& WzMMz^ «P Bill mm mm .. mm -:- mm 4. . . NLP1 DD573Dfib 5 3V' *3*£ inches) to the occipito-frontal (4 inches) and biparietal, and if traction is continued it will cause the occipito-mental (5 inches) to engage. The head should be extracted where the woman needs assistance by taking the body of the child in the hands and shoving the head up and making flexion to bring the most favorable diameters to engage. If the head is not expelled then the body is carried over the pubes, or the fingers are placed on the malar bones on either side of the head, and ex- pulsion facilitated. We do not recommend to put the finger on the lower jaw, as it is too fragile, but the finger can be put in the rectum of the woman, or pressure made with one hand on the fundus of the uterus. If these means are not sufficient the forceps should be applied. It has been suggested that the vulva be held away from the mouth of the child so that it can breathe, but it is doubtful if this can be successfully done. Second position of breech presentation.—The sacrum looks toward the right acetabulum, the pubes toward the left sacro-iliac joint, the right tuberosity of the ischium toward the left acetabulum, the left. tuberosity toward the right sacro-iliac joint. The mechanism is the same as in the first position, except that the rota- tions are in the opposite direction. It is much more frequent than the first. Third position of breech presentation.—The sacrum looks to- ward the right sacro-iliac joint, the pubes toward the left acetabulum, the right tuberosity of the ischium toward the right acetabulum, the left tuberosity toward the left sacro iliac joint. There is little or no difficulty in the birth of the hips. They pass into the cavity of the pelvis, the right hip strikes on the right anterior inclined plane, and is rotated under the arch of the pubes, the left hip strikes on the left posterior inclined plane, is rotated into the hollow of the sacrum and sweeps the perineum, and both hips are born simultaneously. The shoulders come down, strike the same planes, rotate in the same direc- tions, and are born simultaneously. Restitution takes place after each part is born. Passage of the Head.—There is very great disposition here for the third to become converted into the second as in vertex cases. When the occiput strikes anterior to the spine of the ischium, the head is born in the same way as in the second position. But if the occiput strikes pos- terior to the spine of the ischium, it rotates into the hollow ofthe sacrum, and looks posterior, while the bregma looks anterior, and rotates under the arch of the pubes, and engages there. The occiput sweeps the peri- neum until the neck reaches the posterior commissure of the vulva, when it engages there, and the bregma is born by flexion. This birth can be facilitated by bringing the back of the child toward the spine of the mother. 165 166 Fourth position of breech presentation.—The sacrum looks toward the left sacro-iliac joint; the pubes toward the right acetabulum; the right tuberosity of the ischium toward the right sacro-iliac joint; the left tuberosity toward the left acetabulum. The mechanism is the same as that of the third position, except that the rotations take place in an opposite direction. In ninety-five per cent, of breech cases occurring in the third and fourth positions, they are converted into the second and first, respectively. Hence the first and second positions are the most favorable in breech pre- sentations as they are in vertex. It is also as important to convert the third and fourth into the second and first when the head is being born. Disadvantages of Breech Presentations. (1) The breech is the smallest part, the shoulders the next, while the head is the largest. There is, therefore, a separate dilatation with each, and, consequently, a continual delay. (2) The breech being soft and irregular, does not dilate the os so well. (3) The circulation of the child is not so well maintained. The cord is compressed, and the delay causes it to be compressed for a long time, while the placenta is generally peeled off before the child is born. (4) Irregularity of the breech may allow the cord to become prolapsed. (5) The air irritates the skin of the child, and causes it to gasp, often drawing in mucus, blood, etc., and drowning it. (6) The great danger of displacement upward of the arms and exten- sion of the head. In births by the breech the different portions of the body as the child is born should be wrapped in a warm, soft cloth. Sometimes when assist- ance is necessary the blunt hook, the fillet, or the forceps can be used, of which the scope of this work will not permit more than brief mention. 167 CHAPTER XI. DYSTOCIA. This term applies to those cases in which safe delivery of the child cannot be accomplished by the mother, but where it becomes necessary for the physician to interfere. The operations which he may be called upon to perform are divided into two classes—those in which the hand alone is used, and those in which the hand is armed by some instrument. Operations Performed by the Hand Unarmed. In order that the child may be safely delivered, one of its extremities must present. In some cases the child is situated crosswise in the uterus, presenting neither extremity. In such position delivery is of course impossible. These are termed by different authors variously, cross, ob- lique, or irregular presentations. They are nearly always converted into shoulder presentations. Shoulder Presentations.—There are four ways in which the child may lie, which occur in frequency according to the following order: 1st. Head in left iliac fossa; spine forward. 48%. 2d. Head in right iliac fossa; spine forward. 43%. 3d. Head in right iliac fossa; spine backward. 4th. Head in left iliac fossa; spine backward. It will be observed that almost invariably the spine looks forward. This occurs because the curve of the spine corresponds to the curve of the anterior uterine wall, and, therefore, naturally assumes the position in which it fits best; and, again, as the spine is heavier and the abdomen more or less dependent, the force of gravity tends to make it assume this position. The first occurs more frequently than the second, there being a dispo- sition for the head to be to the left. The reasons given for the spine being forward cause the second to be more frequent than the third. The third occurs more frequently than the fourth, because of the rectum and sigmoid flexure. Shoulder presentations occur once in 130 to 150 labors. Formerly, the percentage was given as much smaller than this, but the difference is due to the fact that physicians are now better able to diagnose positions. After the bag of waters is ruptured, nature tends to convert these into vertex or face cases, and this change often took place without being noticed. 169 170 Causes of Cross Positions.—The movements of the child may acccount for it, as the child may move and become fixed. A contracted pelvis may modify the position of the child; as also may attachment of the placenta low down, by altering the shape of the uterus, and pushing the child to one side. Large children are more frequently oblique than small, so it occurs more frequently with males than females. In multiple pregnancy it occurs very frequently. A previous irregularity in position seems to generally cause another, as the shape of the uterus appears to be permanently altered by the mal- position. Monstrosities; or children with tumefactions are apt to have irregular positions. Premature birth is a very frequent source. Other causes are poor development of the child, prolapsed extremities, hydrops of the amnion, maceration of the fcetus, pendant abdomen in women who have not been properly bandaged in previous confinement, blows and jostling, and retching from excessive vomiting and long con- tinuance in the recumbent position. Diagnosis.