A System of Midwifery

by Edward Rigby

Although in cases of malposition where turning has become excessively difficult and dangerous, the spontaneous expulsion must be looked upon as a most fortunate process by which nature effects delivery, still, however, we must never venture to wait for it without making such attempts to turn the child as the state of the patient may justify. It is always more or less dangerous to the mother, and almost certainly fatal to the child. Indeed, it is our opinion, that the spontaneous expulsion can rarely, if ever take place, except where the child has been already dead some time, or where it is premature. “Nor can any event,” says Dr. Douglas, “ever be calculated upon than that of a still-born infant. If the arm of the fœtus should be almost entirely protruded with the shoulder pressing on the perineum, if a considerable portion of its thorax be in the hollow of the sacrum with the axilla low in the pelvis, if with this disposition the uterine efforts be still powerful, and if the thorax be forced sensibly lower, during the presence of each successive pain, the evolution may with great confidence be expected.” (Op. cit. p. 42.)

On the other hand, if either from the rigidity, &c. of the child or of the passages, but little material advance is made in the manner above-mentioned, if the soft parts are become swollen and inflamed, and the powers of the patient are beginning to flag, and exhaustion coming on, if turning has been attempted as far as could be done with safety, and still without success, we have no choice left but that of embryotomy; the chest and abdomen must be evacuated of their contents as already directed under the head of Perforation, and in this manner the child delivered.

Malposition with deformed pelvis, or rigidity of the uterus.—Where the pelvis is deformed, or the uterus (from the early escape of the liquor amnii) spasmodically contracted upon the child, and the os uteri in a state of rigidity, the difficulties and danger of the case are greatly multiplied: in the former complication the embryotomy must be carried much farther, in the latter we must have recourse to bleeding, opium, warm-bath, &c. as recommended under the head of Turning.

The prolapsed arm is not to be put back or amputated.—Where the arm has been some time prolapsed, and, from the pressure of the soft parts, much swollen, it fills up the vagina so completely that it would seem almost impossible to introduce the hand, unless we push up the arm first: experience however confirms the valuable rule of La Motte, viz. that we must slide our hand along the arm into the uterus; we shall rarely find, where the passages are in a proper state for undertaking the operation, that the prolapsed arm presents any serious obstruction to the passage of the hand. “An arm presenting,” says Chapman, “and advanced as far as the armpit, is not to be returned, but the hand is to be introduced (which, as Deventer justly observes, is often found to penetrate with much more ease when the arm hangs down than when it is thrust back again) and the feet to be sought for, which, when found, the arm will prove no great hindrance in turning the child.” (Chapman’s Midwifery, p. 46. 2nd. ed., 1735.)

In no case is it necessary to separate the arm at the shoulder, “for I have found it,” says Dr. Denman, “a great inconvenience, there being much difficulty in distinguishing between the lacerated skin of the child and the parts appertaining to the mother.” (Essay on Preternat. Labours, p. 32.)

Dr. Meigs, of Philadelphia, has added another powerful argument against this practice, viz. that cases have occurred where the arm had been cut off and where the child was nevertheless born alive.

As to how far it is possible or advisable so to alter the position of the child as to make it present with the nates or head, this has already been considered in the chapter upon Turning.

The presentation of the arm with the head is of very rare occurrence, so much so that some have doubted if it really existed: two cases of this kind have come under our own notice, in both of which the child was born in this position, although with some difficulty.

“Independent of the awkwardness of position which the head may assume, from the circumstance of the hand or arm descending with it into the pelvis, there will be so much increase in the bulk of the part as to render its passage slow and difficult; yet if the case be not interrupted by mismanagement, it will terminate favourably, for this complication of presentation seldom happens but in a wide pelvis.” (Merriman’s Synopsis, p. 48, last ed.)

It is by no means uncommon to feel the hand lying upon the side of the head or on the cheek; but this produces no impediment to the labour, for as the head descends through the brim of the pelvis the hand usually slips up: in the other case we have felt the arm bent over the head, and pressing the ear on the opposite side.