PRESENTATIONS OF THE LOWER EXTREMITIES.
It has already been remarked, in another place, that breech presentations mostly terminate spontaneously, and that but few of them require interference. In some of them even, when the pelvis is large, or the fœtus small, the delivery is effected quite rapidly. Still such presentation occasionally causes delay and difficulty, and necessitate more or less assistance.
As soon as the mouth of the Womb is opened sufficiently, unless the labor is rapidly progressing without it, one of the fingers may be introduced and hooked over the groin, and a little gentle force exerted upon it. This will assist very much, and will often be all sufficient. If the pelvis is too small, or the fœtus too large, and the delivery is evidently arrested, the breech must be pushed up, if possible, and the feet be brought down, as in turning. The remarks of Dr. Lee on this presentation are so plain and practical, and marked with such good sense, that I think a better explanation of what should be done in such cases-could hardly be given, I will therefore quote his remarks in full:—
"Having ascertained that the nates present, whatever the position of the fœtus may be, whether the abdomen look backward or forward, we cannot alter it with safety, and no change can be required to be made till the nates and lower extremities are expelled. The os uteri dilates slowly in most cases of nates presentation, but we cannot employ any means with advantage to accelerate the delivery, and in most cases, if we do not interfere, but wait patiently, they are gradually pressed lower and lower into the pelvis, and at last escape from the vagina without any assistance. If the os uteri and vagina are imperfectly dilated, and the nates are drawn down or pass rapidly through the pelvis, the child is often lost. The membranes should not be ruptured, and the expulsion of the nates should be left entirely to the natural efforts, unless the labor is protracted and exhaustion takes place. Except supporting the perineum, nothing is required in a great proportion of these cases before the nates and lower extremities have been expelled, when it becomes necessary to ascertain precisely the relative position of the child to the pelvis, to rectify this if it is unfavorable, and artificially extract the superior extremities and head, to prevent the fatal compression of the umbilical cord. If we find, after the expulsion of the nates and lower extremities, that the toes are directed forward, or that the child is in the position represented in the second figure, with its abdomen applied to the anterior part of the uterus, and that its back lies along the spine of the mother, we should wrap the nates and sides in a soft napkin, and turn the child very gently round during a pain, observing to which side the feet are inclined to turn, till its abdomen is to the spine of the mother, and the toes are directed backward to the hollow of the sacrum, or to the side of the pelvis. In many cases the nates turn round in the passage spontaneously, so that it is not required artificially to alter the position. It is necessary always to recollect that it is possible to turn the body of the child round without turning the face round into the hollow of the sacrum, and that the chin may be over the symphysis pubis when the front of the chest and abdomen are turned backward. After the lower extremities and body of the child have been expelled, and placed in the most favorable position for the extraction of the superior extremities and head, it is necessary to proceed without loss of time to draw these through the pelvis, that the child may not be destroyed by compression of the umbilical cord. As pressure upon the cord for a very short time will in some cases kill the child, it is proper to watch closely the pulsations of its arteries. Draw the body of the child forward as far as the arm-pits, and place it over the palm of your right hand and fore-arm, and gently draw the body towards the left thigh of the mother; then pass the fore and middle fingers of your left hand along the back part of the left arm of the child to the elbow-joint, and press down the arm with your lingers along the thorax of the child, and extract it. Then transfer the body of the child and left arm to your left hand and fore-arm for support, and with the fore and middle fingers of your right hand disengage and bring down, in the same way, the right arm of the child; then pass the fore and middle fingers of your left hand into the mouth of the child, or rather over the lower and upper jaw, and at the same time place the fore and middle fingers of your right hand over the back part of the neck and occiput, and with the fingers of the two hands thus applied extract the head, in the line of the axis of the pelvis. The perineum is very rigid in some cases of nates presentation, where it is the first child, and it will be torn if the head is extracted hastily, and not drawn forward to the symphysis pubis. When you feel the pulsations of the cord beginning to cease, you may be tempted to employ greater extracting force than the neck of the child and perineum can bear, and both may be destroyed. The only method of obviating this is to press back the edge of the perineum, that the air may gain admission into the mouth of the child, and the respiration go on, when the circulation in the cord has been arrested, until the perineum is sufficiently dilated to slide back over the face, and allow the head to pass. I have seen from twenty minutes to half an hour elapse in some cases, after the cord had ceased to pulsate, before the perineum would allow the head to escape, during which time the respiration was regularly performed. This is not a new practice; it has been alluded to by some of the older accoucheurs, and some others; and the advantages to be derived from it were fully pointed out some years ago by Dr. Bigelow, in a paper published in the American Journal of the Medical Sciences, 'On the means of affording Respiration to Children in Reversed Presentations.' The object of Dr. Bigelow in this paper is to show that in many cases the life of the child may be saved by forming a communication between the mouth and atmosphere previous to the delivery of the head. If the head be low down, the fingers alone can give the necessary assistance; but if it is high in the pelvis, and is reached with difficulty, the assistance of a tube may be necessary. He recommends a flat tube, which is to be guarded, and kept within the fingers of the inserted hand.
"Where the pelvis of the mother is small or distorted, and the child large and unfavorably situated, the efforts of nature may be insufficient to expel the child, either alive or dead. The nates may become so firmly impacted in the pelvis, that they cannot advance without artificial assistance. A finger should be passed up to one of the groins, and when a pain comes on a considerable extracting force may be exerted with it, without injuring the child; or a soft handkerchief may be passed between the thigh and abdomen, and the nates drawn down; but this cannot be done unless they have descended low into the cavity of the pelvis. Where these means fail, and it is impossible to extract the child alive, the blunt hook or crotchet must be employed. In cases of nates presentation, where the pelvis is distorted, after the extraction of the trunk and extremities, it is necessary to perforate the back part of the head, and complete the delivery with the crotchet. In presentations of the feet and knees the treatment does not essentially differ from that required in presentations of the nates."
PRESENTATIONS OF THE SHOULDER.
These are the most dangerous of all the presentations, and most frequently require assistance; in fact the delivery can seldom be terminated naturally when the shoulder presents.
Sometimes the child will pass doubled up, as formerly explained, but this must not be too confidently expected. Dr. Lee says—
"It is now a general rule, established in all countries where midwifery is understood, that in cases of preternatural labor, where the shoulder and superior extremities of the child present, the operation of turning ought to be performed. But the hand must not be forced into the uterus, if the orifice is rigid and undilatable; it should be dilated nearly to the size of half-a-dollar piece or more, or the margin ought to be very thin, soft, and yielding, if it is expanded to a smaller extent than this when turning is attempted. If the os uteri will not admit the extremities of the fingers and thumb in a conical form to be introduced without much force, if it is thick, hard, and unyielding, some delay is necessary, that the parts may relax, death being almost always the consequence of thrusting the hand with violence through the orifice of the uterus in a rigid and undilatable condition, whether the membranes be ruptured or not. But as soon as it will admit of the safe introduction of the hand, where you have ascertained that an arm presents, no time should be lost in completing the delivery, otherwise the membranes may give way, the liquor amnii be evacuated, and a case of little difficulty and danger be suddenly converted into one equally hazardous to the mother and child. In all cases of labor, where the first stage is far advanced without the nature of the presentation being positively determined, or a superior extremity is felt through the membranes, the patient should be kept in the horizontal position, that they may not be ruptured; and you should remain in constant attendance upon the patient, and be prepared to interfere the instant the necessity arises."
Speaking of the operation of turning in these cases he remarks as follows:—