—This presents, comparatively speaking, little difficulty, and should be made before the rupture of the bag of waters. The child does not lie so low in the pelvis, so sometimes there is difficulty in reaching the uterus. The os is irregularly opened by the shoulder, and the sac is oblong and irregular. On inserting the finger the shoulder is felt, and the finger can be put in the axilla. This is distinguished from the mouth or anus by feeling the shoulder blade and the humerus, which can be felt for its whole length. It has been said that if there is any doubt, the bag of waters can be ruptured, and the presenting part brought down and examined, but this is not good practice, unless operative procedure is immediately proceeded with, as it diminishes the chances for the life of the child, and causes the uterus to contract so as to prevent necessary manipulations of the child. The foot can be told from the hand, because the thumb can be abducted and the big toe cannot. If still the part cannot be made out, it can be brought down and looked at. Such a procedure, however, ought not to be necessary. Can tell which hand it is by shaking hands. The hand with which this can be done belongs to the same side as the hand employed. It is said that the posi- tion can be diagnosed by the hand, but it is better to pass the finger up beside it and make the examination. Delivery.—In this connection it is well to define the terms sponta- neous version and evolution. Spontaneous version is where the child changes its position before it 171 172 engages; spontaneous evolution is where it changes its position after it has become engaged. The delivery of a living child in a cross position, without changing it, is impossible. Something must be done to effect a safe delivery, and this is to turn the child so that it will present by either the head or the breech. It has been advised to examine the woman before labor, and if any mal- position is present to correct it by palpation, but very few women will submit to be examined before confinement. But even should the exam- ination be made and the irregularity corrected, it would be a very hard matter to keep it so. Bandages and compresses would have to be used, and a fixed position on one side. Such measures would in all probability break down the health of the woman, and the irritation caused by manip- ulation would tend to provoke premature labor, so that the attempt at cure might prove worse than the disease, especially as in a number of cases nature may correct the irregularity. The best time to interfere is after labor has set in and the os has par- tially dilated, but before the waters have ruptured. Manipulation by palpating the abdomen.—The woman is put on the side on which is the head. The head is manipulated by the right hand while the left hand manipulates the breech. The child is gradually brought around until the head or breech, as may be selected, is present- ing at the os, when the bag of waters is ruptured, and the head allowed to engage. If the abdominal walls are fat or swollen with dropsy so that this cannot be done, the old practice was to resort to podalic version. Cephalic version is, however, preferable. Some authorities teach that if the case is seen before the shoulder en- gages, a good rule is to bring down the nearest part. Braxton Hicks' method of performing cephalic version.— This is sometimes called the combined or the bi-manual method. The hand with which the operator is most skillful should be introduced into the vagina with the thumb, ring, and little fingers doubled over into the palm. The other hand is placed on the abdomen over the uterus, and assists in the manipulation. The index and middle finger of the hand in the vagina are then introduced into the uterus, and with them the shoul- der is shoved toward the feet, bringing the head down toward the os. The other hand assists by bringing the breech into the fundus of the uterus. In this way the child is held between one hand at the breech and two fingers at the head. The head is walked or manipulated with these two fingers until the vertex presents, when the child is held in this posi- tion until the head engages. If there is any delay in delivery, the forceps can be used. This method is best used while the waters are intact, but it can some- times be used after they have broken. Its performance requires a certain 173 174 amount of practice. Should the efforts made not succeed it would be proper to pass the whole hand into the uterus, working only in the inter- vals of pain, shoving the shoulder up while the head is brought down into position. Hicks' method robs version of much of its danger. If the hand is intro- duced into the uterus there is danger of rupture, or the uterus may be torn, leading to septicaemia, or it may be bruised, causing an abscess. Should it be necessary to introduce a hand, the other hand should be placed over the fundus to prevent danger of tearing the uterus from its attachments. Cephalic version is the best way to treat shoulder cases. Where it can-. not be accomplished podalic version must be practised. Podalic Version or version by the feet.—This is commonly done by pulling on the knees instead of the feet. It converts the case into delivery by the breech. Besides being useful in shoulder cases it is useful under other circum- stances. In placenta praevia, when hemorrhage threatens to cause death, the lower extremity can be brought down and used to plug the os. The child may be presenting by the brow or face, and the position of the head cannot be corrected. In such cases it may be necessary to perform podalic version. It may also be useful in inertia and occipito-posterior cases. Operation.—The knee is usually close to the os, so near that it can be brought down by Braxton Hicks' method. If the body turns so that the spine is posterior, it should be further turned until it becomes anterior. If a hand has been brought down, it should not be passed back as was formerly the case, until a fillet has been tied around it to prevent it going up over the head. The old practice was to bring down both feet, but it is now considered better to bring down the most convenient foot, and if this one is not suffi- cient to effect delivery, a fillet can be tied around it while the hand goes up to bring down the other foot. One foot, however, is as a rule all that is necessary. It may be impossible to deliver the feet by Hicks' method, and it then becomes necessary to pass in the whole hand. That with which the operator is most dexterous, is the best one to use. The hand should be lubricated only on the outside, leaving the palm in a condition to grasp firmly. It is then introduced coned until it gets within the uterus, when it is carried to the abdominal surface of the child, and a knee or foot is felt for. The foot can be distinguished from the hand by the greater mobility of the thumb. The elbows point to the breech and the knees to the head. The knee or foot is then brought down through the os. 175 * 176 Podalic version should not be practised tinder certain conditions.