A System of Midwifery

by Edward Rigby

Rules for finding the feet. In searching for the feet we must endeavour to gain the anterior surface of the child, for (unless its position be greatly distorted) they are usually turned upon the abdomen: in arm presentations the position of the hand will also guide us, the palm of it being mostly turned in the same direction as the abdomen, and therefore points to the situation of the feet; the rule also, as above given by Boer, of passing the hand along the inside of the presenting arm, is well worthy of recollection, for this can scarcely fail to guide us to the anterior part of the child. Where, either from the pressure of the uterus or other circumstances, it is difficult to distinguish the precise position of the child, it will be better to follow Dr. Denman’s simple rule, that the hand “must be conducted into the uterus, on that side of the pelvis where it can be done with most convenience, because that will lead most easily to the feet of the child.” The soft abdomen, the curved position of the child, and its extremities crossed in front are so many reasons why there should be more room in this direction.

During all this time the other hand placed externally will be of great service, not only in supporting the uterus, but in fixing the child and rendering the different parts of it more attainable. Where the feet are at some distance, we frequently come first to an arm or thigh, which soon leads us to the elbow or knee; if the introduction of the hand has been attended with some difficulty, it will not be very easy to distinguish these joints from each other, without bearing in mind the following diagnostic points:—the knee present two rounded prominences (condyles of the femur) with a depression between them, whereas, the elbow presents also two rounded prominences, but with a sharp projection (olecranon) between.

If the foot is not easily reached, there will be no need of forcing up the hand farther to gain it: it will be much better and safer to hook the finger into the bend of the knee and hold by it for a pain or two: this will generally be sufficient to bring it within reach; or during an interval of the pains, the leg may be gently disengaged and brought down. Not unfrequently we can only feel the toes with the extremities of our fingers, and therefore cannot maintain a sufficient hold upon the foot so as to bring it down: here again the same rule will be applicable, for by keeping but a slight hold upon it during a pain, it will be found to have approached nearer when the pain has gone off; in fact our first attempt to move the child must be done in this cautious manner, and we shall effect our object with greater certainty by merely holding the feet still during the pain, not allowing them to recede from that position in which we had placed them during the intervals, than by using considerable efforts to bring them to the os uteri. By the time we have got one foot fairly within grasp, the other is seldom very distant and should always be brought down if possible: by bringing down both feet we cause the hips of the child to enter the brim of the pelvis more equally; whereas, if one leg only is brought down, the pelvis of the child comes more or less awry, and the ischium of the other side is apt to lodge against the brim of its mother’s pelvis.[92] This practice has been recommended on the grounds that, by bring down only one leg, we make the presentation rather resemble a breech case, which is known to be more favourable for reasons already mentioned, and that by having the other leg turned upon the abdomen it will protect the cord from undue pressure. As far as the abdomen is concerned this may possibly be the case, but the pressure of the head upon the cord, which is the real source of danger to the child in turning, can in no wise be influenced by this position.

In bringing down the feet it must be done with the articulation, that is, the child must be turned forwards; at the same time the hand upon the abdomen, externally, will be of great service in assisting us to move the child, and in preventing the change of its position from taking place in too sudden and violent a manner, a circumstance which is apt to paralyze the uterus considerably, and even produce alarming symptoms from the shock it occasions.

Extraction. When once we have brought the feet into the vagina, the first part of the operation, viz. the changing the position of the child, is completed: it has now become a presentation of the feet, and as such ought to be treated, unless some source of danger be present which requires that the delivery should be hastened. The value of this practice in footling cases was first pointed out by Deleurye,[93] and particularly applied to the second act of turning by Wigand. “I have made it,” says he, “a strict rule in turning, from the moment that I have brought a foot of the child as far into the vagina as I can without force, to do nothing beyond patiently waiting for the return of the pains, even if this did not take place for many hours, and leaving the rest of the labour entirely to nature. I have found by doing so that when the pains at length began to expel the child, they did it with so much force and activity as was not even seen in the most natural case of head presentation.” (Geburt des Menschen, vol. ii. p. 130.)

As the feet descend towards the os uteri, the presenting part, particularly if the arm has been prolapsed into the vagina, begins to recede, the hand externally will assist in moving the child round, and we should perform this step of the operation so gradually as to be assured that the presenting part has quitted the pelvis before the feet have entered. Without attention to this point, the child may easily be fixed across the upper part of the pelvis, or even the body brought down, while the head is wedged into the cavitas iliaca of the ilium, and produce a serious obstacle to its farther advance. This is a sort of mishap which can rarely happen except to young practitioners. If the process be slowly and carefully conducted, we doubt much if it be ever necessary to disengage the presenting part as has been so frequently recommended: the uterus in fact will move the child round with very little assistance on our part, and we shall find that after every pain the advance of the feet and recession of the part has increased considerably. From our own observations we would say that in all difficult cases, of turning especially, it is desirable for the patient to have several pains between the moment of gaining the feet and bringing them fairly into the vagina: very little force is required to bring them down, and the uterus does not appear to suffer; but where the position of the child has been rapidly changed, its contractile power seems to be injured, and it is ill able to make those exertions during the last stage, which will be required of it in order to save the child’s life.

