Thismeans the escape of a portion of the cord before the child itself. It is most frequent in the irregular presentations, as they do not so fully close up the mouth of the Womb, and it is most likely to occur at the commencement of labor, though not impossible at a later stage. Very often the cord descends when the membranes break, being carried down by the rush of the waters; and sometimes it is already in the sack, or bag, before the rupture takes place. This accident is comparatively frequent, being found to occur as often as once in about three hundred cases.
The causes which produce procidentia of the cord, are most likely these:—A large quantity of liquor amnii, and its sudden discharge,—Unnatural presentations,—Deformities of the superior strait of the Pelvis,—A very long cord,—and rupturing the membranes too early. But it may also happen from other causes with which we are unacquainted.
There is seldom much difficulty in detecting this accident, because if the membranes are broken it protrudes into the Vagina, and if they remain whole it can be felt within the sack, and its pulsation willbe quite distinct. Sometimes, it is true, it may be so firmly compressed, between the fœtus and the walls of the pelvis, that its pulsation may be very indistinct, or even totally suspended for a time; but this only necessitates a little extra care.
Procidentia of the cord may be very serious for the child; in fact, it is a frequent cause of its death. The reason of this will be evident when the functions of the cord are borne in mind. The circulation in it is as necessary for the life of the child before birth, as breathing is after, and when protruded first it can seldom escape being so pressed upon as to stop its circulation, and hence the danger. To the mother it makes no difference whatever, unless it be told and alarm her; or unless violent efforts are made to correct it. She had therefore better not know if it occurs.
If assistance is not rendered in this accident the consequences are almost always fatal to the child, though in some instances the cord has remained hanging from the Vulva several inches, for an hour or more, and still the infant has been saved.
If the fallen cord is detected before the membranes are broken, it may frequently be put back into the Womb without much difficulty. The accoucheur must wait till the mouth of the Womb is fully dilated, and then watch his opportunity, in an interval between two contractions, to push the cord upwards, between the fœtus and the uterine walls. If he succeeds in this, as is usually the case, he must then break the membranes during the next pain, and this will bring the presenting part at once into the upper strait, and so block up the passage. To effect this manœuvre it is requisite to introduce two or three fingers, and sometimes even the whole hand. Itmust never be attempted till the mouth is fully dilated, otherwise the membranes may be ruptured too soon, and the delivery be delayed, thus increasing the danger.
After the rupture of the membranes the replacing of the cord becomes a much more difficult matter, and frequently cannot be effected at all; particularly if the head be descended far down. Every effort however must be made, and if unsuccessful the delivery should be hastened as much as possible. In many such cases theforcepsare applied, and the child brought away at once, because every moment's delay increases the risk to its life.
Several different kinds of instruments have been invented to return the cord, but they are seldom at hand when needed, and none of them are so good as the hand itself.
If the return of the cord cannot be effected, and the progress of the labor will allow of it, the hand is introduced and the child turned, unless the position of the head will allow of the advantageous application of the forceps, in which case they are mostly resorted to. The only general rule is, to terminate the labor as speedily as possible, consistent with the welfare of the mother. In spite of all that can be done the pulsation is often found to cease, and when the child is born it is either quite dead or breathes but a few times.
A very frequent indication that the fœtus suffers from compression of the cord, is a greenish color of the water discharged, owing to the discharge ofMeconiumfrom the child's bowels. This is brought about, most probably, by its straining, and its efforts to relieve itself.
The cord is sometimes too short, and this may operate very unfavorably in many ways. It may keep the fœtus up in the Womb, and prevent it from descending to the bottom of the Vagina,—it may cause the placenta to be torn away too soon, and so lead to serious flooding,—it may pull down and invert the Womb,—or it may make the labor very tedious, and cause the death of the child.
Unfortunately there are but few signs of this accident, even after the rupture of the membranes, and none at all before, that can be depended upon. If the head has descended properly, and the parts be fully relaxed, but still the expulsion is delayed from no obvious cause, it may reasonably be supposed that shortness of the cord exists; and if so there is very soon given a proof of it by a discharge of blood. This is owing either to the breaking of the cord, or to the separation of the placenta, and is frequently the first intimation the assistant has of the accident. All that can be then done is, to conclude the delivery as soon as possible, and in the best way that circumstances will allow.
