Part 16 (2/2)
_Indications._ The artificially delivering the child with the hand alone, or the extraction of it with the feet foremost (which of course presumes that it has presented with the feet, either originally or has been brought into that position by interference of art,) is indicated in all cases where the labour requires to be artificially terminated either on account of insufficiency of the expelling powers, or from the occurrence of dangerous symptoms. Under this head, on the part of the mother, are violent floodings, especially under certain circ.u.mstances, convulsions with total loss of consciousness, great debility, faintings, danger of suffocation from difficulty of breathing, violent and irrepressible vomiting, rupture of the uterus, death of the patient, &c.;--on the part of the child, prolapsus of the cord under certain circ.u.mstances. (Naegele, _Lehrbuch der Geburtshulfe_, ---- 394, 395. 3d edit.) Hence, therefore, the general indications of turning are the same as those of the forceps, it being indicated in all those cases where nature is unable to expel the foetus, or which demand a hasty delivery of the child, but which cannot be attained by the application of the forceps.
Turning is an operation which is far inferior to that of the forceps, both as regards the safety of the mother and her child, and also the ease with which it is performed. Whenever the circ.u.mstances under which it is undertaken are unfavourable, it not only becomes a very difficult operation, but also one of considerable danger: for the child especially is this the case, as the very circ.u.mstance of its being born with the feet foremost shows that it is necessarily exposed to the same dangers as those already mentioned in nates presentations, in addition to those of the first part of the operation, viz. the changing its position.
The most favourable moment for undertaking the operation of turning is when the os uteri is fully dilated and the membranes are still unruptured.
In this state, the v.a.g.i.n.a and os uteri are most capable of admitting the hand, and the uterus, from being filled with liquor amnii, is prevented contracting upon the child, the position of which is changed with great ease and safety; but when the os uteri is only partially dilated, its edge thin and rigid, the membranes ruptured, and the liquor amnii drained off for some hours, it becomes a matter of great difficulty and danger either to introduce the hand into the uterus under such circ.u.mstances, or to attempt changing the child's position: the os uteri tightly encircles the presenting part, and the uterus contracts upon the child itself so as to render it nearly, if not altogether immoveable.
The os uteri ought always if possible to be fully dilated: this however is not so essential as with the forceps, for when once it has reached the size of a crown piece, it mostly yields easily to the introduction of the hand. Where turning is indicated in malposition of the child we may safely await its full dilatation so long as the membranes remain unruptured.
Where the membranes have been ruptured some hours and the os uteri hard, thin, and rigid, it will be impossible to turn until, either spontaneously or by proper treatment, it becomes soft, cus.h.i.+ony, and dilatable.
In cases which require turning as a means of hastening labour, as for instance in flooding from placenta praevia and other causes, the haemorrhage is seldom so severe as to demand it without at the same time rendering the os uteri so relaxed as to present little or no obstruction to the hand.
Where convulsions indicate turning, the bleeding and other depleting measures, which are necessary to control them, will have a similar effect in preparing the os uteri for this purpose.
In ordinary cases of turning there will be no need to change the patient's position, as it will be just as easy to perform it as she lies upon her left side, merely bringing her pelvis nearer to the side of the bed in order to reach her with greater facility. Where, however, from the position of the child or from the state of the uterus, the introduction of the hand and searching for the feet will probably be attended with considerable difficulty, it may be advisable to place her across the bed, sitting upon its edge, her back supported by pillows, her feet resting on two chairs, in the same way as it is used by the Continental pract.i.tioners for applying the forceps; or if it be really a case of very unusual difficulty, it will be better to put her upon her knees and elbows, for in this position we gain the upper and anterior parts of the uterus with greater ease.
