The forehead towards the arch of the pelvis at the time of delivery is not favorable, but unless the pelvis is proportionately small no interference is necessary.
The BREECH may present at the brim in different positions, and the breech is distinguished by its roundness and softness, by the cleft between the buttocks, by the arms and by the organs of generation. In some cases the labor is concluded as quickly as if the head descended, in others it is more tedious. The results as regards the mother are as favorable as in head presentations. The danger to the child is in direct proportion to the length of time between the birth of the body and that of the head.
When the body is expelled so far as the umbilicus, the danger to the child commences, for at this time the cord may be pressed between the body of the child and the pelvic walls. A loop of the cord should be pulled down, and if it freely pulsates the child can probably be delivered alive. Generally a judicious traction on the part of the accoucheur, combined with firm pressure through the abdomen applied by an assistant, will effect delivery of the head before the delay has had time to prove injurious to the child. If the arms of the child are above at the side of the head, the doctor will bring one down by passing a finger over the shoulder as near as possible to the elbow, and then drawing it across the face and chest until it arrives at the external orifice, but all this time it is the part of the nurse to continue to make effective pressure upon the abdomen of the mother—also while he delivers the shoulders—and while he perhaps introduces two fingers into the vagina of the mother to reach the upper jaw of the child and make pressure upon it, so as to depress the chin and facilitate the expulsion of the head.
Presentation of the knees and PRESENTATION OF THE FEET is identical in its progress with breech cases, and the treatment of breech cases applies to footling presentations, but it is best to avoid pulling on the foot or feet that come down, as it is safer for the child if the lower part of the body is delivered quite slowly. Even if the nurse should in an emergency deliver the child, she should help principally by pressure on the mother’s abdomen.
The only rule that I would have the skilled nurse adopt in regard to these cases, is that it is necessary that she should discover as early as possible if the labor is not a natural one, and if it is unnatural, should obtain the services of a physician as soon as possible. The same rule applies to cases of placenta previa hemorrhage, but I shall have more to say of these hereafter. A case of compound presentation where the hand and arm presents with the head, or in which the feet and hands, or one of each present together, also imperatively demand the services of an experienced accoucheur without delay. The nurse will be impotent to give any efficient help until the doctor arrives.
Presentation of the SUPERIOR EXTREMITIES will receive from me a full and complete description, because I believe that under certain circumstances the nurse should be prepared to operate by turning. As this radical opinion may perhaps be opposed by my medical brethren, I offer the following reasons for it which I consider a sufficient justification.
1. Cases of this class commence with the ordinary symptoms of labor; their peculiar character cannot usually be distinguished until the os is well dilated, and this is the only favorable time to perform the operation of turning.
2. Although in cities and villages generally, a physician’s services can in most instances be immediately obtained, in the country it is not always practicable to obtain them within an hour or two of time.
3. Such knowledge as is necessary for the performance of this operation may be obtained from such description and instruction as can be given in books.
4. There are some women who possess the necessary traits of character, the complete exercise of their faculties, with the perfect coolness which is demanded of the operator in such a case.