Obstetrical Nursing / A Text-Book on the Nursing Care of the Expectant Mother, the Woman in Labor, the Young Mother and Her Baby

by Carolyn Conant Van Blarcom

Fig. 110.—Two types of easily made leggings suitable for use during delivery or obstetrical operations.

Pubiotomy, or hebotomy, consists in sawing through the pubic bone on one side of the symphysis with a string or Gigli saw. This operation is performed in some cases of moderately contracted and funnel pelves, through which the normal expulsive forces of labor are unable to force the child. The separation of the bone allows it to gape, because of the hingelike movement of the sacro-iliac joint, and thus the superior strait is appreciably widened and the child may be delivered by high forceps or version. As the bone heals by fibrous union, there is sometimes permanent enlargement of the pelvis and there are seldom any unsatisfactory after-effects, such as impairment of locomotion. Pubiotomy is sometimes the operation decided upon when a patient is seen for the first time after labor is well advanced, and a conservative Cæsarean section is thought inadvisable because of the risk of infection. But the operation is becoming more and more rare, for the general practice of measuring the pelvis and supervising patients during pregnancy discloses serious disproportions early enough to make a Cæsarean section the elective operation.

Symphysiotomy. This operation is a cutting through the cartilage of the symphysis pubis, instead of through the pubic bone, as in pubiotomy. It was formerly performed for much the same reasons that pubiotomy is now used, but has been practically abandoned since the development of the latter operation. The reasons for giving it up were that the close proximity of the bladder to the symphysis resulted in frequent injuries to that organ, and as the cartilage of the symphysis does not heal as well as the pubic bone, the patients frequently experienced difficulty in walking and showed a tendency to tire more easily after the operation than before it was performed.

Vaginal Hysterotomy, or vaginal Cæsarean section, as it is sometimes called, consists of incising the cervix anteriorly and posteriorly, delivering the child and placenta and suturing the wounds. It is sometimes performed in cases which for some reason require immediate delivery, as in severe cases of eclampsia. It is only possible when the relation between the pelvis and the child’s head is such as to permit the child to pass through the inlet. It is rarely done in primiparæ, because rigidity of the outlet prevents proper exposure; or in multiparæ at term as the incisions have to be extended so high to deliver a term baby, that there is danger of tearing the lower uterine segment.

Cæsarean Section is the operation by means of which the child is delivered through an incision in the abdominal and uterine walls. It is believed by some that the operation was named for Julius Cæsar, who was presumably delivered by this method, but this seems scarcely probable. The operation was frequently fatal in those days and, moreover, as the uterine wall was not sutured after the child was extracted, a woman was not likely to have other children afterward even if she did live, and Cæsar’s mother had several children after he was born. Another explanation for the name is that during Cæsar’s reign a law was passed which required that the abdomen be opened and the child extracted in every case in which a woman died late in pregnancy, as one means of increasing the population.

Thus it will be seen that the operation itself is very ancient, but as performed to-day it embodies the most modern and scientific knowledge and methods. The usual indications for it are cases of contracted or deformed pelves; cases of tumors which block the birth canal or when very speedy delivery is imperative as in some cases of eclampsia.

The anatomical indications for Cæsarean section are dependent upon the degree and character of the pelvic contractions and upon the size and mouldability of the child’s head in relation to the pelvis. This explains why in two women with pelves of the same size and shape, one will have a spontaneous delivery and one will require a section. The former has a relatively small child which can pass through her pelvis; while the second woman’s baby is too large, or the head not sufficiently mouldable, to pass through hers.

This is one exemplification of the great importance of pelvimetry and of constant watching during pregnancy, for the best results from Cæsarean section are obtained when it is recognized that spontaneous delivery is unlikely or impossible; the operation accordingly is performed at a time which is deliberately selected by the obstetrician. The elected time is often about two weeks before the expected date of confinement in order that the baby may have the longest possible intra-uterine life and that the operation may be performed before the patient goes into labor. In these cases in which it is known that a section is to be performed vaginal examinations are omitted after the pelvic measurements are taken, in order to minimize the possibilities of infection, this being one of the great risks of the operation.

Until recent years the operation was usually delayed until after the patient had been vaginally examined, had been in labor long enough to be exhausted and the only other courses open were high forceps or a destructive operation upon the child. The results of the operation undertaken under such circumstances were not good, and the maternal deaths from infection were so frequent that the operation on the whole was very hazardous. But improved surgical technique and extended knowledge of the pelvis have so revolutionized Cæsarean section that it is now successful in the majority of cases.