of the forceps, or lower blade is to be inserted first ; the hands
having been thoroughly cleansed and antisepticized, the fingers
of the right hand should be introduced into the vagina between
the head and the wall of the birth canal ; grasping the left blade
of the instrument at its centre with the left hand, the physician
gently inserts the left blade guided by the fingers of the right hand.
(Fig. 53). To facilitate introduction, the left blade should be held
with its handle parallel with Poupart's ligament of the right side ;
the thumb of the right hand gently pushes against the posterior
surface of the cephalic portion of the blade, the instrument gliding
gently between the head and the fingers of the right hand (Fig. 54).
When properly applied, the forceps blade slips in almost imper-
ceptibly ; the handle of the blade will tend naturally to drop
toward the floor, and should be held by an assistant. The fingers
of the left hand having next been introduced as a guard, the
right blade should be grasped in the right hand of the physician,
and inserted toward the right side of the mother's pelvis. If it
fits easily over the head, an effort may then be made to lock the
blades by allowing the right or upper blade to fit down upon
the left, and the parts of whatever lock may be present to adapt



THE FORCEPS.



95



FIG. 53.



themselves to each other. If the forceps will not lock easily, the
blades should be slightly shifted with great gentleness until they
lock easily.

Locking having been accomplished, the physician may then by
gentle traction try to move the head.
A very moderate force, such as that
exercised by the fore- arms of the
operator only, is all that it is safe to
use. Traction should imitate so far
as possible uterine contractions and
the normal expulsive efforts of the
mother. If the mother be conscious,
she should be urged to "bear down,"
and traction by the forceps should
be simultaneous with her effort. If
she be anaesthetized, traction may
be made every five or ten minutes
as the case demands. In simple
cases such as that under consider-
ation, the force should be directed
first slightly downward, then di-
rectly outward, and last, upward.
By this means the occiput will be
brought out from beneath the pubic
joint ; traction directly outward
should then follow until the head
begins to distend the perineum.
By this means the occiput will
have emerged from beneath the
pubic joint, and will be distend-
ing the vulva. Traction should
then be almost directly upwards,
w hen the head will be delivered over the perineum.

In this way the natural mechanism of labor is imitated, and
laceration of the perineum through downward pressure of the head
may often be prevented. The simple procedure of Episiotomy,




THE LEFT HAND GRASPING THE
LEFT FORCEPS BLADE.



9 6



MANUAL OF PRACTICAL OBSTETRICS.



to which reference has already been made, is especially well
adapted to such cases. After the delivery of the head, the
shoulders will usually follow if the uterus be roused to con-
traction by friction. After delivery, the patient should receive a
thorough douche of bi-chloride of mercury one to five thousand,

FIG. 54.




THE INTRODUCTIOX OF THE LEFT BLADE COMPLETED.

and any slight lacerations should be thoroughly dusted with an
antiseptic powder. Although lacerations very frequently occur
when the forceps is used, yet in many cases a laceration is pre-
vented through the better control afforded the practitioner by his
instrument (Fig. 55).



THE FORCEPS.



97



In other countries, the patient is frequently placed upon the side
during forceps delivery, although the position upon the back is
the favorite one in America. The low-forceps-operation, or use
of the instrument when the head is upon the pelvic floor, is a

FIG. 55.




PROTECTION OF THE PERINEUM IN FORCEPS DELIVERY.

Patient upon the left side.

comparatively simple and safe procedure. When, however, the
head has not rotated, and especially if the head be situated at the
brim of the pelvis, the application of the forceps is a difficult and
dangerous manipulation.
5



CHAPTER XV.

THE APPLICATION OF THE FORCEPS AT THE BRIM OF THE PELVIS :
AXIS TRACTION.

ANY one who has ever introduced the instrument, both blades
being in position and locked, into the pelvis of a skeleton so high
that he could grasp a head situated at the brim of the pelvis,
must have observed that when traction was begun with the forceps
so applied, the result was either failure to cause the head to
descend, or its extraction with great difficulty. If the cause for
such difficulty was sought, it was found that when the forceps was
turned strongly forward, the tips of the cephalic portions of the
blades impinged against the walls of the pelvis, and progress be-
came impossible. In a living patient, the lining membrane of
the birth-canal would have been badly lacerated by such an effort.
If, however, a piece of tape be passed through the fenestrae of the
forceps, and when introduced to the brim of the pelvis, traction
be made downward and backward by pulling upon the tape, this
difficulty is avoided, and a comparatively easy traction will
result. Remembering that the direction of the axis of the birth-
canal is downward and backward until the pelvic floor is reached,
when it is deflected upward and forward, it will be seen that trac-
tion in this direction may be appropriately termed axis traction
(Fig. 56).