—The child should be certainly 28 weeks old, and should be alive. If a child cannot be delivered which will live, or if it is already surely dead, it is not right to subject the woman to this operation. The child would be born afterwards as pulp, or could be delivered by crushing. The os should be fully dilated or nearly so, as dragging a child through a constricted os might cause rupture of the uterus, or kill the child. The bladder and rectum should always be emptied. This operation should not be performed on a moribund woman, as it would hasten her death, and nothing would be gained for the child. It could be delivered preferably by Caesarian section, which will give it a better chance for life. Great care should be observed in introducing the hand, always working in the absence of pain. It should be seen that the pelvis is normal. If Bandl's ring has become so thinned that it has become a thin band of flesh, while all above is a hardened mass, introduction of the hand would, undoubtedly, rupture the uterus, and the woman would perish. It will occur in every doctor's life that he will have desperate cases. If the child has become so tightly wedged into the pelvis by protracted efforts at delivery, so that the fingers or the hand cannot be carried far enough to manipulate the child, or if for any cause version cannot be per- formed, it becomes necessary to mutilate the child. Where labor is allowed to proceed for too long a time, it is possible for the child and the uterus to become decomposed. Some operators have cut off an arm. This is useless mutilation, and this raw surface is liable to cut or perforate the uterus. Decapitation has also been practised. As a rule it is only necessary to crush the head. Obstetrical Operations Performed with the Hand Armed. Fillet.—This is the simplest instrument used, and is one that is always convenient. It may be a simple strip of cotton or linen cloth, or if there is enough time, it may be made as a long, very narrow sack, and stuffed with some soft material. The objection to its use is that it is apt to work into a narrow band, when it is liable to cut. This is not so when it is folded often upon itself or stuffed. It is used altogether as a tractor. It is of use in many ways, but its chief field is to make traction in breech cases. Mode of Using.—It is held bunched in the palm of the hand, with one end over the index finger. This finger is introduced until it reaches to the groin. The finger is then withdrawn, with a rotatory motion, and introduced again with a fold of the fillet on the tip. This procedure'is 177 12 178 continued until enough of the fillet has been pushed up to make it come out on the other side of the thigh. This end is then brought down, leaving the fillet looped around one thigh. The loop should be examined with the finger to see that the genitalia are not caught. Traction is then made by pulling on both ends. If the child is too far up for the finger to be used in introducing the fillet, something else, such as a catheter, can be used as a guide or director, but the finger is better where possible. It is said that the fillet can also be used as a lever to bring the occiput down in head cases. Blunt Hook.—This is used for the same purpose as the fillet. It has the advantage of being stronger and stouter, and is easier to introduce. Recently another blade has been added to guard the point. Previous to this the index finger of the left hand was used. The same care should be exercised not to engage the genitalia. One handle of a Hodge forceps can be used, and answer this purpose first rate. Vectis.—Some are made double, with a blade at each end—one small and the other large. The blade is fenestrated to make it lighter and hold better. It is used both as a lever and a tractor. If the finger fails in making the conversion in 3d and 4th vertex, and in the after-coming head 3d and 4th pelvic, the vectis makes a more powerful lever. It can also be used to assist or make flexion of the head. When it is used as a tractor, the finger is used in lieu of another blade to make counter-pressure. It is dangerous when used this way on account of its liability to slip. When used as a lever, care must be taken not to press on the parts of the woman, as she may be severely bruised in this way. One blade of the forceps can be used-as a Vectis. With a pair of Hodge's forceps, the physician not only has a first-rate instrument, but a blunt hook and vectis as well. Obstetrical Operations with Instruments may be Classified as follows : 1. Operations on the child—beneficent to mother and child. Use of forceps is a good example. 2. Operations on a child already dead, or operations which will kill the child. Made for the benefit of the mother. They have in the past been frequently made, but are generally unnecessary now. 3. Operations on the mother, dangerous to both, but which have as an object saving the lives of both. Caesarian section is a good example. 4. Operations on the mother alone, and beneficent to both. Example: Induction of premature labor. 179 ISO Forceps.—The history of forceps dates back to 1640. Chamberlin's instrument, invented at that date, consisted of two solid flanges of iron, tied together with a string. Their use was kept secret for some time, and in this way the inventors, greatly to their discredit, monopolized their use. The invention consisted in making an instrument that could be taken apart, introduced, and locked again. The original instrument was like a pair of hands, and had only the cephalic curve. In time the secret was bought and given to the profession, and it was then that it began to be improved upon. The first improvement was to make a fenestrum. By this arrangement, when the instrument is clasped to the head, it adds nothing to its thick- ness, as the parietal boss and ear protrude through the fenestrum, and not only does this prevent the diameter being increased, but gives a better hold. The next change was adding the pelvic curve. Locks were then added and improved upon. The first lock was made by having a slot in one blade in which the other blade fitted. This was an English invention. The Germans then put a pivot in one blade which fitted through a slot in the other. Hodge's lock was then added, and makes an instrument which can be made thoroughly aseptic, is very convenient of application, and holds firmly. There was also added another curve to the blade, the concavity of which is at right angles to the cephalic curve, and looks toward the other blade. The fenestrum is also made oval instead of kite-shaped, as it fits the parietal boss better. Hodge's forceps in this way make no dent on the head. When Hodge's forceps are closed the diameter of the concavity between the blades is greater nearer the handle. This fits the head, and when the forceps are pulled upon the head slips back to the smaller portion, wedg- ing in and making the hold tighter. Forceps are of two styles—short and long.—The short can only be used at the inferior strait; the long even before the superior strait is reached bv the head. The short forceps are oftenest required, but the long answers for both, and when only one pair is gotten should be selected. Axis traction forceps are a modification which consists of a hook which fits on the forceps, so that traction can be more conveniently and effectu- ally made along the axis of the parturient canal. Sometimes when compression of the head must be made, it is difficult to continue to hold the blades of the forceps close enough together. A 181 182 string can be used for this purpose, applied around the handles, but a knife or scissors should always be at hand so that it can be immediately severed when it is no longer required. It is very important to have a real good instrument, and only hand- forged should be used. A physician should also have one favorite instru- ment which he uses more frequently than others, as in that way he be- comes well acquainted with it, and can use it to better advantage. Conditions requiring the use of forceps.