In some cases the cord is not too short absolutely, but is made so by being twined round the body or limbs of the child, which are oftencut offby it. M. Tasil saw a case where the cord round the neck had nearly severed the head; and Montgomery gives several instances in which the limbs had been amputated in this way. Two of these are represented below:—
PLATE XLIX.Limbs cut off by the CordFig. 1.Fig. 2.Limbs cut off by the Cord.Occasionally the cord can be slipped over the head, or limbs, when wound round them, and the strain upon it be thus removed. If this cannot be done however, and the danger increases, relief may be obtained bycutting the cord, particularly if it be absolutely short. But this must not be done till everything indicates that the labor will probably soon terminate; and the end connected with the child must be carefully held, or tied.
PLATE XLIX.
PLATE XLIX.
Limbs cut off by the Cord
Fig. 1.Fig. 2.
Fig. 1.
Fig. 2.
Limbs cut off by the Cord.Occasionally the cord can be slipped over the head, or limbs, when wound round them, and the strain upon it be thus removed. If this cannot be done however, and the danger increases, relief may be obtained bycutting the cord, particularly if it be absolutely short. But this must not be done till everything indicates that the labor will probably soon terminate; and the end connected with the child must be carefully held, or tied.
Limbs cut off by the Cord.
Occasionally the cord can be slipped over the head, or limbs, when wound round them, and the strain upon it be thus removed. If this cannot be done however, and the danger increases, relief may be obtained bycutting the cord, particularly if it be absolutely short. But this must not be done till everything indicates that the labor will probably soon terminate; and the end connected with the child must be carefully held, or tied.
One Arm.—The descent of one arm along with the head may cause some delay and difficulty, but Nature nearly always overcomes the impediment. It is seldom that the arm can be reduced, and therefore but little can be done at first; if the delivery be evidently arrested by it the accoucheur must at last assist in the most feasible manner. Sometimes even it is necessary for him to apply the forceps.
The Two Arms.—Even this difficulty is oftenovercome spontaneously, though much more rarely than the former one. As soon as it is detected, the accoucheur must endeavor to return one or both of the limbs, if the labor has not proceeded too far; and if he cannot succeed the delivery must be accomplished as soon as possible, either by turning or with the forceps, unless there be reasonable ground for delay.
The Feet.—Either one or both of the feet may also descend with the head, at first, though they usually recede and allow the head to be born alone. When they are so impacted as to prevent the delivery being completed, the accoucheur must interfere. In most cases he will find it quite easy to push the feet above the head, and allow that to descend alone; but if this is not possible he must introduce one hand, grasp the feet with it, and pull them down, while the other pushes the head up. This will turn the child, and if it be in no immediate danger, and the mother is not suffering, the rest may be left to nature; but if the contrary is the case, the delivery must be finished as speedily as possible. When the head is very low down it may be necessary to use the forceps, but great care must be observed not to grasp the feet along with the head when using them.
A Foot and Arm.—The proceeding is the same as with the foot alone. If the limbs cannot be returned the head and arm must be pushed up, while the foot is brought down.
In most cases where there are two or more children the delivery is easier than with one, because they are generally small, and the first one so prepares theway that the rest are born without difficulty. It is also a fact that twins are nearly always born before full term, and consequently are not quite grown.
The expulsion of the second fœtus usually takes place, immediately after the first, though sometimes the Womb stops contracting, and it is not born for half an hour or more, and it may even remain for hours or days. It is a question whether, in such a case, the second delivery should be left for Nature to finish, or whether the accoucheur should terminate it sooner artificially. The most general practice is to wait only about half an hour, and then, if the Womb is still inert, use friction, or other necessary means, to excite it, and accomplish the second delivery as soon as possible. If there be more than two the proceeding is still the same.
