The blades may now be thrust deep into the brain; then the handles may be separated for the purpose of enlarging the orifice as much as possible. The contents of the cranium are now to be broken up thoroughly by the blades of the instrument, which are then to be withdrawn protected in the same manner as in their entrance. Now if the pains are energetic, a spontaneous expulsion may take place.
Fig. 125.
Mode of introducing and using Smellie’s scissors.
If not, the forceps may be again resorted to. And finally, if this means fails, Meigs’ Craniotomy Forceps, and the Crotchet, will most likely be required.
In using the forceps in these cases, the bones should be seized on the inside of the scalp, so that this integument may remain entire when the bone comes away, and thus capable of giving protection to the uterus and other soft parts. And every spicula of bone that cones away should be protected between the fingers of the free hand, so that its rough edges shall not injure the mother. Finally, the crotchet may be introduced the finger guarding the sharp hook till it enters the brain, when we must endeavor to lodge the hook in the thick occipital bone. Traction may then be made, the finger as much as possible guarding the sharp hook, so that if it do give way it may wound the finger rather than the mother. (The best crotchest is one furnished with a sheath or guard, which does not hinder the sharp point from becoming fixed upon the inner side of the cranium, like a tooth, but which affords entire immunity in case the point tears or slips out from the bone.) Still it is better to use the finger rather than the steel guard of the crotchet. In this manner we may finally secure the expulsion of the child.
If the breech should present, and the head remain after the expulsion of the body, we must reduce the size of the head by operating through the base of the cranium. In a large majority of cases after the perforator has been thoroughly used, the forceps will be found efficacious.
In trunk presentations and pelvic deformities, if the head cannot be brought into the superior strait, pelvic version must be resorted to. I do not believe it will be necessary, from my experience, ever to sever the neck in these, cases, even if the child is forced very far down into the superior strait. I have succeeded in turning the most difficult cases of this kind. After a firm hold has been secured upon the foot, slip a noosed pocket- handkerchief upon the ankles as before described, and make steady but powerful traction, at the same time steadying the uterine tumor at the abdomen. After aversion has been accomplished and the trunk delivered, evacuate the contents of the cranium, through its base, as above already directed, and apply the forceps.
In all these trying difficulties we must keep the judgment clear, and take advantage of any innovation that may present itself to the mind, that is safe in its application. Abnormalities are at once strange and varying, and we must try to be prepared for all cases of emergency, however new and difficult. Simplicity is the great art; and the greatest difficulties will oftentimes disappear under the patient application of the simplest means.
DELIVERY OF THE PLACENTA.
The delivery of the placenta constitutes the third stage of labor. The placenta being a spongy, non-contractile mass, does not follow the example of the uterus in shrinking to a very considerable degree after the expulsion of the foetus; consequently, from the placenta being unable to adapt itself to the changing size of the uterus, the one must become separated from the other. This is precisely what does happen; this explains both the cause and the mode of the separation. The uterus retracts and pulls itself away from the placenta, which latter of course be becomes a large foreign body within its cavity, as was the foetus at the outset of labor, and with about the same relative proportion of bulk when compared the one with the other. Next arises organic contractility, and the placenta is driven forth into the vagina, by whose contraction, aided by that of the uterus, it is expelled beyond the vulva.
Sometimes it happens that the placenta becomes detached during the latter part of the process of expelling the child; in these cases large quantities of clots, and sometimes even the placenta itself, escape with the child.
If left entirely to itself, the placenta will usually be delivered spontaneously in about fifteen, twenty, or twenty-five minutes after the expulsion of the foetus. If it is not delivered in about this time, we may take hold of the cord with a dry napkin, and make slight traction in the axis of the inferior strait. But if it appears that the placenta is above the superior strait, we may place a finger or two
Fig. 133.
Mode of extracting the placenta.
on the cord above the inferior strait, which will cause traction to be made in the axis of the superior strait. If any crepitation be felt, as if the cord were about the separate from the placental mass, we must desist, unless the placenta can be reached by the finger, when it can quite easily be hooked down and delivered at once. But if the placenta be not within reach, or should seem immovable, there is reason to suppose that it has not yet been thrown off by the retraction of the uterus, and a remedy must be selected for the existing condition.
Sometimes also the placenta is found to be retained by a spasmodic contraction of the neck of the uterus, so that it is impossible to extract the placenta till this spasm has been abated.
Sometimes again, and more frequently, we find what is called the hour-glass contraction, as shown in figure 134. Other abnormal contractions may occur, which will render utterly impossible the delivery of the placenta, until the proper remedy has been found and administered to relieve the morbid irritability which gave rise to such abnormalities. All these anomalies have a vital origin, as well as all other abnormalities; and we have only to interpret rightly the symptoms which they present, by exhibiting the corresponding remedy, and the whole difficulty will give way, as my own experience abundantly testifies.
In all these various irregularities, we must administer the remedy which corresponds most nearly with the presenting symptoms. And in these various abnormalities, the following remedies have been employed with very great success:
Fig. 134.
The hour-glass contraction of the womb.
Belladonna. Where there are redness of the face, injected eyeballs, much distress, and great heat in the vagina, with dryness. The placenta may be spasmodically retained. Constant moaning. Hemorrhage hot.
Pulsatilla. This has been more frequently used, in these cases, than all the other remedies put together. It answers to a want of action in the uterus; and also to the spasmodic forms of the difficulty. The symptoms must decide its use, which has a very great range. The patient is of a mild, yielding disposition. Rather tearful; weeps because she is not delivered. Alternating hemorrhage. Restlessness, &c.
Sabina. Pain, or an uneasy, had feeling, extending from the sacrum to the pubis. A slight sensation as of motion in the abdomen.
Secale c. She has a constant sensation of bearing down in the abdomen; it seems to her too strong to be effectual. Passive hemorrhage. Every thing seems loose and open; no action. Particularly useful in thin, scrawny subjects.
Sepia. She complains of little sharp-shooting pain in the neck of the uterus, sometimes with burning.
Caulophyllum, Gelsemium, Cimicifuga, and Gossypium, ( See Hale’s Materia Medica.) from clinical reports, bid fair to be extremely useful in these cases; but no special indication is yet known for their administration, except it be for:
Gelsemium – Cutting pain from before, backwards and upwards.
All placenta retained by spasmodic action of the uterus should be removed by administering the specific remedy; no mechanical effort or violent force should be employed in such cases. Hour- glass contractions, contractions of the external or internals os, and want of contractions all are best remedied by medicinal agents.
Adhesion s of the placenta are not always so easily managed, but even here the properly selected remedy may cause a spontaneous expulsion. It will be very, very rarely, and more and more rarely as Homoeopathy comes more and more into genera l use, that these adherent placentas will occur; for they all arise from some diseased condition of the system, which Homoeopathy dissipates when its practice is strictly adhered to. In some cases the placenta so adheres to the uterus that they seem to form one and the same tissue, when it is utterly impossible to separate the one from the other. At the very best, we can in these cases only imperfectly tear off a portion. We may infer that the placental is absolutely adherent, when, in making traction upon the cord, the elasticity of the uterus causes retraction of the cord again upon relaxing out effort at extraction.