Any forceps fitted with a device for performing this manoeuvre,
namely, pulling downward and backward when the forceps is ap-
plied at the brim of the pelvis, is an axis-traction-forceps. The
more elaborate of these instruments possess metal tractors hinged
upon the cephalic portion of the blade, which are not detachable.
The simpler axis-traction-forceps have some convenient device
for the accomplishment of this purpose by which traction is gen-
98



APPLICATION OF FORCEPS AT BRIM OF PELVIS.



99



erallymade with tape or bandage, the whole being easily attached
or disconnected. Of the first class are the elaborate instruments
of Tarnier, Simpson and Breus, and their modifications. The
latter form of instrument is well represented by the tape attach-
ment devised for the forceps by Poullet, which may be applied
to any ordinary pair.

If we consider the best means of promoting flexion in cases in
which rotation is deficient, we shall see that traction in the axis

FIG. 56.




Axis TRACTION.



a. b. Traction with the ordinary forceps.
c d. Traction with the axis traction forceps.

of the pelvis is among the most valued of resources. The axis-
traction-forceps then is especially valuable in this complication,
and hence it is that posterior rotations of the occiput and defec-
tive rotations are often best treated by axis-traction.

An equal advantage in face presentations is often gained by the
use of such an instrument in the ability to secure perfect extension.
Before proceeding to consider the application of the forceps at



100



MANUAL OF PRACTICAL OBSTETRICS.



the brim of the pelvis, we may be allowed to repeat that the case
already described is the simplest condition calling for the use of
this instrument, namely, failure in expulsive force, the occiput
presenting and having rotated anteriorly, the head resting upon
the pelvic floor, the child being proportionate in size to the pel-
vis; the function of the forceps is simply to imitate the mechan-
ism of the last portion of the second stage of labor. The dan-
gers attending its use in such a case are undue compression of the
foetal head and laceration of the perineum and pelvic floor.

We next proceed to the more serious conditions requiring the
use of the instrument, namely, the expulsive forces of the mother
failing before the head has descended to the pelvic floor while

FIG. 57.




LUSK'S TARNIER'S AXIS-TRACTION FORCEPS.



rotation is as yet incomplete, and in cases in which, often-times,
the child is not proportionate in size to the mother's pelvis.
The use of forceps in face presentation and when the child pre-
sents by the breech, is comparatively rare.

It not infrequently happens that the mother's strength becomes
exhausted when the head has engaged at the brim of the pelvis
and before descent and rotation have occurred. In such cases
the dangers of exhaustion and foetal death are greater than in the
cases just described, as are the risks of injury to the mother by
the instrument itself.

The two classes of instruments already described were designed



APPLICATION OF FORCEPS AT BRIM OF PELVIS.



101



with a special reference to these cases. Thus the Tarnier axis-trac-
tion-forceps and the Simpson long-axis-traction forceps represent
two theories of application (Fig. 57). In the first, the operator
endeavors to apply the forceps accurately to the sides of the head ;
the instrument is firmly secured in its grasp of the foetal head,
traction is made in the axis of the pelvis, and the instrument and the
head are allowed to rotate together (Fig. 58). In the use of the sec-
ond instrument mentioned, the forceps is applied to the sides of the
pelvis and in the pelvic axis, grasping the head as it conveniently

FIG. 58.




TARMER'S LATEST AXIS-TRACTION FORCEPS.



can. Intermittent traction is then made in imitation of labor
pains and between the tractions the blades are slightly separated,
and the head is allowed to rotate by degrees until, by the time
the pelvic floor is reached, it has fitted itself gradually to the in-
strument (Fig. 59).

