Having evacuated the bladder and rectum, 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 pass up easily along the palm; the passage of the knuckles is the most difficult, for as the os externum is the narrowest part of the vagina, 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 vagina, 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 pushing it onwards, but endeavour to insinuate it by a writhing movement, alternately straightening and gently bending the knuckles, so as to make the vagina gradually ride over this projecting part as the hand advances.
In passing 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 pass the os uteri with greater ease, but we prevent in great measure the liability there must be to laceration of the vagina from the uterus, in all cases where the turning is at all difficult. “In those cases (says Professor Naegelé) where artificial dilatation of the os uteri is required to let the hand pass, 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 pass. This must only be done under circumstances 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 Geburtshülfe, 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 hæmorrhage. But we may frequently promote the dilatation of the passages in a remarkable manner by moistening and relaxing them and diminishing 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 passive 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 passed 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 vagina 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, passes 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 passing 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 vagina 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, détacher les membranes des parois de ce viscère, et les percer à l’endroit où 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 Naegelé.
Turning under these circumstances 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 passed 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 circumstances, if carried to the extent it should be. A small bleeding in such cases is of no possible advantage, for unless the practitioner 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 vagina is never so soft, so dilatable, and capable of admitting the hand as during the presence of an active hæmorrhage, and this is equally the case in primiparæ 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 circumstances delays to introduce his hand until the hæmorrhage shall have ceased. The moment this is the case, the vagina 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 rectum 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 assist its diaphoretic action. The warm bath will also prove a valuable remedy.
“If the arm or funis of the child presents and is prolapsed into the vagina, we must not try to push back these parts into the uterus again, but we must endeavour to pass 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 passed out of the vagina 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 passing 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 circumstances 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 quantity 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.