Some difficulties may arise however with twins, which it is necessary to be prepared for. Thus the two heads may come together, and mutually impede each other. In this case the one which moves the easiest must be pushed up till the other is descended sufficiently low. One head may also descend with one or two feet; in which case, if the feet cannot be returned, the head must be pushed up, and they must be brought down. The force exerted however, must not be very great at first, becauseone may belong to each of the children, and much injury may be done; a little gentle traction will soon detect this however, with ordinary care. If two arms, or one arm and a foot descend, the same care is also required, before pulling upon them, to ascertain that they are not parts of thetwochildren. Sometimes when the head of one twin descends along with the feet of the other they may, if small, descend together. But if this is impossible, and interference is needed, we must firsttry to push up the head; and if this cannot be done,itmust be drawn upon, not the feet; because if the feet were drawn down the two children would soon occupy the passage together, body and head, and would perhaps become firmly wedged. In nearly every case one of the twins presents by the head and the other by the feet, as formerly shown.
Fœtus too large.—It is very rarely the case that the Fœtus is so large as not to pass easily through a well-formed Pelvis, though such cases have been known. The mode of proceeding is of course precisely the same as if the pelvis were too small. If no means will succeed in abstracting the Fœtus whole, it must be made less; but Nature should be first allowed full time to act with all her force.
Hydrocephalus.—This consists of an accumulation of water in the head of the child, and is usually termed watery head. The bones of the cranium will sometimes be widely separated by it, and the head be made so large that it cannot possibly be born till made less. The causes which produce this disease before birth are unknown.
In cases of hydrocephalus the head does not descend into the straits, owing to its size, and is felt to be full and firm, during a pain, but soft and yielding during the intervals, especially at the fontanelles and sutures, which are also very large. The bones are usually very wide asunder, or even totally separated, as if floating in the fluid.
In some cases, when the quantity of fluid is but small, the delivery may terminate spontaneously;the head lengthening, from being so soft, and thus adapting itself to the size and form of the strait. Most frequently however, assistance is rendered in such cases, either by the forceps, which will sometimes succeed, or by puncturing the head, and letting out the fluid. This operation has been performed and the child saved, though such an occurrence can never be reasonably anticipated. Such instances however, show that great care should be taken not to injure the brain, as that would destroy the small chance there is.
Dropsy may also occur in the chest, or abdomen of the child, causing similar difficulty with dropsy of the head. If the natural or artificial expulsion of the child cannot be effected without, the part must be carefully punctured, and the fluid evacuated.
Tumors on the Fœtus.—Sometimes various kinds of tumors form on the child's body, but they are rarely so large as to prevent delivery, though they may delay it. If they should be too large however, it will be necessary to remove them, as in the case of tumors in the Pelvis.
Occasionally the bones of the head will be so hard, and so closely united, that they will not overlap, in which case the labor may be very difficult, unless the head is small, or the pelvis very large. If after waiting a reasonable time, there be no prospect of the labor terminating naturally, and the female is exhausted, it must be terminated artificially, as if it were a case of deformed pelvis. It is seldom however, that the head does not eventually give way.
Presentations of the Face.—These are usually more difficult, and longer, than those of the head. They will nearly always however, terminate spontaneously, or with ordinary assistance; but, if they should not, artificial delivery must be practised, either by turning, if the case be not too far advanced, or with the forceps. Some of the most celebrated authors recommend that all these cases should be treated like cases of natural labor. Dr. Merriman says that in somevery favorableinstances turning may be practised with safety and advantage; but Dr. Lee says, "My firm belief is, that the child, even under such favorable circumstances, would have a far better chance to be born alive if the labor were left wholly to Nature; or, if the natural powers were inadequate, to be extracted with the forceps." In such cases there is often too little patience, and too much interference.
The forehead inclined against the Pubes.—In this position the labor may be long delayed, and difficult, and most practitioners endeavor to turn the head round, if they cannot bring down the feet, or else apply the forceps at once. Dr. Lee however remarks, and very properly, "From all that I have seen of these cases, I am disposed to believe that it is best to leave them to the natural efforts, and to avoid all interference, all attempts to change the position, while the pains continue regular, and the head advances, however slowly." If the labor does not progress at all, or the female becomes exhausted, of course artificial delivery is necessary.
Severalvarietiesof head and face presentations may also retard labor considerably, but Nature nearly always overcomes the difficulty; or if she cannot do so mere ordinary assistance is required.
It has already been remarked, in another place, that breech presentations mostly terminate spontaneously, and that but few of them require interference. In some of them even, when the pelvis is large, or the fœtus small, the delivery is effected quite rapidly. Still such presentation occasionally causes delay and difficulty, and necessitate more or less assistance.
