it done so, the immediacy of face-to-face contact, access to surgical intervention, and the support of colleagues would have made the situation less onerous. However, that was not to be. When first encountered by our consultant, the situation seemed hopeless. He was paralyzed by distance. He was not there; he was not where he needed to be to make a difference. He felt there was nothing he could do. What transpired, however, in the moments that followed demonstrates the resilience of healthcare training and the innovation of new communication technologies that provide virtual, participatory platforms in real-time that can make a difference when nothing else seems possible.

Simulation training has been used extensively in the aviation industry since the 1930s and in the medical field in the early 1960s with simple resuscitation mannequins [13]. In 2006, a team from Bristol introduced PROMPT (Practical Obstetric Multi-Professional Training), a team-based practice training program for healthcare professionals using simulated obstetric emergencies to develop real-life skills and communication. Following its introduction, a comparative evaluation of maternal and neonatal outcomes showed a 50% reduction in neonatal hypoxic brain injuries and a 70% decrease in injuries after shoulder dystocia compared to outcomes four years prior [14]. PROMPT is now integral with mandatory training for all healthcare workers employed in women’s health in Australia. Courses are held each year and continue to promote outcomes that encourage teamwork, safety, communication and leadership perspective. They practice drills and skills to manage conditions requiring high levels of cognizance or that are not often seen in routine daily practice. In so doing, they develop a repertoire of performance behaviours integral to effective critical care. This is how our clinician coped. He was not expecting the events that were to unfold before him. He could not have prepared for them. Nevertheless, it took just moments to identify what he could do. He could innovate and improvise, take stock of the situation with perspective and acknowledge the available resources. He could communicate effectively with those present and work with them to do what was possible using clear instruction and direction. At some point, we may all be called upon to deal with things entirely outside our comfort zone or normal expectations, but the faculty we keep from simulation training can help us stay poised to do the best we can. It does not mean things will always work out, but we know if they do not, it is not through a lack of trying.

Telehealth brings the ability to share information across distances. It began with telegraph and radio in the 1900s and later included video links in the 1950s. The 1990s saw a renewed commitment to bring communities closer together and ensure reliable outreach from medical services [20, 21, 22]. Since the early peak of COVID-19, reliable audio-visual platforms have been widely used using digital and satellite internet connections. We cannot make the land any smaller. We cannot bring everyone to the city, but, in some sense, we can be with them in their community and share important decisions in real time. We can talk, we can counsel, and offer choices. We can make plans to support, provide retrieval services, and, as in this report, we can be there in whatever way is possible to do the things that are needed as best we can. This need has never been greater. Of the many aftermaths of COVID-19, social isolation has worsened, the cost of living has risen, marginalization of population subsets has become more extreme, and the gap between idealized and actual health care outcomes has failed to narrow. This is nowhere more evident than in the communities of remote Australia. Telehealth has expanded to meet the challenge, but many limitations remain. Infrastructure, including internet access, is not available in all locations. The maintenance of equipment, security, and up skilling of the local population to utilize it effectively may still be lacking [15]. There may also be social or cultural barriers to its integration, such as a preference for traditional interactions by community and health practitioners unfamiliar with the interface. The Government is implementing education programs to break down barriers and create incentives to encourage health workers to work in rural areas. In our report, the Obstetrician was on study leave as part of a personal commitment to engage and experience the Indigenous community from the ground up. For him, this was appropriate. It is not necessarily something that all health care workers should do; however, it is something they may want to do if encouraged to take the opportunity to do so.

The Royal Australasian College of Surgeons (RACS) acknowledged that less than 12 % of their specialist workforce practised beyond urban boundaries [16]. In the coming years, one of their biggest priorities is to institute a Rural Health Equity Strategy, which will address the inequity of health services and incentives to increase awareness of this need and the importance of cultural and societal sensitivity [16]. Similarly, the Rural Health Outreach Fund (RHOF) supports outreach programs to improve the egress of medical specialists, general practitioners and allied health care providers to regional, rural and remote clinical practice [17].