—Want of power on the part of the woman to deliver. She becomes tired and worn out, and the pains are becoming weaker. Or the head may be too large or unusu- ally ossified, or the pelvis contracted. If the head stops at the inferior strait it may be due to a firm and rigid perineum. The physician should wait for 3, 2?, 2, H, or 1 hour. There can be no fixed rule, but action must be taken entirely on the merits of the case and the condition of the woman and child. When delay is too long it is destructive to the child and the mother as well. It bruises the soft parts of the woman and shuts off circulation, causing possibly sloughing with resulting fistulae, and making the woman perhaps an invalid for the remainder of her life unless she is cured by subsequent operation. When the forceps are properly applied they should not add anything to the pain. They do not add to the stretching of the parts, and any screaming is usually due to fright or the normal pains of delivery. After the head commences to be delivered, there is the pain dependent upon that, but this is inevitable in all deliveries without anaesthesia. The distance between the widest part of the blades is 2] inches, less than that of the child's head. This has been urged as an objection. The same measurement in most other forceps is 31 inches. It is, however, a distinct advantage in the hands of the skillful prac- titioner, as when the head is larger or the pelvis smaller than normal, it allows of compression of the head, thus facilitating delivery. Otherwise the head would in such cases have to be crushed. The head can generally be compressed four lines without danger, and in some cases has been compressed half an inch and a living child de- livered. Some people introduce a finger between the handles to prevent com- pressing too much, but this is not necessary. Rule.—The forceps should be held tight enough to make the head and forceps move as one body. Otherwise the child or mother might be lacerated. Motion in Delivering with Forceps.—There is a disposition in delivering with forceps to make slight motion from side to side. Delivery is thus thought to be facilitated. The motion should be very slight, never moving more than two inches on either side of the medianline. * is 3 184 If the child's head is unusually small, these forceps can close down on it without difficulty. Rules for Application of Forceps.—The os should be completely dilated, or nearly so, and dilatable. If not, introduction of the forceps would be dangerous. The force necessary to dilate the os frequently tears it, incurring for the woman all the evils of laceration. It may also cause rupture of the cervix or uterus. The forceps should not be applied until the bag of waters has ruptured and the head is free of the mem- branes. Otherwise if the membranes are caught, the placenta might be peeled off, which would mean death to the child and serious uterine hemorrhage. The forceps should never be applied without carrying one hand along with the blade as a guide. If this precaution is not taken, it might be forced through the vault of the vagina instead of into the uterus. The concavity of the forceps should be kept in relation to the convexity of the child's head. The point should never rest against the child's head, as it might go in through one of the sutures, or might amputate an ear. Introduction should never be attempted during a pain. As a general rule forceps cannot be applied to a movable head, so the physician when possible should wait until the head becomes fixed. If the forceps are applied when the head is movable, it is liable to be grasped in an improper manner. Under such circumstances version by the breech is generally resorted to. It may happen that the woman is in convulsions, and it becomes necessary to deliver at once. If the head has not become fixed, an assistant should be directed to press down upon the fundus of the uterus. This will steady the head to a certain extent. Obstetricians are divided into two classes as to the manner of applying the forceps. Some teach that the forceps should simply be applied one blade on either side of the pelvis. No successful defense can be made of this teaching. In our opinion if the head is at the inferior strait, it will be grasped properly if the child is in the usual position As it is at this point that failure to deliver usually takes place, less injury than might be expected is done to the child by this method. But it is often required that forceps must be applied higher up. The head is then oblique, and will be grasped in such a way as may mutilate the child. The proper way of applying the forceps is to always apply them with reference to the position of the child's head. When properly applied after this teaching, the long diameter of the fenestrum should correspond to the occipito- mental diameter of the head. The forceps are applied in such a manner as to embrace this diameter, and when the head is oblique the forceps will also be oblique. When traction is made, nature rotates the head, so that when the inferior strait is reached, the blades are then on either side of the pelvis. If this method is not followed and the forceps are applied 1S5 186 on either side of the pelvis when the head is high up and oblique, when the inferior strait is reached the forceps may then lie obliquely in the pelvis, and will be in danger of cutting the woman. So the position of the child should be correctly diagnosed before forceps are applied. It is always good practice to examine every case for position of the child, as it is only in this way that facility in making diagnosis can be acquired, a facility that is often of the greatest importance in properly treating such cases. When the forceps are applied high up it is not necessary to endeavor to rotate the child, but only to make traction, and nature will rotate. Trac- tion is made by pulling a little and then releasing the grip on the forceps to let the child recover. The amount of force to be used should only be such as can be exerted by the arms alone. Forceps should not be applied for the convenience of the practitioner, but only to prevent suffering or to save the life of the mother or child. Naming the blades.—When the forceps have a lock they are named male and female, the female blade being the one with the slot. With the English lock this does not apply, and they are named right and left, and the blade derives its name from the side of the woman on which it is placed. The administration of chloroform rests entirely on the merits of the case. If the woman is nervous and worn out it can be administered, but if she is calm and cool chloroform is not needed any more than if for- ceps were not to be used, as the forceps do not add to the diameter of the head. Some women become frightened at the sight of an instrument, and require chloroform to allay their fears and make them manageable. Position of the woman.—The woman should lie on her back. If she is on her side it is hard to keep her in a fixed position. Mechanism has been studied while she was lying on her back, so it is easier for the practitioner to keep the position of the child in the parturient canal in mind. The hips are brought to the edge of the bed, and the feet placed in chairs. In this way plenty of room is secured to work in, and the depres- sions of the handles of the forceps is not interfered with by the bed. It is also easier to make traction in this way. After a woman has been delivered by forceps once it is common for her to appeal to the physician to use them subsequently. Application of Forceps Considered at the Different Straits. At the inferior strait.