The first method of application is the more difficult ; the second
is comparatively easy, but requires discrimination and skill in fa-
voring the rotation of the head. We have employed for some



102 MANUAL OF PRACTICAL OBSTETRICS.

time in axis traction the ordinary Simpson forceps to which we
have adapted the tape attachment of Poullet. A brief descrip-
tion of the method of adapting these tapes is as follows : The
blade of the forceps is made in its cephalic extremity a little
heavier than ordinary, the fenestra of the blade measures four and
one-half inches in length ; two and one-half inches from the cephalic
end an aperture is made in each limb of the blade surrounding
the fenestra one-quarter of an inch in length, one-eighth of an
inch in width ; this aperture is so bevelled as to present no sharp
surface ; through it is passed a piece of strong linen tape one-half
inch in width, inserted from within outward through one aper-

FIG. 59.




SIMPSON'S AXIS-TRACTION FORCEPS.

ture, and then from without inward through the other ; each
piece of tape is one yard long, or eighteen inches after it has
been doubled by passing through the forceps blade ; the tapes
are received in a traction bar consisting of a straight portion
eight inches long curving downward a distance of four inches, and
terminating in a rotary traction handle ; just before the traction
bar curves downward, it has upon the upper surface a cross piece,
two and one-quarter inches long, which has at each end an aper-



APPLICATION OF FORCEPS AT BRIM OF PELVIS. 103

ture for making fast the tapes ; the end of the traction bar which
is nearest the mother has a rim of metal through which the tapes
pass to be tied into the apertures ; the forceps is applied to the
sides of the pelvis in the usual manner, the tape being held along
the blade by the obstetrician and the instrument being first in-
troduced on the left side of the mother as is customary ; care is
taken that the tape rests between the forceps blade and the head
of the child ; the tapes are then passed through the ring of the
traction bar, passing below the locked forceps, and are made se-
cure at the cross piece ; to prevent cutting the perineum and pos-
terior wall of the vagina, Sim's speculum or any suitable depres-
sor or guard may be used.

It has been found by experience that a special screw for hold-
ing the forceps firmly locked is not necessary; extraction is made
with one hand, while with the other the forceps is grasped as
usual and easily held and applied to the head ; the pull upon the
tapes is such as to tend to keep the forceps tightly applied to the
head instead of drawing the blades apart. We are accustomed
to carry the tape and traction bar with us, using the forceps with-
out them when axis traction is not necessary. The fact that this
attachment can be fitted to any forceps with which the practi-
tioner is familiar, its little cost compared with expensive axis-
traction instruments, the ease with which it is cleaned and car-
ried in the regular obstetric bag, have made the instrument a
very convenient one in our hands (Fig. 60).

The high forceps operation, or the application of the instru-
ment at the brim of the pelvis, is admissible only when the child
is proportionate in size to the birth-canal of the mother ; when
the head has at least partially engaged at the brim of the pelvis ;
when there exists no obstacle to delivery in the centre of the
bony pelvis and at the pelvic floor ; when the membranes have
ruptured, and, as is the rule in these cases, when mother or
child, or both, are in danger from delay.

While it is sometimes possible in the simple or low forceps
operation to perform delivery without changing materially the
patient's position, in the application of forceps to the head at



104 MANUAL OF PRACTICAL OBSTETRICS.

the brim of the pelvis, the patient must be brought to the edge
of the bed or table, her hips projecting over the edge sufficiently
far t6 enable traction to be made in the axis of the pelvis. An
anaesthetic is nearly always indispensable. As in all obstetric
operations, the bladder and rectum should be thoroughly emp-
tied, and means should be at hand for promptly resuscitating the
child. In selecting an instrument, the average practitioner will
do better with one to which he is accustomed than with a strange,

FIG. 60.




SIMPSON'S FORCEPS,

With Poullet Tape Attachment for Axis-Traction.

although possibly superior instrument. The patient being anaes-
thetized, a thorough examination should be made to determine
as far as possible the exact position of the head. If the operator
purposes to apply the forceps to the sides of the pelvis, the blades
may then be introduced as usual in the pelvic axis, and passed in
sufficiently far to grasp the head. If the instrument is selected
to fit upon the sides of the head, especial care should be taken
to apply and secure it in the proper manner.



