the perineum from the chin to the occiput successively by a mo-
tion of perfect flexion. When the back of the child rotates pos-
teriorly toward the back of the mother, the chin often pivots
LABOR IN BREECH PRESENTATIONS. Ill
behind the pubic joint, and delivery may take place by expulsion
with strong extension (Figs. 62 and 63).
When the back of the child is toward the right side of the
mother in the second position of breech presentation, the mech-
anism is the same, with a reversal in the direction of the rotation.
The treatment of breech presentations requires, so far as
possible, very early recognition of the presentation. It is of espe-
FIG. 62.
DESCENT OF THE TRUNK, BREECH PRESENTATION.
Second Position.
cial importance whenever the obstetrician detects an abnormal
presentation that the membranes be not ruptured until the very
last moment. One of the dangers to which the child is exposed
in abnormal presentations arises from the defective dilatation of
the os and cervix, which contract about the head and neck of the
foetus at the moment of delivery, often causing death by asphyxia.
This is especially true in labor with breech presentations, in which
MANUAL OF PRACTICAL OBSTETRICS.
the head, coming last, is exposed to pressure and resistance from
an imperfectly dilated birth-canal. The membranes, then, should
FIG. 63.
FIG. 64.
THE SHOULDERS EMERGING, BREECH
PRESENTATION.
Second Position.
EXPULSION OF THE HEAD IN
BREECH CASES.
FIG. 65.
be retained until the breech has de-
scended, and oftentimes until the
membranes begin to protrude at the
vulva (Figs. 64 and 65).
In a simple case of labor with
breech presentation, the obstetrician
should avoid hastening the descent
of the trunk. Traction carelessly
made upon the hips and limbs will
often cause the ascent of the arms to
the sides of the head, seriously com- HEAD BORN IN BREECH LABOR.
LABOR IN BREECH PRESENTATIONS. 113
plicating its delivery. As the breech emerges, the wedge formed by
the breech and flexed thighs will be gradually decomposed, and the
limbs will become gradually extended. It occasionally happens
that descent of the limbs is present from the beginning of labor,
constituting what is often known as a ''footling case." As the
FIG. 66.
BRINGING DOWN THE HIPS IN A DELAYED BREECH LABOR.
body of the child descends the physician should support it with
his hand, or with a warm towel, standing ready to raise the body
of the child toward the mother's abdomen with one hand, while
making prompt and energetic pressure over the uterus behind the
pubic joint with the other, at the moment when the head emerges.
5*
MANUAL OF PRACTICAL OBSTETRICS.
FIG. 67.
These two simple manoeuvres will result in the prompt expulsion
of the head in uncomplicated cases. If an anaesthetic has been
used, itsadministration
should be discontinued
before the head reaches
the pelvic floor, so that
the mother's conscious
efforts may be solicited
at the critical moment
when the head is pass-
ing (Figs. 66 and 67).
It is well in all breech
cases to have at hand
the forceps ready for
instant use, and also
appliances for resusci-
tating an asphyxiated
child. Of the latter,
the warm bath accom-
panied by a fine stream
of cold water directed
upon the chest, is the
best. It is well to have
a small English cathe-
ter which may be in-
troduced into the tra-
chea, should direct in-
flation of the lungs be
necessary. In the ma-
jority of cases an as-
phyxiated child in
whom circulation per-
sists can be resuscitated
by placing it in a hot
bath, directing a fine
BRINGING DOWN THE TRUNK IN BREECH CASES, stream of cold water
LABOR IN BREECH PRESENTATIONS. 115
upon its chest and making passive respiratory movements. The
application of cold water should be brief, and the stream should
be so fine as to resemble a jet of spray. The entrance of air into
the foetal chest can be secured by Schultze's method of inflation.
The foetus is grasped by both hands, the palmar surfaces on the
scapulas, the thumbs on the sternum, the head between the hands.
The body is then raised until the legs drop over the physician's
head; it is swung gently outwards and forward, in the arc of a
FIG. 68.
THE ARMS BESIDE THE HEAD.
circle, until it almost touches the floor. Expiration occurs during
ascent; inspiration during descent. Should the heart's action
fail, digitalis or strophanthus given by hypodermic injections, and
the application of heat are often useful. The precaution should
always be taken to remove mucus from the child's mouth and
fauces with a bit of soft, old linen dipped in a solution of boracic
acid.
When the arms of the foetus have become extended beside the
head, the physician must liberate them and bring them down.
To accomplish this, the thighs of the child are grasped, we will
u6
MANUAL OF PRACTICAL OBSTETRICS.
say, by the left hand ; downward traction is first made upon the
body, and then the trunk is bent strongly toward the mother's
right side and obliquely upward and outward. The index and
middle finger of the right hand are then passed over the child's
right scapula, and along the upper surface of the humerus, until
the bend of the elbow is reached. The foetal arm is then flexed at
the elbow and carried downward and across the child's chest, when
FIG. 69.
THE ARMS BESIDE THE HEAD.
it easily drops into the vagina. Grasping the thighs with the right
hand, the body is then carried obliquely upward toward the
mother's left side, and the left arm of the foetus is liberated by
the left hand of the physician.
The arms having been delivered, an effort should be made to
deliver the head by the simple procedure already described.
Should flexion not be well marked, the head may delay and the
LABOR IN BREECH PRESENTATIONS.
117
life of the child be lost through the pressure of the pelvic floor
upon the blood-vessels and nerves of the foetal neck. It is
necessary then to act with promptness. The physician should
FIG. 70.