—The forceps should be washed with soap and warm water, and then put into a warm antiseptic solution. The prac- titioner's hands and arms are likewise prepared. The bladder and the rectum are emptied of their contents. The blades are applied here paral- 187 1SS lei to the labia. The male or left blade is introduced first. It and the back of the right hand are anointed with vaselin. It is then taken in the left hand with the handle well over the abdomen. With the right hand as a guide the blade is introduced, and depressed between the legs at the same time. If necessary, the handle can then be given to an assistant, but this is usually not necessary, as it is wedged in tight enough to hold itself. The female or right blade is then introduced in the same manner, reversing the hands. With the finger the grasp of the blades is then ex- plored, to be sure that nothing has been accidentally caught. The instrument is then securely locked, and if it is properly applied the handles will be horizontal and the lock look up and down. The handles are gradually elevated as traction is made, so that the handles finally come parallel to the symphisis. The physician should work with the pains or simulate them, and should occasionally feel the head to see that it is in the right place and not slip- ping in the forceps. Sometimes introduction of the blades causes reflex contractions. When this is the cases they are to be disregarded. With the Head in the Cavity of the Pelvis.—This is the next most frequent position. The head is not completely rotated, and lies obliquely in the pelvis. The principles of application are the same as at the inferior strait, but the instrument has to ascend higher, and the forceps when applied, instead of being horizontal will look obliquely. The rule is not to make but to facilitate rotation. Traction must be made downward until the inferior strait is reached, when the handles are elevated gradually as directed in delivery at that point. Many books will say that when the head reaches the vulva the forceps should be removed to prevent injury, and nature will complete delivery. There can be no risk if the forceps are properly handled in allowing them to remain, and removal in this way may be harmful. The blade has to be carried away from the child's head, as the parietal boss has buttoned into it. Thus there is danger of injuring a portion of the scalp or of injuring the mother, and occasionally it happens that the mother is not able to deliver, when the forceps have to be re-applied. This makes an embarrassing situation, and is always to be deplored. At the Superior Strait.—The principles for application here are essentially the same as in the cavity, except that the head is higher up, so that there is greater difficulty in applying the forceps and in with- drawing the child. As the child is in the uterus there is the additional danger from introducing a body into the uterine cavity, and the hand cannot well act as a guide. After the forceps are applied, the handles will look obliquely up and down, and the lock obliquely sideways. 189 190 The head must rotate, but nature will do this as in other cases already considered, and the rule is the same: do not make, but facilitate rota- tion. If the forceps are held loosely in the hand, the head can be felt rotating. Traction is made at first directly downward and forward. The physi- cian should get down on his knees and pull until the head gets into the cavity of the pelvis, when the head is delivered after the manner already given. It is somewhat difficult to make traction in such cases, so Tarnier has devised axis traction forceps. They are applied in the same manner as other forceps, and the principle lies in the addition of an attachment by which traction can be made along the axis of the pelvis. Traction is made with this until the head reaches the cavity of the pelvis, when this is removed, and delivery completed as with ordinary forceps. There are steel hooks which can be applied and used for axis traction on almost all kinds of forceps. These can be removed from the forceps when not required. Sometimes a strap to the knee is used so that the handles can be mani- pulated with the hands, and traction made with the knee. Elliott's Forceps.—These have metal and hard rubber handles, which give a good grip, and can be thoroughly cleansed. There is also a screw in the handle which can be adjusted so that the handles cannot be closed beyond any desired point, the object being to prevent crushing or making too much pressure on the head of the child. The fenestra are so arranged that the child's head cannot so well pro- trude, and they add to its diameter. Elliott's cannot compress the head. There is no danger of making undue compression or crushing the head of the child with the Hodge's forceps, when they are held properly, but it can be done if desired, thus sometimes obviating craniotomy. Application of the forceps at the vulva is the same as at the inferior strait. Saving the perineum.—There is usually more danger of rupture o.f the perineum when delivery is effected by forceps. It is saved in the manner already described, by gathering up the tissue on either side of the vulva, and making a so-called gutter. If the perineum tears, sew it up immediately after the completion of delivery. If there is prolapsus of the cord or of an extremity, especial care must be used not to embrace them with the forceps. In the second position vertex, the application of the forceps is the same as in the first. In occiput posterior cases application is extremely difficult, but the prin- ciple is the same. 191 192 In face cases the same diameters are engaged, except that the face is forward. Forceps are applied on the same principle. In breech cases forceps have been applied to the pelvis, but the practice is not to be commended. Everything needed can be done with the blunt hook or fillet without injuring the child, whereas the forceps are liable to crush the bones or in- jure the intestines. It may be necessary, and it is sometimes desirable, to apply the forceps when the head is being born. This is done on the same principle as in vertex cases. Dangers of the Forceps. To the child.—If properly applied the danger is slight. If the forceps grasp the face great damage may be done, and may result in death. Where the pelvis is small or the head large compression of the head may be fatal. Sometimes the scalp is wounded. Sometimes pressure on the facial nerve causes paralysis, but this usually passes off in a few days. Pressure may cause inflammation, but the indentations from the forceps usually pass off in a few days without injury. To the mother.—There should be no danger if properly applied and manipulated. It has been said that in making a quick delivery that the placenta has been peeled off, causing delayed contraction and retraction, but it has been observed that this objection is not material. The forceps may injure by pulling the child through a tight place. The necessity for doing this is a question which the physician must decide. It often causes less injury than would result from other efforts at delivery. A frequent cause of recto and vesico-vaginal fistulae is not applying for- ceps soon enough, allowing too long compression of the parts, and causing sloughing. Tearing of the perineum and vulva are due' more to a lack of skill. In our opinion, it can be said with truth that the forceps have saved more lives than any other instrument. Operations for Effecting a Delivery where the Head is too Large or the Pelvis too Small for the Child to be Delivered by the Simple Application of Force. Compression of the head.—This can be done with the forceps. It is generally considered that the head can be compressed four lines and effect delivery of a living child. Compression can be carried to six lines with a hope for life, and some authorities say more. If the patient has an antero-posterior diameter of the pelvis of 3} inches, the physician can hope to deliver by making compression with the for- 193 13 194 ceps. Hodge has delivered when the diameter was only three inches, but this can hardly be given as a rule. If a woman with such a contracted pelvis is seen before labor induction of premature labor should be advised, if there is sufficient time before delivery. But if it is too late, or labor has already set in, Caesarian sec- tion should be first advised. This, however, is not always practicable, if, for instance, the head has engaged. Or the child may be dead, when it would be improper to subject the woman to this operation. Symphysiotomy.