In choosing which is the best hand for performing the operation, the pract.i.tioner must not only be guided by the position of the child, but also by the hand with which he possesses most strength and dexterity: many always use the left hand for turning when the patient lies upon her left side; for our own part we have always used the right, and have never failed except in one or two cases of great difficulty, where we judged it more prudent to put the patient on her knees and elbows than risk any injury by using too much force. In introducing the hand into the v.a.g.i.n.a as the patient lies on her left side, the right is moreover preferable, as we can pa.s.s it more completely in the axis of the v.a.g.i.n.a, than we can the left.[88]
The directions which are usually given to introduce one hand or the other according to the child's position, are not practical, because cases occur where it is impossible to ascertain this point without pa.s.sing the hand into the uterus, as in placenta praevia, and occasionally in shoulder presentations; and it would be by no means justifiable to make the patient undergo the suffering from a repet.i.tion of this operation, merely because the position of the child is such as is stated in books to require the left hand instead of the right.
Having evacuated the bladder and r.e.c.t.u.m, and greased the fore-arm and back of the hand, we should gently insinuate the four fingers, one after the other, into the os externum: the whole hand must be contracted into the form of a cone; the thumb will pa.s.s up easily along the palm; the pa.s.sage of the knuckles is the most difficult, for as the os externum is the narrowest part of the v.a.g.i.n.a, and the hand is widest across the knuckles, it follows that this is the point of the greatest resistance and suffering, and that, when once this is overcome, our hand will advance with greater ease both to ourselves and to our patient. This part of the operation can scarcely be conducted too gradually or gently, for if we give the soft parts sufficient time to yield, it is scarcely credible what an extent of dilatation may be effected by a comparatively moderate degree of pain; the os externum is also the most sensitive part of the v.a.g.i.n.a, and serious nervous affections may even be provoked by the intolerable agony arising from a rude and hasty attempt to force the hand through it.
We must not advance the hand merely by pus.h.i.+ng it onwards, but endeavour to insinuate it by a writhing movement, alternately straightening and gently bending the knuckles, so as to make the v.a.g.i.n.a gradually ride over this projecting part as the hand advances.
In pa.s.sing the os uteri the same precautions must be observed, particularly when the os uteri is not fully dilated; at the same time we must fix the uterus itself with the other hand, and rather press the fundus downwards against the hand which is now advancing through the os uteri. In every case of turning we should bear in mind the necessity of duly supporting the uterus with the other hand; for we thus not only enable the hand to pa.s.s the os uteri with greater ease, but we prevent in great measure the liability there must be to laceration of the v.a.g.i.n.a from the uterus, in all cases where the turning is at all difficult. ”In those cases (says Professor Naegele) where artificial dilatation of the os uteri is required to let the hand pa.s.s, it should be done in the following manner:--during an interval of the pains, we introduce, according to the degree of dilatation, first two, then three, and lastly four fingers; and by gently turning them and gradually expanding them we endeavour to dilate it sufficiently to let the hand pa.s.s. This must only be done under circ.u.mstances of absolute necessity and always with the greatest caution--in fact, only in those cases where the danger consequent upon artificial dilatation of the os uteri is evidently less than that, to avert, which we are compelled to turn before it is sufficiently yielding or dilated.” (_Lehrbuch der Geburtshulfe_, p. 212. 3tte ausgabe.) This observation from so high an authority evidently applies to those cases where the os uteri is not only soft and yielding, but also nearly dilated; the _forcible_ dilatation of the os uteri is justly deprecated by Madame la Chapelle: ”I never attempt to produce this forced dilatation, _not even in cases of haemorrhage_. But we may frequently promote the dilatation of the pa.s.sages in a remarkable manner by moistening and relaxing them and diminis.h.i.+ng their state of excitement, viz. by the steams of hot water, tepid injections, and more particularly by warm baths and bleeding.” (p.
49.) Her diagnosis of the condition in which the os uteri will yield to the introduction of the hand is well worthy of attention. ”If the inactive uterus be unable to expel the child, or to make the head clear its orifice although considerably dilated, if, in this state of affairs, the membranes give way, we can feel the os uteri retract, from being no longer pressed upon. How different is this state of pa.s.sive contraction to the rigidity of an orifice which has not yet been dilated: in this case, although the os uteri is contracted and even thick, it is soft, supple, and easily dilatable; there is no feeling of tightness or resistance; it is little else than a membranous sac, and the head has not descended sufficiently to press upon it; or if the head does not present, it is some part of the child, as for instance the shoulder, which is unable to advance and act upon the os uteri: in this case operate without fear--in the other wait.”
