A System of Midwifery

by Edward Rigby

Where, however, the circumstances of the case require that labour should be hastened in order to avert the impending danger, the extraction of the child with the feet foremost, by means of the hand alone, becomes a distinct operation.

The artificially changing the child’s position into a presentation of the feet is indicated in cases where, on account of malposition of the child, the labour cannot be completed, or at least without great difficulty.

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 circumstances, 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 circumstances. (Naegelé, Lehrbuch der Geburtshülfe, §§ 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 fœtus, 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 circumstances 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 circumstance 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 vagina 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 circumstances, 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, cushiony, and dilatable.

In cases which require turning as a means of hastening labour, as for instance in flooding from placenta prævia and other causes, the hæmorrhage 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 practitioners 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 practitioner 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 vagina as the patient lies on her left side, the right is moreover preferable, as we can pass it more completely in the axis of the vagina, 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 passing the hand into the uterus, as in placenta prævia, and occasionally in shoulder presentations; and it would be by no means justifiable to make the patient undergo the suffering from a repetition 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.