As soon as the mouth of the Womb is opened sufficiently, unless the labor is rapidly progressing without it, one of the fingers may be introduced andhookedover the groin, and a little gentle force exerted upon it. This will assist very much, and will often be all sufficient. If the pelvis is too small, or the fœtus too large, and the delivery is evidently arrested, the breech must be pushed up, if possible, and the feet be brought down, as in turning. The remarks of Dr. Lee on this presentation are so plain and practical, and marked with such good sense, that I think a better explanation of what should be done in such cases-could hardly be given, I will therefore quote his remarks in full:—
"Having ascertained that the nates present, whatever the position of the fœtus may be, whether the abdomen look backward or forward, we cannot alter it with safety, and no change can be required to be made till the nates and lower extremities are expelled. The os uteri dilates slowly in most casesof nates presentation, but we cannot employ any means with advantage to accelerate the delivery, and in most cases, if we do not interfere, but wait patiently, they are gradually pressed lower and lower into the pelvis, and at last escape from the vagina without any assistance. If the os uteri and vagina are imperfectly dilated, and the nates are drawn down or pass rapidly through the pelvis, the child is often lost. The membranes should not be ruptured, and the expulsion of the nates should be left entirely to the natural efforts, unless the labor is protracted and exhaustion takes place. Except supporting the perineum, nothing is required in a great proportion of these cases before the nates and lower extremities have been expelled, when it becomes necessary to ascertain precisely the relative position of the child to the pelvis, to rectify this if it is unfavorable, and artificially extract the superior extremities and head, to prevent the fatal compression of the umbilical cord. If we find, after the expulsion of the nates and lower extremities, that the toes are directed forward, or that the child is in the position represented in the second figure, with its abdomen applied to the anterior part of the uterus, and that its back lies along the spine of the mother, we should wrap the nates and sides in a soft napkin, and turn the child very gently round during a pain, observing to which side the feet are inclined to turn, till its abdomen is to the spine of the mother, and the toes are directed backward to the hollow of the sacrum, or to the side of the pelvis. In many cases the nates turn round in the passage spontaneously, so that it is not required artificially to alter the position. It is necessary always to recollect that it is possible to turn the body of the child round without turning the face round intothe hollow of the sacrum, and that the chin may be over the symphysis pubis when the front of the chest and abdomen are turned backward. After the lower extremities and body of the child have been expelled, and placed in the most favorable position for the extraction of the superior extremities and head, it is necessary to proceed without loss of time to draw these through the pelvis, that the child may not be destroyed by compression of the umbilical cord. As pressure upon the cord for a very short time will in some cases kill the child, it is proper to watch closely the pulsations of its arteries. Draw the body of the child forward as far as the arm-pits, and place it over the palm of your right hand and fore-arm, and gently draw the body towards the left thigh of the mother; then pass the fore and middle fingers of your left hand along the back part of the left arm of the child to the elbow-joint, and press down the arm with your lingers along the thorax of the child, and extract it. Then transfer the body of the child and left arm to your left hand and fore-arm for support, and with the fore and middle fingers of your right hand disengage and bring down, in the same way, the right arm of the child; then pass the fore and middle fingers of your left hand into the mouth of the child, or rather over the lower and upper jaw, and at the same time place the fore and middle fingers of your right hand over the back part of the neck and occiput, and with the fingers of the two hands thus applied extract the head, in the line of the axis of the pelvis. The perineum is very rigid in some cases of nates presentation, where it is the first child, and it will be torn if the head is extracted hastily, and not drawn forward to the symphysis pubis. When you feel the pulsations of the cord beginning to cease, you maybe tempted to employ greater extracting force than the neck of the child and perineum can bear, and both may be destroyed. The only method of obviating this is to press back the edge of the perineum, that the air may gain admission into the mouth of the child, and the respiration go on, when the circulation in the cord has been arrested, until the perineum is sufficiently dilated to slide back over the face, and allow the head to pass. I have seen from twenty minutes to half an hour elapse in some cases, after the cord had ceased to pulsate, before the perineum would allow the head to escape, during