A System of Midwifery

by Edward Rigby

Such cases seldom permit the application of the forceps; the head is already pressing too firmly against the brim, and its greatest bulk having not yet passed, a still farther increase of pressure will be required to effect this object, which therefore cannot be attained without producing serious mischief. Where, however, the head has fairly engaged in the cavity of the pelvis, and the case is rather becoming one of deficient power, the forceps will be justifiable, and generally quite sufficient to effect the delivery safely.

The young practitioner must be cautious not to mistake an increase in the swelling of the scalp for an actual advance of the head itself—an error which may very easily be committed if he merely touches the middle of the presenting portion: he must carefully examine the circumference of the presenting part, where the head is pressing against the pelvis, and where there is little or no swelling, and he will frequently find to his disappointment, that although the cranial swelling may have even nearly approached the perineum since his last examination, the head itself has remained unmoved.

Where the forceps has been determined upon, we should endeavour to render its action as favourable as possible, viz. by bleeding, by the warm bath, and by evacuating the bladder and rectum before proceeding to the operation: we thus improve the condition of the soft parts, and diminish the chances of its acting injuriously.

From what has now been stated respecting the various circumstances which may tend to aggravate or alleviate the existing degree of pelvic deformity, it will be seen how incorrect and unpractical must be the attempt to classify the means of treatment merely according to the dimensions of the pelvis. To assert that within certain limits of pelvic contraction the child can be delivered by the natural powers, and that beyond these limits the forceps must be used; and that where it proceeds to a certain extent farther, it can only be delivered by perforation, &c. is evidently objectionable: for there are no two cases alike, even supposing that the degree of pelvic contraction is exactly similar; hence, on the one hand, we might (under such fallacious guidance) be induced to trust to the natural powers when they are wholly incompetent to the task, and on the other, to have recourse to art when the real condition of the case justified no such interference.[126]

With regard to the diagnosis and treatment in the case of obliquely distorted pelvis (pelvis obliqué ovata,) our data are still too scanty to enable us to give any decided rules: the immobility of the head, although the antero-posterior diameter appears of its full length, the shortness of one oblique diameter, and consequent undue pressure upon the head in this direction, and the unusual length of the other, are the characteristics which we have observed in the only case of the kind which has come under our notice during life. In all the cases of labour rendered difficult by this condition of the pelvis, which have been collected by Professor Naegelé, the perforation has been strongly indicated; and where the forceps has been used, it has either failed, as with us, or if the delivery has been effected by this means, it has been attended with fatal consequences.

In exostosis of the pelvis we must be guided by our knowledge of the healthy pelvis, and by our carefully ascertaining the form and size of the bony growth, and in what degree it is likely to impede the passage of the child. As in cases of simple projection of the promontory, the head may be capable of passing, but in doing so becomes more or less distorted: thus Dr. Burns quotes a case from Dr. Campbell, where from exostosis within the pelvis, the left frontal bone was so greatly sunk in, as to make the eye protrude. Professor Otto, of Breslau, mentions a woman who had pelvic exostosis being the mother of four children, in each of whom a small portion of the cranium was depressed and not ossified.

An interesting case has been described by Dr. Kyll, of Cologne, where the patient was the mother of seven children; her former labours had been perfectly natural, except that in the last there had been preternatural adhesion of the placenta, which had required to be removed by the hand; in six days after she was seized with feverish symptoms and violent pain at the spot where the placenta had been attached. The attack yielded to proper treatment, but she continued feverish at night with perspirations, frequently deranged bowels, difficulty in passing water, and severe pain in the abdomen, especially when she tried to stand on the right leg. An abscess formed in the right groin, which was opened and discharged a large quantity of pus, from which her recovery was very slow, and in three years afterwards she became again pregnant. When labour came on, no presenting part could be reached; after a long time the feet came down one after the other, but the nates would not advance. Dr. Kyll found the child resting with the hips on the brim of the pelvis, and completely wedged fast by a hard immoveable tumour as large as a hen’s egg, springing from the upper part of the right sacro-iliac symphysis, and apparently having been a result of the pelvic abscess; the child was delivered with great difficulty by embryotomy.

Exostosis of the pelvis.

Perhaps the most remarkable case of pelvic exostosis is that which has been described by Dr. Haber of Carlsruhe, and where also the cause was ascertained to have arisen from a violent fall on the ice when carrying a heavy load upon the head; on coming to herself the woman found that she was unable to move, and in this state was conveyed home; she recovered to all appearances in a few weeks, married, and soon became pregnant. When labour came on it was found impossible to deliver her, from the pelvis being entirely filled with a huge exostosis: the Cæsarean section was performed, but she died, and on examination after death an immense mass of bony growth was found springing from the sacrum, which had been apparently fractured, not only filling up the whole cavity of the pelvis, but arising to a considerable extent above the brim.