APPLICATION OF FORCEPS AT BRIM OF PELVIS. 105

With the former, traction should be made downward and
backward at intervals resembling as far as possible the contrac-
tions of the uterus during labor. Between the tractions the grasp
of the forceps should be slightly relaxed to afford the head an
opportunity to rotate. As the head descends, especial care
should be taken when the pelvic floor is reached to relax the
forceps more than in the earlier traction. It will be remem-
bered that it is not until the pelvic floor is reached that rotation
occurs,, and hence the necessity for allowing the head greater
freedom at this time. If the Poullet tapes are used, they can be
disconnected from the traction bar after the pelvic floor is
reached, and the head delivered as in an ordinary application at
the pelvic floor. If the axis-traction-forceps with non-detachable
traction bars are used, these bars may be folded up upon the
shank of the forceps when no longer in use.

In applying axis-traction forceps to the sides of the head, care
should be taken to clamp them sufficiently to secure a firm hold.
Traction, however, should be made as in the former case, in the
axis of the pelvis toward the median line. The use of the for-
ceps as a rotator is a secondary, and not a primary employment
of the instrument. The forceps and head must rotate together
when the instrument is applied to the sides of the head ; but the
rotation must be effected by traction in the axis of the pelvis,
and not by forcible rotary movements. Compression and lever-
age are also secondary functions of the forceps ; but the operator
should not purposely compress the head to any great extent, nor
pry it loose from an impacted position. Only such compression
and leverage as are incidental to the securing of a firm grasp and
making traction in the axis of the pelvis are admissible.

Research has shown that the diameters of the fcetal head are
lessened in some directions, and enlarged in others, by pressure
with forceps. If the forceps is so applied that either a trans-
verse or antero-posterior diameter be lessened, the vertical diam-
eter may be slightly increased without serious damage. In nor-
mal labor such increase takes place through the projecting of the
parietal bones at the sagittal suture, and this may be imitated



106 MANUAL OF PRACTICAL OBSTETRICS.

during forceps delivery. A physiological pressure upon the foetal
head may be said to be such as would force cerebro-spinal fluid
from the ventricular spaces of the brain into those of the cord,
and vice versa, thus temporarily lessening the volume of one
portion of the cerebro-spinal nervous axis at the temporary ex-
pense of the other. The writer has observed, after several cases
of forceps delivery where the death of the child resulted within a
week or ten days, patches of cerebral softening not resembling
those occasioned by embolism, but apparently resulting from
pressure.

When the head does not engage at the brim of the pelvis, as a
rule the forceps should not be applied. Version, or some other
obstetric operation, is then indicated. A method of obtaining
axis-traction, sometimes useful, consists in passing a piece of
tape through the fenestrae of the blades sufficiently long to reach
nearly to the floor. The tapes are then tied together while the
operator makes traction by the handles; the loop of tape is
passed about his feet, and downward pressure in this way rein-
forces the usual methods of traction.

THE USE OF THE FORCEPS IN POSTERIOR ROTATION OF THE
OCCIPUT. In occipi to -posterior positions, it will be remembered
that, as a rule, rotation occurs when the head reaches the pelvic
floor. To secure this end, however, the expulsive forces of the
mother must be good, and the resistance of the pelvic floor be
also considerable. Flexion of the head must be present to secure
this result. The use of the forceps in these cases is to promote
flexion, and aid the descent of the head. For this purpose, axis-
traction is desirable. The instrument most appropriate is that of
Simpson, or some modification, which leaves the head free to ro-
tate as labor progresses.

When, however, the occiput is turned directly backward into
the hollow of the sacrum, axis-traction is not necessary, and de-
livery can usually be secured by applying the instrument to the
sides of the head, and making traction directly outward and
slightly downward until the forehead of the child begins to ap-
pear beneath the pubic joint. The grasp of the instrument should



APPLICATION OF FORCEPS AT BRIM OF PELVIS. 107

then be relaxed, the handles should be slightly lowered, and a
fresh grasp obtained. A movement of flexion should then be
performed by the forceps, the handles being slowly raised to allow
the occiput to pass over the perineum. In such cases, laceration
of the perineum usually occurs, is generally considerable in
extent, and sometimes complete.

THE FORCEPS IN FACE PRESENTATIONS. The best authorities
agree that the application of the forceps in face presentations is
not to be commended. It is true that a narrow-bladed straight
instrument has been employed on several occasions successfully,
securing perfect extension, and favoring the rotation of the chin
anteriorly. As a rule, however, the use of the instrument results
in such injury to the child and the mother as to render version a
far more desirable expedient.