which time the respiration was regularly performed. This is not a new practice; it has been alluded to by some of the older accoucheurs, and some others; and the advantages to be derived from it were fully pointed out some years ago by Dr. Bigelow, in a paper published in the American Journal of the Medical Sciences, 'On the means of affording Respiration to Children in Reversed Presentations.' The object of Dr. Bigelow in this paper is to show that in many cases the life of the child may be saved by forming a communication between the mouth and atmosphere previous to the delivery of the head. If the head be low down, the fingers alone can give the necessary assistance; but if it is high in the pelvis, and is reached with difficulty, the assistance of a tube may be necessary. He recommends a flat tube, which is to be guarded, and kept within the fingers of the inserted hand."Where the pelvis of the mother is small or distorted, and the child large and unfavorably situated, the efforts of nature may be insufficient to expel the child, either alive or dead. The nates may become so firmly impacted in the pelvis, that they cannotadvance without artificial assistance. A finger should be passed up to one of the groins, and when a pain comes on a considerable extracting force may be exerted with it, without injuring the child; or a soft handkerchief may be passed between the thigh and abdomen, and the nates drawn down; but this cannot be done unless they have descended low into the cavity of the pelvis. Where these means fail, and it is impossible to extract the child alive, the blunt hook or crotchet must be employed. In cases of nates presentation, where the pelvis is distorted, after the extraction of the trunk and extremities, it is necessary to perforate the back part of the head, and complete the delivery with the crotchet. In presentations of the feet and knees the treatment does not essentially differ from that required in presentations of the nates."
"Having ascertained that the nates present, whatever the position of the fœtus may be, whether the abdomen look backward or forward, we cannot alter it with safety, and no change can be required to be made till the nates and lower extremities are expelled. The os uteri dilates slowly in most casesof nates presentation, but we cannot employ any means with advantage to accelerate the delivery, and in most cases, if we do not interfere, but wait patiently, they are gradually pressed lower and lower into the pelvis, and at last escape from the vagina without any assistance. If the os uteri and vagina are imperfectly dilated, and the nates are drawn down or pass rapidly through the pelvis, the child is often lost. The membranes should not be ruptured, and the expulsion of the nates should be left entirely to the natural efforts, unless the labor is protracted and exhaustion takes place. Except supporting the perineum, nothing is required in a great proportion of these cases before the nates and lower extremities have been expelled, when it becomes necessary to ascertain precisely the relative position of the child to the pelvis, to rectify this if it is unfavorable, and artificially extract the superior extremities and head, to prevent the fatal compression of the umbilical cord. If we find, after the expulsion of the nates and lower extremities, that the toes are directed forward, or that the child is in the position represented in the second figure, with its abdomen applied to the anterior part of the uterus, and that its back lies along the spine of the mother, we should wrap the nates and sides in a soft napkin, and turn the child very gently round during a pain, observing to which side the feet are inclined to turn, till its abdomen is to the spine of the mother, and the toes are directed backward to the hollow of the sacrum, or to the side of the pelvis. In many cases the nates turn round in the passage spontaneously, so that it is not required artificially to alter the position. It is necessary always to recollect that it is possible to turn the body of the child round without turning the face round intothe hollow of the sacrum, and that the chin may be over the symphysis pubis when the front of the chest and abdomen are turned backward. After the lower extremities and body of the child have been expelled, and placed in the most favorable position for the extraction of the superior extremities and head, it is necessary to proceed without loss of time to draw these through the pelvis, that the child may not be destroyed by compression of the umbilical cord. As pressure upon the cord for a very short time will in some cases kill the child, it is proper to watch closely the pulsations of its arteries. Draw the body of the child forward as far as the arm-pits, and place it over the palm of your right hand and fore-arm, and gently draw the body towards the left thigh of the mother; then pass the fore and middle fingers of your left hand along the back part of the left arm of the child to the elbow-joint, and press down the arm with your lingers along the thorax of the child, and extract it. Then transfer the body of the child and left arm to your left hand and fore-arm for support, and with the fore and middle fingers of your right