(_Pratique des Accouchemens_, p. 86.)
If the membranes be not yet ruptured we should use the greatest caution to preserve them uninjured: the hand must be gently insinuated between them and the uterus, and should be pa.s.sed either until the feet are felt, or at least, until it has gained the upper half of the uterus. Now, and not till now, ought they to be ruptured. As this is done at the side of the uterus little or no liquor amnii escapes, for the torn membranes are pressed closely against the uterine parietes, and the v.a.g.i.n.a is completely closed by the presence of the arm in it acting as a plug; the uterus is unable to contract upon the child on account of the fluid which surrounds it, and the hand, therefore, pa.s.ses up with great facility. The uterus is not diminished by the loss of its liquor amnii; its contractile power is, therefore, not increased. When the hand has broken the membranes it can move about in perfect freedom: if the feet have not as yet been reached they will now be easily found, and the position of the child will be changed without difficulty.
The importance of pa.s.sing in the hand without rupturing the membranes was first shown by Peu in 1694.[89] But it excited little or no notice at the time, not even by La Motte, who paid so much attention to improving the operation of turning. Dr. Smellie appears to have been the first after Peu who recommended this mode of practice, although he makes no mention of his name. ”Then introducing one hand into the v.a.g.i.n.a we insinuate it in a flattened form within the os internum, and push up between the membranes and the uterus as far as the middle of the womb: having thus obtained admission, we break the membranes by grasping and squeezing them with our fingers, slide our hand within them without moving the arm lower down, then turn and deliver as formerly directed.” (_Treatise on the Theory and Practice of Midwifery_, vol. i. p. 327. 4th edit.) In 1770, Deleurye again pointed out the value of this mode of introducing the hand, and expressly directs us ”introduire la main dans la matrice _sans_ percer la poche des eaux, detacher les membranes des parois de ce viscere, et les percer a l'endroit ou l'on juge que les pieds peuvent le plus naturellement se trouver.”[90] Dr. Hamilton, of Edinburgh, five years afterwards recommended the same method, and in nearly the same terms. Little notice, however, has been taken of it since, either in this country or upon the Continent, and the old objectionable mode of rupturing the membranes at the os uteri is still taught even by the most modern authors. The celebrated Boer also added his testimony in favour of Deleurye's mode of practice,[91] and it has still farther been confirmed by Professor Naegele.
Turning under these circ.u.mstances is an easy operation, and a very different affair compared with its performance in cases in which the membranes have been some time previously ruptured, and the uterus drained of liquor amnii: the hand is pa.s.sed up with difficulty, the feet are quickly found, and the child moved round with a degree of facility which is scarcely credible. Where, however, the uterus is irritable and closely contracted upon the child, the liquor amnii having long since escaped, where the os uteri is not more than two-thirds dilated, its edge thin, hard, and tight, as is especially seen in a neglected case of arm or shoulder presentation, every step of the operation is attended with the greatest difficulty, and in fact is neither possible nor justifiable, until by bleeding to fainting, by the warm bath and opiates, we have succeeded in producing such a degree of relaxation as to enable us to introduce the hand. ”Blood-letting is the only remedy with which we are acquainted that has any decided control over the contracted uterus. It is one almost certain of rendering turning practicable under such circ.u.mstances, if carried to the extent it should be. A small bleeding in such cases is of no possible advantage, for unless the pract.i.tioner means to carry the bleeding to its proper limits, which is a disposition to, or the actual state of syncope, he had better not employ it.” (Dewees'
_Compendious System of Midwifery_, -- 629.) ”The v.a.g.i.n.a is never so soft, so dilatable, and capable of admitting the hand as during the presence of an active haemorrhage, and this is equally the case in primiparae as in those who have had several children: and it is a mistaken kindness in the medical attendant, who in order to spare his patient's sufferings, under these circ.u.mstances delays to introduce his hand until the haemorrhage shall have ceased. The moment this is the case, the v.a.g.i.n.a regains more vitality, sensibility and power of contraction, the hand now experiences much more opposition, and excites far greater pain than during the state of syncope.” (Wigand, _Geburt des Menschen_, vol. ii. p. 428.)