THE FORCEPS APPLIED TO THE BREECH. In cases of breech
presentation where the progress of labor is slow, it has been
found possible to favor descent by applying the forceps in such a
way that the trochanter of each side should fit into the fenestra
of each blade. If the instrument is applied in any other man-
ner, serious injury may be done through pressure of the tips of
the blades upon the abdomen of the child. Traction in the pel-
vic axis should be made.

MORBIDITY AND MORTALITY CAUSED BY THE FORCEPS.
When the indications for the use of the forceps are intelli-
gently comprehended, and the instrument is rationally employed
with strict antiseptic precautions, its use does not increase the
maternal morbidity and mortality of labor, but under other con-
ditions a very considerable increase in both occurs. The injuries
most common to the foetus from the forceps are bruising and
laceration of the scalp, fractures of the cranium and face, and in-
juries to the brain through pressure. It occasionally happens that
very extensive laceration of the scalp occurs, followed by sloughing
after birth. Fractures of the cranium and bones of the face are
rarely fatal of themselves, and are serious in proportion as they
are accompanied by injuries to the brain through pressure. Frac-
ture of the jaw rarely occurs and will often recover perfectly



108 MANUAL OF PRACTICAL OBSTETRICS.

without the application of a splint. Paralysis of the facial nerve
by pressure upon the trunk soon after it emerges from its foramen
is not uncommon, but is usually temporary in character. Pres-
sure upon the brain may produce limited areas of softening as
already described, and even death from extensive injury to the
vital centres. Although it has been believed that idiocy is often
the result of pressure by forceps, yet proof of this is wanting in
the majority of cases, while a causal relation between forceps
delivery and epilepsy is also not proven.



Plate III.



Davis' Obstetrics.




Uterus with Twins in cranial and breech presentation
(two ova). (Smellie.)



CHAPTER XVI.

LABOR IN BREECH PRESENTATIONS.

A BREECH presentation may be diagnosticated before labor by
feeling the foetal head in the upper portion of the abdomen, by
hearing the foetal heart sounds at or above the umbilicus, by
detecting at the brim of the pelvis a body less round and hard
than the head, and by mapping out the foetal limbs. At labor,
such a presentation will be suspected when the head cannot be
recognized as the presenting part by its hardness and globular
outline ; a diagnosis can be made with certainty when the thighs
of the child can be felt, and their relative position to the trunk
be recognized.

The natural course of labor in breech presentation is more
prolonged than when the head presents, because the breech is
inferior, as a dilator of the birth-canal, to the head, and also
because delay is apt to occur in the descent and delivery of the
after-coming head. Nature endeavors in these cases to retain
the membranes unbroken as long as possible, thus securing thor-
ough dilatation (Fig. 61).

The positions of breech presentation are designated by select-
ing the posterior surface of the sacrum as the cardinal point upon
the foetus. In the first breech presentation, the back of the
.oetus is toward the left side of the mother, the posterior surface
of the sacrum being opposite the left ilio-pectineal eminence.
The diameter of the foetal body principally concerned in the
mechanism of the engagement and descent of the breech is the
bis-trochanteric, extending from one trochanter to the other,
measuring three and three quarter inches, or nine and five-tenths
centimetres. When labor occurs in the first position, this bis-
trochanteric diameter engages in the right oblique of the pelvis.

109



I 10 MANUAL OF PRACTICAL OBSTETRICS.

The body of the child descends into the pelvic cavity, and the
anterior hip, in this case the left, rotates forward under the pubes.
If the child be small and the birth-canal capacious, the hips may
emerge diagonally across the outlet of the pelvis. The body is
bent slightly upon itself by lateral flexion as it emerges.

In normal cases the arms of the child remain folded across its
breast. The left shoulder of the child engages first under the
pubic joint, and pivots beneath the articulation while the right

FIG. 61.




BREECH PRESENTATION, THE LEGS EXTENDED.

First Position.

shoulder sweeps over the perineum. The back of the child then
turning anteriorly, if flexion be complete, the chin emerges
closely approximated to the breast, and the occiput pivots be-
neath the pubic joint. Flexion continuing, the head passes over