Dr. T. S. Bullock: The woman was a primipara; the cord was very short, it was tied and severed, then the delivery completed with forceps. I would like to ask the gentleman whether, in those cases where they have employed Crede’s method of delivering the placenta, they have noted a cupping of the uterus from efforts to extrude the afterbirth?
Dr. J. A. Larrabee: I have occasionally noticed cupping of the uterus under those circumstances.
Dr. F. C. Simpson: I remember a certain practitioner in this city several years ago made the statement that he seldom tied the cord after cutting it; that he did not see any necessity of tying the cord. If this is true, then there would certainly be no danger in severing the cord in cases such as Dr. Anderson has reported, and it would not even be necessary to tie it until after the delivery had been completed.
Dr. Wm. Bailey: I want Dr. Anderson to speak to one point in particular in closing the discussion, viz., would there not be great danger if the placenta was separated at a time when the child was still partly in the uterus?
Dr. F. C. Wilson: The only point I wish to bring out in connection with the case is the possibility of detecting the fact that the cord is around the neck of the child before delivery, and being on our guard for it. Encircling of the cord around the neck of the child ought to give rise to a funic bruit. You can hear very plainly a funic bruit, a bruit which is synchronous with the fetal heart sounds. Where this can be detected at a point where we know the neck of the child lies, it indicates to us that the chord is around the neck.
There are certain other circumstances under which we may also detect a bruit: For instance, the one mentioned by Dr. Cecil, where the cord was tied into a hard knot. I have met with several such cases in my practice, and a bruit can be produced in this way, but at a different place from the location of the neck, and it is a permanent bruit; a bruit that is heard all the time. Where that is the case, of course it indicates that there is some permanent obstruction of the cord, and the likelihood is that it is due to a knot tied in the cord. We know that sometimes the cord slips over the neck, and then the child’s body slips through the cord, thus making a perfect knot; it then may be drawn tighter and tighter, finally producing considerable obstruction. If the bruit that is heard is evanescent, heard sometimes when you are listening and not at others, that indicates simply a temporary pressure upon the cord which may produce a bruit that is fetal in its rhythm, at the same time it is heard occasionally only. Where the cord encircles the neck and is drawn tightly it is apt to give rise to a bruit that is more or less permanent, and always heard at a point where we know from other methods of examination that the neck of the child is located. Where this occurs we ought to be on the lookout and prepared to find the cord encircling the child’s neck, and ought to endeavor to release it in the first place, and where we are unable to do that, then the question of severing the cord will come up. The cord being pulseless in the case reported by Dr. Anderson would have simplified that question very materially. The cutting of a cord that is not pulsating is an easy thing and not at all dangerous. Even where the cord is pulsating I have cut it repeatedly without even attempting to tie it, simply holding one end—of course you have to make a guess as to which end is attached to the child. You can not always tell that, but you can easily see from the continued bleeding or pulsating whether you have the proper end or not, and by simply holding that between the fingers the delivery can be expedited, and then the cord can be tied immediately afterward. Where the cord is pulseless there would be no danger in severing it and leaving it untied and even unheld. I have time and again, after delivery of the child, cut the cord and not tied it, but always waiting till pulsation had ceased. I think there is no danger in doing this. If a cord is cut after it ceases to pulsate and does not bleed by the time the child is washed and ready to be dressed, there will be no hemorrhage from it afterward.
Dr. Turner Anderson: Referring to the point made by Dr. Howard, I believe, whenever the umbilical cord presents anomalies as illustrated by the case reported, that it is as a rule abnormally long. The cord in this case was abnormally long.
Dr. Larrabee made a point to which considerable importance should be attached, viz., that it would not have been an easy matter to have divided the cord in this case. I think practically he presents the case exactly right. When a cord encircles the child’s neck twice, then branches off and goes under the arm, then branches off over the back, it presses the neck so tightly and the conditions are such that it would be a very difficult matter to get one’s finger beneath the cord at the neck and divide it. It is not such an easy matter to sever a cord under these circumstances as one might suppose. I believe the majority of obstetricians content themselves, when they find the cord is encircling the neck, by simply making an effort to stimulate uterine contraction, and to deliver the child as rapidly as is consistent with safety to the mother, and while so doing take the precaution to support the head, to hold it up well against the vulva and prevent undue traction on the placenta.
It is seldom that we fail to resuscitate a child born under these circumstances. The cord as a rule is not encircling the child so tightly so as to prevent our ability to resuscitate it.
Dr. Bailey has correctly stated that arrest of pulsation in the cord does not occur until after delivery of the head, and we have a limited time then to stimulate uterine action and to disengage the body of the child and release the cord from the neck. Contraction and arrest of pulsation of the cord do not occur prior to that time as a rule. I can conceive it possible that it might do so, but as soon as the head is delivered, contraction then is so great that unless the cord is very long there is an arrest of pulsation and the danger commences. Fortunately we have recourse to stimulating uterine action, and have a chance to deliver the child in the manner I have suggested with sufficient promptness.