hand disengage and bring down, in the same way, the right arm of the child; then pass the fore and middle fingers of your left hand into the mouth of the child, or rather over the lower and upper jaw, and at the same time place the fore and middle fingers of your right hand over the back part of the neck and occiput, and with the fingers of the two hands thus applied extract the head, in the line of the axis of the pelvis. The perineum is very rigid in some cases of nates presentation, where it is the first child, and it will be torn if the head is extracted hastily, and not drawn forward to the symphysis pubis. When you feel the pulsations of the cord beginning to cease, you maybe tempted to employ greater extracting force than the neck of the child and perineum can bear, and both may be destroyed. The only method of obviating this is to press back the edge of the perineum, that the air may gain admission into the mouth of the child, and the respiration go on, when the circulation in the cord has been arrested, until the perineum is sufficiently dilated to slide back over the face, and allow the head to pass. I have seen from twenty minutes to half an hour elapse in some cases, after the cord had ceased to pulsate, before the perineum would allow the head to escape, during which time the respiration was regularly performed. This is not a new practice; it has been alluded to by some of the older accoucheurs, and some others; and the advantages to be derived from it were fully pointed out some years ago by Dr. Bigelow, in a paper published in the American Journal of the Medical Sciences, 'On the means of affording Respiration to Children in Reversed Presentations.' The object of Dr. Bigelow in this paper is to show that in many cases the life of the child may be saved by forming a communication between the mouth and atmosphere previous to the delivery of the head. If the head be low down, the fingers alone can give the necessary assistance; but if it is high in the pelvis, and is reached with difficulty, the assistance of a tube may be necessary. He recommends a flat tube, which is to be guarded, and kept within the fingers of the inserted hand.
"Where the pelvis of the mother is small or distorted, and the child large and unfavorably situated, the efforts of nature may be insufficient to expel the child, either alive or dead. The nates may become so firmly impacted in the pelvis, that they cannotadvance without artificial assistance. A finger should be passed up to one of the groins, and when a pain comes on a considerable extracting force may be exerted with it, without injuring the child; or a soft handkerchief may be passed between the thigh and abdomen, and the nates drawn down; but this cannot be done unless they have descended low into the cavity of the pelvis. Where these means fail, and it is impossible to extract the child alive, the blunt hook or crotchet must be employed. In cases of nates presentation, where the pelvis is distorted, after the extraction of the trunk and extremities, it is necessary to perforate the back part of the head, and complete the delivery with the crotchet. In presentations of the feet and knees the treatment does not essentially differ from that required in presentations of the nates."
These are the most dangerous of all the presentations, and most frequently require assistance; in fact the delivery can seldom be terminated naturally when the shoulder presents.
Sometimes the child will pass doubled up, as formerly explained, but this must not be too confidently expected. Dr. Lee says—
"It is now a general rule, established in all countries where midwifery is understood, that in cases of preternatural labor, where the shoulder and superior extremities of the child present, the operation of turning ought to be performed. But the hand must not be forced into the uterus, if the orifice is rigid and undilatable; it should be dilated nearly to thesize of half-a-dollar piece or more, or the margin ought to be very thin, soft, and yielding, if it is expanded to a smaller extent than this when turning is attempted. If the os uteri will not admit the extremities of the fingers and thumb in a conical form to be introduced without much force, if it is thick, hard, and unyielding, some delay is necessary, that the parts may relax, death being almost always the consequence of thrusting the hand with violence through the orifice of the uterus in a rigid and undilatable condition, whether the membranes be ruptured or not. But as soon as it will admit of the safe introduction of the hand, where you have ascertained that an arm presents, no time should be lost in completing the delivery, otherwise the membranes may give way, the liquor amnii be evacuated, and a case of little difficulty and danger be suddenly converted into one equally hazardous to the mother and child. In all cases of labor, where the first stage is far advanced without the nature of the presentation being positively determined, or a superior extremity is felt through the membranes, the patient should be kept in the horizontal position, that they may not be ruptured; and you should remain in constant attendance upon the patient, and be prepared to interfere the instant the necessity arises."