—This operation consists in dividing the symphisis and displaying the parts. The gain in diameter is, in the opinion of the writer, out of proportion to the risk of the operation, and it is not to be advised. There are two other operations open to choice. Craniotomy and Embryotomy. Craniotomy consists in perforating the head and emptying it of its con- tents, when it will contract so as to be easily delivered. Embryotomy is the name given to the operation where it is necessary to mutilate the child—removing it by piecemeal. It is an operation of the most ancient character, and in recent years has passed into disuse. Most cases can be delivered safely by premature labor, thus avoiding the neces- sity of both of these operations. There are some cases where this operation is not sufficient, and ceph- alotripsy must be resorted to. This consists in crushing the head into a soft mass by means of a cephalotribe. There are still other cases where even this is not sufficient. When the pelvis only measures 2i inches, the danger of delivery per vaginam is so great that Caesarian section is to be unconditionally recommended. Rule.—When the pelvis is contracted to 31 inches, delivery should be effected if possible by compression with forceps. If the pelvis is between 3] and 21 inches, premature labor should be induced if there is sufficient time before delivery, if not Caesarian section should be advised. If consent cannot be gotten for this, craniotomy, embryotomy, or ceph- alotripsy should be performed. If the diameter is less than 1\ inches, Caesarian section is the only re- source left. Cephalotripsy.—The head is crushed in different directions with the cephalotribe until it is reduced to a pulpy mass. Hodge says that the spiculae of bone never cut through the scalp. Its use is rarely to be recommended. It is very dangerous to the mother; kills the child, and the head has still to be delivered after it is crushed. Winckel has de- livered 15,000 cases, and has never used it. Craniotomy accomplishes everything with less danger to the mother. It is an operation that can never pass into oblivion, and will always, in 195 196 some cases, be necessary. It consists in perforating the head, washing out the contents, and afterward crushing the head if necessary. The bladder and rectum should both be emptied, and the patient anaes- thetized. It is advised that the perforator should enter at a suture or fontanelle, but through a well-marked bone does better, and there is no danger of slipping if the instrument is a good one. The head may be perforated with a trephine. This is not generally used. There are a pair of scissors for the purpose with blades opening out- ward, but which require two hands to operate. There is another kind which require only one hand (Naegele's). This makes a perfect per- forator. There is a bar running between the handles to hold the blades together. It is introduced with the blades closed, using one hand as a guide. The point is forced through the skull, the bar at the handles broken, and the blades separated. This is repeated until the skull is well perforated, when it is projected into the brain and that well broken up. The contents of the skull are then washed out with a syringe and aseptic fluid. The skull then usually collapses, and the mother may deliver the child herself. If not, a tractor made for the purpose, is used, having one blade on the outside and one on the inside of the skull. It may even then be necessary to cut the skull up with scissors, removing the pieces with forceps. The crotchet is an instrument used to make traction by inserting it into the foramen magnum or sphenoidal fissure. Craniotomy has been done successfully with a po.cket knife and a small stick tied on a piece of string, when nothing else could be gotten. The head is perforated with the pocket knife, and the stick inserted through the aperture and turned crosswise, when traction is made on the string. Symphisiotomy dates back to 1773, when it was introduced by Sigault. It is said to do good, not only by increasing the diameter of the pelvis, but also by making an opening through which the head can pass. When first introduced it was received very favorably, but afterwards fell into disuse, and has only been revived in the last five or ten years. The operation is, in the opinion of the writer, to be condemned. It is improper because, should the ends of the bones be separated one inch, there is a gain of only five lines in the antero-posterior diameter. It has been found that even this amount of separation is sometimes dangerous, 2 or 3 inches is always so, and often it is necessary in addition to deliver the child with forceps or by craniotomy, as it is impossible to accurately determine the size of the child. The bones have been splayed open as much as H and 2£ and 3 inches. Two inches gives a gain of only three lines over one inch, making the total gain eight lines. Anything over one inch subjects the woman to danger. Women on whom this operation 197 198 has been performed, have sustained serious injury to the bladder and the rectum, and the operation has also been followed by fatal inflammations, or have left fistulae, etc. Very often the joint has failed to regain its vigor of union, so that loco- motion has been interfered with or prohibited. This operation does very little more than can be done with Hodge's forceps. The statistics area mortality of mothers, 33J%; of children, 40%. Method of performing.—The parts are shaved and sterilized. The liga- ments of the joint are then divided with a knife. This operation has been modified by sawing through the rami of the pubes instead of dividing at the joint. This gives more room, but is much more dangerous to the mother. Cesarian Section.—The record of this operation is very old, dating back to 1000 B. C. It was originally suggested in order that a living child might be delivered from a dead mother. This operation is now known as post mortem Caesarian Section. It had been found that where women had died suddenly, as from apoplexy, injury, etc., that by cutting down through the abdomen and uterus the child could occasionally be taken out alive. Caesar is said to have been delivered this way (?). Obstetricians and surgeons believe that the child has lived 25 minutes after the death of the mother. But if 25 minutes has elapsed it is useless to perform the operation. Although it must be done with a certain amount of haste, it should be performed in proper method, so that if, per chance, the mother should not be dead she will not be unnecessarily injured. The operation is more common in recent years. Formerly the mor- tality was so great, 75% dying, and so many of the children, that it was only performed as a last resort. Since aseptic surgery has been intro- duced the mortality has been reduced to 8.2% of the mothers, and 80% of the children have been taken out alive. These statistics are from the best hospitals, and if statistics from private houses were included the mor- tality would doubtless be greater. The maternal mortality when craniotomy has been performed is only 2 to 3%, and where no attempt has been made at delivery with forceps it approaches zero. When these two operations are weighed, one against the other, it is suggested that the woman should take the additional risk in order to save the child. This is explained to the woman and relatives, and they are left to decide. In certain cases there is no choice of operation, as when the pelvis measures 2\ inches or less, or where there is a tumefaction in the canal, *. or cicatrices which will prevent parturition, or where the uterus has passed through a hernia and become pregnant in that position. 