When once a powerful impression has been made upon the system by an active bleeding, opiates, which before it, would have only tended to render the patient feverish, are now of great value: they relax the spasmodic action of the uterus, allay the general excitement and irritability, and induce sleep and perspiration. As with bleeding in these cases, they must be given in decided doses: a grain of hydrochlorate of morphia given at once, or in two doses quickly repeated, and at the same time from half a drachm to a drachm of Liquor Opii Sedativus thrown into the r.e.c.t.u.m with a little thin starch or gruel, will rarely or never fail to produce the desired effect. The opiate by the mouth may be advantageously combined with James's powder, and thus a.s.sist its diaph.o.r.etic action. The warm bath will also prove a valuable remedy.
”If the arm or funis of the child presents and is prolapsed into the v.a.g.i.n.a, we must not try to push back these parts into the uterus again, but we must endeavour to pa.s.s our hand along the inner surface of the presenting arm; or if it be the cord, we must guide it so as to press the cord as little as possible: if however a coil of it has pa.s.sed out of the v.a.g.i.n.a and is still beating, we had better carry it upon the hand with which we are about to turn the child.” (Boer, _op. cit._ vol. iii. p. 5.
1817.) For farther information on this head we must refer to the observations on _Malposition of the Child_.
If the head or nates be occupying the brim of the pelvis it will be necessary to raise them gently and press them to one side: this however is usually effected by the very act of pa.s.sing up the hand, and seldom produces any difficulty, unless these parts have already advanced deeper into the pelvis; in which case, as turning under these circ.u.mstances can only be undertaken with a view to hasten labour, it will become a matter of consideration whether we shall not be able to attain this object better by the aid of the forceps.
Although it ought ever to be considered as a rule that turning must not be attempted whilst the pains are violent, the introduction of the hand into the uterus always excites it more or less to contraction: the degree of pressure and impediment which it will produce to the progress of the hand will in a great measure depend upon the quant.i.ty of liquor amnii which it contains. Where the uterus has been drained of the fluid, every contraction will be felt in its full force by the operator: his hand is firmly jammed against the child, and if it happens to be caught in a constrained posture at the moment, is liable to be attacked with a severe fit of cramp, which benumbs and renders it powerless. Wherever we find that the hand is tightly squeezed during a pain, we should lay it flat with the palm upon the child, and hold it perfectly still: in this posture it will bear a powerful contraction without inconveniencing ourselves or injuring the uterus; and by letting it be quite flaccid and motionless we shall not provoke the uterus to farther exertions. Attempting to turn during the pain would not only be useless, but we should exhaust the strength of our hand which cannot be spared too much; we should torture the patient unnecessarily, and run no small risk of rupturing the uterus.
In letting the pressure of our hand be upon the child during a pain, instead of against the uterus, we must select any part rather than its abdomen, for pressure here seems to act as injuriously as pressure upon the umbilical cord.
_Rules for finding the feet._ In searching for the feet we must endeavour to gain the anterior surface of the child, for (unless its position be greatly distorted) they are usually turned upon the abdomen: in arm presentations the position of the hand will also guide us, the palm of it being mostly turned in the same direction as the abdomen, and therefore points to the situation of the feet; the rule also, as above given by Boer, of pa.s.sing the hand along the inside of the presenting arm, is well worthy of recollection, for this can scarcely fail to guide us to the anterior part of the child. Where, either from the pressure of the uterus or other circ.u.mstances, it is difficult to distinguish the precise position of the child, it will be better to follow Dr. Denman's simple rule, that the hand ”must be conducted into the uterus, on that side of the pelvis where it can be done with most convenience, because that will lead most easily to the feet of the child.” The soft abdomen, the curved position of the child, and its extremities crossed in front are so many reasons why there should be more room in this direction.
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