"It is now a general rule, established in all countries where midwifery is understood, that in cases of preternatural labor, where the shoulder and superior extremities of the child present, the operation of turning ought to be performed. But the hand must not be forced into the uterus, if the orifice is rigid and undilatable; it should be dilated nearly to thesize of half-a-dollar piece or more, or the margin ought to be very thin, soft, and yielding, if it is expanded to a smaller extent than this when turning is attempted. If the os uteri will not admit the extremities of the fingers and thumb in a conical form to be introduced without much force, if it is thick, hard, and unyielding, some delay is necessary, that the parts may relax, death being almost always the consequence of thrusting the hand with violence through the orifice of the uterus in a rigid and undilatable condition, whether the membranes be ruptured or not. But as soon as it will admit of the safe introduction of the hand, where you have ascertained that an arm presents, no time should be lost in completing the delivery, otherwise the membranes may give way, the liquor amnii be evacuated, and a case of little difficulty and danger be suddenly converted into one equally hazardous to the mother and child. In all cases of labor, where the first stage is far advanced without the nature of the presentation being positively determined, or a superior extremity is felt through the membranes, the patient should be kept in the horizontal position, that they may not be ruptured; and you should remain in constant attendance upon the patient, and be prepared to interfere the instant the necessity arises."
Speaking of the operation of turning in these cases he remarks as follows:—
"In some favorable cases of shoulder and arm presentation, the uterus is widely dilated before the membranes are ruptured and the liquor amnii discharged; and no difficulty is experienced in passing the hand into the uterus, laying hold of the feet, andextracting the child by the operation of turning. If the uterus is not contracting strongly and at short intervals, little resistance is offered to the introduction of the hand, and the delivery may be speedily accomplished with safety both to the mother and child. But if the membranes have burst, the liquor amnii escaped, and the uterus has been contracting firmly upon the child many hours before the operation of turning is attempted, the child is often destroyed by the pressure, and the coats of the uterus exposed to great danger from contusion and laceration in passing up the hand and bringing down the feet. The shoulder and thorax become so strongly impacted in the pelvis, that great force is required to introduce the hand to grasp the feet, and much exertion necessary before the position can be changed."In other cases of shoulder and arm presentation, the membranes burst and the liquor amnii escapes at the commencement of labor, and the os uteri is rigid and undilated, so that the hand cannot be passed into the uterus after the labor has continued many hours. The difficulty and danger of these cases is greatly increased when the uterus is contracting with violence, and the pelvis is distorted, or a disproportion exists between the child and pelvis from any other cause. The greater number of women, if abandoned to the efforts of nature under these circumstances—the uterus having no power to alter the position of the fœtus—would ultimately die undelivered, from exhaustion or rupture of the uterus and vagina."
"In some favorable cases of shoulder and arm presentation, the uterus is widely dilated before the membranes are ruptured and the liquor amnii discharged; and no difficulty is experienced in passing the hand into the uterus, laying hold of the feet, andextracting the child by the operation of turning. If the uterus is not contracting strongly and at short intervals, little resistance is offered to the introduction of the hand, and the delivery may be speedily accomplished with safety both to the mother and child. But if the membranes have burst, the liquor amnii escaped, and the uterus has been contracting firmly upon the child many hours before the operation of turning is attempted, the child is often destroyed by the pressure, and the coats of the uterus exposed to great danger from contusion and laceration in passing up the hand and bringing down the feet. The shoulder and thorax become so strongly impacted in the pelvis, that great force is required to introduce the hand to grasp the feet, and much exertion necessary before the position can be changed.
"In other cases of shoulder and arm presentation, the membranes burst and the liquor amnii escapes at the commencement of labor, and the os uteri is rigid and undilated, so that the hand cannot be passed into the uterus after the labor has continued many hours. The difficulty and danger of these cases is greatly increased when the uterus is contracting with violence, and the pelvis is distorted, or a disproportion exists between the child and pelvis from any other cause. The greater number of women, if abandoned to the efforts of nature under these circumstances—the uterus having no power to alter the position of the fœtus—would ultimately die undelivered, from exhaustion or rupture of the uterus and vagina."
Fortunately these cases are very rare, and when assistance is renderedearly, the difficulty is readily overcome. This is a strong reason why all women especially should know what to do, because a little timely help may save much suffering, or even life.
SECTION VII.ACCIDENTS DURING LABOR WHICH MAY COMPROMISE THE MOTHER'S LIFE.
ACCIDENTS DURING LABOR WHICH MAY COMPROMISE THE MOTHER'S LIFE.