199 200 Operation.—The preparation is the same as in other laparotomies. If there is opportunity fordoing so, the time for operation should be selected, the best being when labor has commenced, the os partially dilated, but the bag of waters not broken. Incision is made along the median line even if the patient has been operated on here before. Cutting down the glistening uterus is reached. Assistants then hold the walls of the abdo- men down on the uterus until all bleeding is stopped by ligatures, etc., to prevent the fluids escaping into the peritoneal cavity. The uterus is then turned out of the wound, and partial sutures inserted. An elastic ligature is then passed around the neck of the uterus lightly, and is not tightened until the child is about to be extracted. The uterus is incised along the median line. If possible, cutting down over the site of the placenta should be avoided. The site can be deter- mined to a certain extent by palpation during the intervals between pains. It has been advised to puncture the uterus with a trochar in order to ascer- tain, but this is a dangerous procedure, and not advised, as it makes a hole which may enlarge and result in septic infection. Having determined as well as possible the location of the placenta in order to avoid it, the in- cision is made of sufficient size to permit of extraction of the head and breech. If the incision is insufficient it can be enlarged with a curved probe pointed bistoury. It has been advised to cut through the placenta if the incision is over its centre, but this should not be done unless it is found impossible to peel it off on one side. An assistant then puts one finger in either end of the cut, so that when the bag of waters ruptures the uterus cannot contract and prevent removal of the child. In re- moving, the breech is preferably selected first. Do not sever the cord until the child has breathed freely. If it does not breathe, an attempt should be made at resuscitation. A new and very good method has recently been suggested by Dr. Dew. The asphyxiated child is taken into the hands, and the child is bent up with its feet over its head. This expels the air, and bringing back causes an inspiration. It has the advantage that it can be practised with the child in a basin of warm water, which assists materially in resuscitation. After the child breathes freely, the cord is tied in the usual way and severed, and the child is handed to an assistant. The ligature around the neck of the uterus is then tightened. This is not done before unless necessity forces it, as it shuts off circulation from the child. The placenta is then peeled off, and it, with the membranes, removed. The uterus is washed with a 5% carbolic solution, and dusted with iodoform. It is then sewed up. This is best done by Sanger's method, which con- sists in sewing first the mucous layer, then the muscular, then the peritoneal. Sutures of the abdominal wall are made in the same manner. After treatment is the same as in other laparotomies. 201 202 Porro suggested that as the uterus is liable to be a source of infection, it should always be removed with the tubes and ovaries. He reduced the mortality to fifty per cent. It is now found that since Sanger's operation has been practised that Porro's is not necessary, except where some abnormality of the uterus would require its removal; as where it is wrong congenitally; where it contains a tumor which endangers life; where the woman has osteo-malacia, which is aggravated by each pregnancy; where the uterus is cancerous, or where it is infected and putrid. Unless some of these indications are present, the uterus should not be removed. Where the uterus is removed, the stump is sometimes treated by being brought into the wound and treated externally, but it is better to stitch up the stump after Sanger's method and drop it. 203 CHAPTER XII. INDUCTION OF PREMATURE LABOR. This is comparatively a recent operation. It had been performed as far back as 1756, but not with any frequency until 1831, when it was en- dorsed by the French academy. No obstetrical operation has done so much to save life. It is performed sometimes for the benefit of the mother, but more frequently for the child. With the mother only three per cent. die, while one-third of the children survive. Conditions requiring premature delivery.—These rest some- times with the mother; sometimes with the child. Contraction of the pelvis is the most frequent cause. As has been already stated the forceps can sometimes compress the head of the child half an inch without death of the child; one-quarter, and by some authorities one-third, without any danger. If this amount of compression is sufficient to deliver at term, induction of premature labor should not be practised. But if this amount of compression is not sufficient, choice lies between premature delivery, craniotomy, and Caesarian section. If contraction is only moderate, premature delivery should be advised, if there is sufficient time before term. Measurements of the child's head at different periods.— These measurements are averaged from those given by Tarnier and other men of eminence. At 9 months............3.54 to 3.74 inches. "81 " ............3.35 "8 " ............3.15 " 7i " ............2.96 "7 " ............2.76 No measurements are given for under seven months, as a child born at that time could not live, except in very unusual cases. After the child reaches seven months, its chances for life increase as it approaches term. This table is necessarily only approximate, as children differ in size with different women. The prudent physician will not make a dogmatic asser- tion or prognosis. Care of child born before seven months.—If a child is born between six and seven months, an effort should be made to cause it to live. Incubators for taking care of such children have been devised. A 205 206 very good and cheap one, though not the best, is one which simulates a double-lined bath tub, and has hot water running between the double lining, and is lined on the inside with carded wool. A reasonably good incubator can be extemporized by using a tub- shaped basket, and lining it with a soft sheepskin and filling it with carded wool. This makes a very thorough protection for the child. If a woman's pelvis measures less than 2.76 inches it is useless to advise premature delivery, as the pressure necessarily made on the head of a viable child sufficient to deliver it would result in its death. In such women either abortion must be induced, or she can be allowed to go to term, and have performed upon her Caesarian section. Definition of premature labor and abortion.—Books differ as to the meaning of these two terms. Abortion should be confined to those cases where the child is delivered before its viability, or before seven months; pre- mature labor to those cases where the child is delivered after viability, or after seven months. Other conditions requiring premature delivery.—Contraction of the parturient canal from cicatrices resulting from previous tears. Cancerous tissues and tumefactions. Certain diseased conditions of the woman. Puerperal convulsions. The woman may become so persistently uraemic, either with dropsy or with toxic symptoms, as to require this operation, although she may not have convulsions. Chorea, epilepsy, tuberculosis, pneumonia, pernicious anaemia, etc., have been given as at times sufficient causes for inducing premature labor, but it has been found that it does not improve these conditions. Extraordinary development of the child.