Not less necessary is it that we should proceed with the second stage as cautiously as possible: the grand principle is the same, viz. to conduct the expulsion as gradually as possible: there is no use whatever in hurrying this part of the operation, for if the child be alive, we place it in imminent danger of its life; and if it be dead, as will easily be known by the cord not pulsating, we are putting the mother to a great deal of suffering for no reason. Now that it has become a footling case, it must be managed according to rules already given for this species of presentation: the uterus must be emptied as slowly as possible, the anterior part of the child must be directed more or less backward, and the funis guided into the vicinity of one or other sacro-iliac synchondroses. By retarding the advance of the child, we resist the action of the uterus somewhat, and thus excite it to contract more actively, the head enters the pelvis in the most favourable position, and as the pains are still brisk, it passes through so quickly as to subject the child to little or no danger by pressing upon the cord. Where however the passage of the head through the pelvis threatens to be delayed, we would strongly recommend the application of the forceps in order to terminate the delivery before the child has begun to suffer: it is to this mode of practice that Professor Busch, of Berlin, attributes the extraordinary success of turning in his hands; of forty-four cases where turning was deemed necessary only three children are stated to have lost their lives from the effects of the operation, a result which is by far the most favourable known.

Turning with the nates foremost. It has been proposed by several authors of the last century to turn the child with the breech foremost, as being a less dangerous operation for it than the common one of bringing down the feet. Levret has distinctly proposed this mode (L’Art des Accouchemens, § 767,) and Smellie on more than one occasion has alluded to bringing down the nates. Dr. W. Hunter has also recommended turning with the breech foremost: still more recently has this mode of practice been confirmed by W. J. Schmitt, of Vienna,[94] also by some other continental authors; but the difficulty in bringing down a part of the child’s body, upon which we can exert so little hold, will always be very considerable, wherever the circumstances under which the operation is undertaken is at all unfavourable. Schmitt recommends that as soon as we reach the nates we should apply the hand flat upon them; while in order to turn the child, active pressure is kept up from without by the other hand: when once we have succeeded in moving the breech somewhat downwards, its farther descent is very easy.

A still more recent modification of turning the child in arm and shoulder presentations has been proposed by Dr. v. Deutsch, of Dorpat: it consists in raising the presenting part, and at the same time turning the child upon its long axis, as the hand placed in the axilla carries the shoulder to the upper parts of the uterus, after which, as the hand descends, it brings the feet along with it into the vagina.

Turning with the head foremost. In former times, as the head was considered the only natural presentation of the child, every deviation of its position from this was looked upon as unnatural, and, therefore, the operation of turning only applied to bringing down the head, which had not presented: as, however, the difficulties already mentioned, in turning with the nates, would apply still more forcibly to bringing down the head, it is plain that this mode of turning would rarely be practicable. “Were it practicable at all times,” says Dr. Smellie, vol. i. book iii. chap. iv. sect. iv. number v., “to bring the head into the right position, a great deal of fatigue would be saved to the operator, much pain to the woman, and imminent danger to the child: he, therefore, ought to attempt this method, and may succeed when he is called before the membranes are broke, and feels by the touch that the face, ear, or any of the upper parts present.” Still, however, he confesses that the usual method of turning by the feet is the safest. In his first volume of cases, (collection 16, number 6, case 5,) he has given a description of this mode of turning. Dr. Spence also turned with the head foremost, as is shown by his thirty-second case, where the hand and cord were prolapsed into the vagina. “I introduced my hand into the vagina, and in the intervals between the pains reduced both the arm and the cord: but as I found they were like to return again upon my withdrawing my hand, I therefore continued to support them till such time as, by the strength of the pains, the child’s head was so far forced down as to prevent any danger of their returning, the happy consequence of which, was, that she was delivered of a live child in about half an hour after: both mother and child did well.” (Spence’s System of Midwifery, p. 465.) Dr. Merriman has recorded a similar case in his own practice: “The arm was returned at two o’clock; there was afterwards no occurrence of pain till six, after which, they became very strong, and between eight and nine the child was born. This was the only infant that Mrs. R. has seen alive out of six.” (Synopsis of Difficult Parturition, 1838, p. 250.) Still more recently turning with the head foremost has been tried by Dr. Michaelis, of Kiel, (Neue Zeitschrift für Geburtskunde, vol. iv. 1836.) When once the faulty position has been altered, the liquor amnii is allowed to drain off, the uterus contracts and presses the head down into the pelvis, and the child is born without farther difficulty.