If the position be one of the left mento-iliac, the right hand is to be used, and the same result brought about.
If the face has became too much engaged to admit of reasonable doubt as to final success, resign the case to nature, at the same time warding off hindrances and complications, as in vertex presentations.
In these facial presentations, we must wait with great patience; supporting, in the mean while, the vital energies for expulsion, with such remedies as each individual case may seem to require. We must wait until rotation is effected, bringing the chin under the arch of the pubis. When the chin, even, is found exactly posterior, by waiting and prescribing as all true Homoeopathicians best know how, the chin will rotate to the front, and spontaneous expulsion take place.
It does sometimes occur, however, that when the chin is posterior, instead of being transverse or anterior, it seems, as descent takes place, to lodge in the great sciatic foramen, and be retained there until the presentation is converted into one of the vertex; this should be regarded as a very happy event. When it becomes necessary to offer instrumental aid to facial presentations, the forceps must be applied in such a manner that the chin may be in harmony with its concavity. This would favor the rotation which brings the chin under the pubic arch. After the chin has engaged under the pubic arch, very great assistance is often afforded by applying the forceps in such manner as to gently aid the process of flexing. It will be recollected that at this stage the sinciput is lying back in the cavity of the sacrum, and the expulsive forces are so applied as to render the flexion of the head every tedious, so that the life of the child may often be saved by producing flexion of the head by artificial means.
when the breech presents, it must be allowed to descend; no turning is ever admissible in these cases. If artificial means are thought necessary, the blunt-hook must be used. It can be applied by putting one finger on the presenting part as a guide to the point of the hook, the handle being held in a perpendicular posture. Now, whilst this point is kept in constant with the breech, the handle should be depressed unto the hook is slipped over the thigh and handle should be depressed until the hook is slipped over the slight over the thigh and into the groin. Before traction is made, one finger must be slipped up between the thighs of the thighs of the child and placed upon the point of the hook. Next, be sure that the hook in the groin is closely applied to the body; for
Fig. 105.
The mode of using the blunt-hook in the breech presentations.
if it should slip down upon the thigh, the latter will certainly be fractured upon making traction. With every return of the pain we may make powerful traction in safety; but never remove the finger from the of the hook, lest it do mischief by penetrating the abdomen of the child, or wound some other organ.
When the trunk presents we always know at once that the intervention, of art is inevitable. And we must at once determine where or in what choose which hand is to be used, always remembering to use that hand whose palmar surface corresponds to the face of the child. Now if the child’s arm be found hanging from the vagina, we must attempt to turn the child at once, by introducing the proper hand. Seizing a foot very gently, withdraw the hand as before directed. No attention need be paid to the arm hanging in the vagina.
If the arm is not hanging externally, the shoulder being felt in the superior strait merely, introducing the proper hand an make an effort to push up the child so as to allow the head to fall into the superior strait in place of the shoulder. We may be aided in this operation by gravity. If the head is found to occupy the right iliac fossa, after crowding up the child as much as possible, allow the patient to lie over upon her left side, whilst the accoucheur is still holding up the child, and the head will be aided in its descent to its
Fig. 106. Fig. 107.
Introducing of the hand in the Mode of seizing the foot in second position of the right same position.
shoulder.
proper place. The hand may than be partially withdrawn, and at the same time aid in placing the head in the proper position. If we succeed, the case can then be abandoned to nature, aided, when requisite, by medicine, or the forceps if necessary. If we fail, the hand should not be withdraw, but should pass on upwards and, seizing a foot, bring down the breech. All we have to think of in any position, is diagnose the child’s relative position, select the hand accordingly, and proceed as above directed.
In those very difficult ceases, when the body is so crowded into the superior strait as to make it almost impossible to introduce the hand, and quite impossible to hold on to the foot to produce version, we must hold the food, form a slip-noose with a strong handkerchief around the arm holding the foot, and then slip the nose up little by little, with the other hand, on to the ankle, when powerful traction can be made and version produced.
We now come to treat of the Forceps. The natural history of the forceps the writer deems quite unimportant in a work of this kind, and feels quite satisfied when he recommends the best forceps he knows of at the present days. Figs. 109, 110. 111, represent the instrument referred to. Fig. 109 represents what is called the male blade, which has about its middle a pivot. Fig. 110 represents the female blade, having a little notch which fits on to the pivot when brought together, and constitutions, when thus brought together, what is called the lock.
We have in general use what are called respectively the short, and the long forceps. The short forceps are more usually resorted to when the head is in the cavity of the pelvis. The long forceps when the head is above the superior strait.
The forceps are to be applied only to the head, either in the vertex Fig. 108.
Mode of seizing the foot in the second position of the left shoulder.
or facial presentation, or when the head remains behind after the body is born. They are to be used always at the discretion of the accoucheur. It is better never to exchange a certainty for an uncertainty. If the head can descend through the pelvis at all, it can better pass vertex first than base first; and the difference in favor of the child’s life is much on the side of the vertex descent. Therefore, when the head presents and resort to mechanism is required for delivery, always apply the forceps if they can be applied; but if there is not space for that, or if delivery by the forceps is no longer possible, be must have recourse to the operation of craniotomy, or, finally, if this is not possible, to the Caesarean section.
The best forceps, those which are most successful in use under all circumstances, are Bethel’s. If long forceps are particularly required, Davis’s are the best. Hodges’ short forceps are very good; as also are Wallace’s.
When it is foreseen that forceps are to come into requisition, it is better to make the fact known to the patient as gently as possible. We might speak of having little silver hands in our possession, which, if applied to the child’s head, would serve to relieve her very much and at the same time to render the life of the child more certain. At all events her confidence must be secured, and her full and free consent obtained. The operation decided upon, she must be placed in the same position as though the operation of version was to be performed. If the child is in the superior strait, the breech should be brought quite down to the very edge of the bed, so that the handles of the forceps when locked may hang over the side of the bed, for traction must first be made directly downward in that stage of the operation.
Fig. 109. Fig. 110. Fig. 111.
Before applying the forceps, they should be warmed to blood-heat, and the external or convex surface well lubricated with hard.
All things being ready, the accoucheur can at once proceed to the operation. Where it is practicable, we should apply the forceps upon the sides of the child’s head, always taking care that the concave margin of the blades shall rotate under the arch of the pubis.
When the head has descended into the cavity of the pelvis and has rotated into the long diameter of the inferior strait, the application of the forceps is a very easy matter. The male blade is to be held in the left hand and in a perpendicular position. With the fingers of the right hand the point of the blade is to be guided to the presenting portion. The point of the blade resting upon the head, it can be very easily slipped round not he head by using a very little forced upon the blade, depressing the handle all the time more and more, as it enters the vagina. When well applied the pivot will stand perfectly perpendicular. The female blade is then to the taken in the right hand, and, guided by the fingers of the left hand, it is to be slipped around to the right side of the head, in the same manner as upon the left in the former instance. If this has been applied correctly the notch in the blade will at once fit on over the pivot, and the instrument is readily locked. In doing this, care must be taken not to embrace in the lock any portion of the soft parts, or even of the hair. Being locked firm pressure upon the handles must be made,