—Some, women have children so well developed and so large that their delivery at term in a natural way is impossible, even if the pelvis is normal. In other children the bones are so well developed, and the head so hard, as to make delivery difficult. Other women carry their children over term. This always causes trouble, as the child continues to grow as long as it is in the uterus. Cases have occurred not infrequently where the child has been carried one month beyond term. Experience will usually dictate when premature delivery is indicated in such cases. A warning.—The mother will often say that the child is dead and want to be delivered. The mother should never be considered as a judge of the viability of the child. But even if the child is dead, this is not of itself a justifiable cause for inducing premature labor, although the pregnancy may be multiple, and one child is alive. The child does not putrefy and the woman is not poisoned, and nature will herself shortly bring on delivery. 207 208 The child is born all the more easily when the head is macerated and soft. Besides, there is no absolute rule for being sure that the child is dead, as absence of the foetal heart beat may be due to position of the child and other causes. But if the bag of waters rupture, and the child is dead, labor must be induced if it does not take place. Methods of Inducing Premature Labor.—Operate only on con- sultation. Everything is conducted as in a natural labor, except that chloroform should not be used, as the woman should be wide awake, so that she can render all assistance possible by bearing down, etc., and so preventing unnecessary use of the forceps. Irritation of the breasts.—It has been thought that this would induce labor, but it is not so. Residence in hot climate has been thought a cause, but this is not so. Drugs.—Various drugs have been used for this purpose, notably ergot; but although ergot is a most powerful drug for stimulating uterine con- tractions after they have commenced, it is doubtful if it can initiate them. Quinine has been thought capable of initiating uterine contractions, and it may do it unless the woman has a clear history of malaria. Aloes have also been used, but no drugs can be relied upon. Puncture of the bag of waters.—This is a sure method, but it is not a good one, as it entails serious disadvantages to both mother and child. The simplest and easiest method of doing it is to open the bag at the presenting point. This subjects the child to very great pressure. Puncture higher up with the bougie or catheter preserves the waters for a longer time, but it still subjects the child to such great pressure as to often be fatal. The child, too, is often born with a caul. It is dan- gerous to the mother from its tedious character. This method has been practically abandoned, as the results are not satisfactory. Vaginal douches.—By this method water is allowed to flow into the vagina, using either a bulb or fountain syringe. The quantity is generally several pints, and it is either hot or cold, or alternating one with the other. This method is very uncertain, and when cold water is used it is liable to produce inflammation, and in rare cases the stream has bored a hole through the vaginal vault. Tamponing the vagina.—This acts by irritation of the vagina, and distention from the large mass in it. The pressure interferes with the bladder and rectum, and is liable to cause injury. It is not at all sure. There is a French instrument, the colpeurynter, which has a bulb on the end of a tube. This can be inflated, and acts in the same manner as the tampon. There are the same objections to its use. 209 14 210 Electricity is very uncertain, and is very liable to destroy the life of the child. Its use has been abandoned. Carbonic acid gas.—This is generated in a retort, and directed toward the mouth of the uterus with a pipe. It is very uncertain, and enough is absorbed by the mother to poison her; sometimes fatally. Dilatation of the os and cervix uteri.—This is a very good method, and is certain. It can be done in several ways. When speedy dilatation is necessary the steel dilator is the quickest and best. Dilatation must be performed with great deliberation, as it is liable to rupture the cervix. If proper care is used, the cervix can, in the great mass of cases, be dilated without tearing. Dilatation should be commenced with a very small instrument, then con- tinued with a larger, and then the largest size. After being carried to a certain extent, it can be completed with the fingers, introducing one, two, and three, or Barnes' rubber dilator can be used. This is a fiddle-shaped rubber bag, fitting on a tube. It is dilated by injecting air or water. In such cases it should always be injected with some antiseptic or sterilized fluid. If air is used, and any should escape, it might pass into the vessels of the uterus with perhaps fatal results. The fluid should be aseptic, so that it can do no harm should it escape. Before using, it should be in- jected to ascertain its capacity, as otherwise it might be ruptured. Instead of metal dilators, tents are often used. These may be of sponge, laminaria, or tupelo wood. The laminaria is to be preferred, as it is smooth, although somewhat slow. The sponge tents are apt to lacerate with their sharp points. Using a tent more than once, however sterilized, would be criminal. More recently this dilatation has been effectually and safely accomplished by packing the os and cervix firmly with iodoform gauze. This is removed from time to time, and the opening is again packed until sufficient dila- tation is procured. There are cases where it is proper to use both gauze and metal dilators. This is best for abortions. Introduction of an object between the uterine wall and the bag of waters.—This is the best method for inducing premature labor. A catheter was used in early days, and is a good enough instru- ment if perfectly sterilized. A solid bougie, No. 8, 9, or 10 French, is, however, better, and the surface can be thoroughly cleansed. The shoulder at the end of the bougie should be cut off. No chloroform is necessary. The physician passes two fingers into the vagina, then introduces one finger through the os, and moves it around the inner surface of the uterus. If the finger cannot be introduced through the os, it should be dilated. The bougie anointed with aseptic vaselin is then passed in between the 211 212 membranes and the uterus, and is coiled around the os in as large a circle as possible. There is no need for introducing to the fundus. There is no risk of rupturing the bag of waters, as the field has been explored by the finger. The tampon is sometimes advised afterward, but is not necessary. The bougie introduced at 4 or 5 in the afternoon will usually cause delivery of the child at about 11 or 12 in the forenoon of the next day. This method very seldom fails, and produces a labor that is perfectly natural, except that it is longer. If the first attempt fails, a second can be made. Glycerin has been injected after the following method: A catheter is well disinfected and passed between the membranes and the uterus. Two ounces of glycerine that has been boiled two hours is then injected through this very gently with a syringe. When the glycerine is prepared there should be enough in addition to fill the syringe and catheter to prevent any risk of introducing air, which would be very dangerous. There is danger of rupturing the bag of waters or from breaking the placenta loose from its attachments. Results have not been good when using this method. After labor has been induced the mechanism is the same as in natural cases. Induction of Abortion, i. -'>PvAA^^aa--Ac. : .---^'«^•-.->. i:-"-'-■<•---c:- IONAl lIKDARY OF NLn 0D5730flb S !• v K ^ i ! NLM005730865