DELIVERING THE ARMS.
stand squarely in front of the patient, who has been brought to
the edge of the bed and placed across it, her hips projecting over
the edge. The left arm should be uncovered to the elbow, thor-
oughly cleansed, and should be turned with the palmar surface of
n8
MANUAL OF PRACTICAL OBSTETRICS.
the hand upward. The body of the foetus should then be placed
astride the fore-arm of the physician, and the index and middle
finger of the left hand should be passed upon the face of the
child, making strong pressure upward and forward upon the malar
prominences. Raising the body of the child upon his left arm,
the physician should press strongly downward with his right hand
FIG. 71.
THE DELIVERY OF THE AFTER-COMING HEAD.
placed behind the pubic joint. Should he not succeed in promptly
effecting delivery, he may place the middle finger of the left hand
in the child's mouth, the index and other fingers resting upon
the child's shoulders. He may thus make strong flexion, com-
LABOR IN BREECH PRESENTATIONS. 119
bining it with external pressure, and urging the voluntary efforts
of the mother.
If great resistance is to be overcome, the pressure behind the
pubic joint may be made by an assistant, while the right hand of
the physician is placed upon the child's back, the fingers of the
hand grasping the shoulders to aid in traction. When the back
of the child is directed posteriorly toward the mother's back, the
same method of manual extraction is indicated, delivery occurring
with the occiput behind ; the forceps can often be used success-
fully to better advantage than when the back is anterior (Figs.
68, 69, 70 and 71).
The morbidity and mortality of breech presentations is not
increased especially with the mother, but is considerably greater
than usual with the child. Asphyxia and exhaustion through
pressure upon the after coming head, the inspiration of matter
from the birth-canal, and injury done to the mouth by efforts at
delivery, are the principal dangers. It is not uncommon, after
the delivery of the child in breech presentation, to have the
development of broncho-pneumonia caused by inspiration. The
use of antiseptic douches during the early stages of labor dimin-
ishes the risk of such pneumonia, and the delivery of the head
without the introduction of the finger into the mouth also lessens
risk. The causes of breech presentation are sometimes found in
a relaxed condition of the uterus, which allows the foetus to
assume various positions during pregnancy. In twin pregnancy,
it is common to find one of the children presenting by the
breech. Labor is longer in breech than in'head presentations as
a rule, and the case demands patience and careful attention.
CHAPTER XVII.
LABOR IN TRANSVERSE POSITIONS.
IN contracted pelves and in large pelves where the membranes
rupture suddenly and the amniotic liquid escapes rapidly, the
foetus may become turned transversely across the birth-canal, giv-
ing rise to a transverse position. The part which usually pre-
sents in these positions is the shoulder. This may best be under-
stood if we suppose a case in which, during the latter months of
pregnancy, the foetus occupied the usual position in the uterus,
that is, the back towards the mother's left side, the head at the
brim of the pelvis, the occiput slightly in front. If now, for any
reason, as contraction at the brim of the pelvis, the foetus cannot
descend through the brim, or if, by the sudden rush outward of
the amniotic liquid the foetus be suddenly moved downward, it
may happen that the head will delay in the left iliac fossa, the
breech will be near the right iliac fossa, the back of the child to-
ward the abdomen of the mother, the feet in the upper portion
of the right side of the mother, while opposite the left ilio-pec-
tineal eminence will be found the posterior surface of the right
scapula. As a rule, should labor pains continue, the right arm
of the foetus will descend and may even protrude.
When the child is of average size, its descent and expulsion
spontaneously may be said to be impossible. It is true that a
small foetus or a foetus in an abnormally large pelvis may be so
folded upon itself by forcible uterine contractions that expulsion
may take place. This occurrence, however, is so rare that the
practitioner should never count upon its occurrence, but when
the transverse position is detected he should at once rectify it and
terminate the labor (Fig. 71).
The nomenclature of transverse presentations commonly ac-
LABOR IN TRANSVERSE POSITIONS. 121
cepted designates the posterior surface of the scapula as the car-
dinal point upon the foetus. The word dorso is used to express
the fact that the back of the child presents in these cases. The
word right or left is added to the word dorso to designate the
shoulder which is presenting. Thus the most frequent transverse
position is that in which the right shoulder is at the brim of the
pelvis, the back of the child directed in front as has been already
explained. It rarely happens that the back of the child is turned
posteriorly (Fig. 72).
FIG. 71.
ATTEMPTED SPONTANEOUS EVOLUTION IN TRANSVERSE POSITION.
The diagnosis of such positions and presentations may be made,
first, by palpation, and then by internal examination. On pal-
pating the abdomen, the head can usually be distinguished upon
one side above the brim of the pelvis. The breech can generally
be recognized upon the opposite side, and if the transverse posi-
tion has existed for some time, a hand and arm will have pro-
lapsed, and can readily be found upon examination. It is of
practical importance to recognize promptly which shoulder is
presenting, and this can be done by determining which hand is
prolapsed. If the hand and fore-arm of the foetus is turned with
6
MANUAL OF PRACTICAL OBSTETRICS.
the radial side or thumb uppermost, and the practitioner grasps
the hand as if to shake hands with it, if the foetal hand fits into
his right hand, palm
FlG - ? 2 - to palm, the foetal
arm is the right, and
the right shoulder is
presenting. If, how-
ever, the prolapsed
hand fits the left hand
of the practitioner, it
is then the left shoul-
der which is present-
ing (Fig. 73).
A further diagnosis
FIG. 73.
RIGHT DORSO-ANTERIOR.
may be made by
reaching the axilla
with the finger, when
the ribs of the child
are easily distinguish-
ed. Passing the finger
over the shoulder,
the clavicle and the
child's neck can
sometimes be felt ly-
ing in a direction op-
posite to that in which
the ribs were felt.
RIGHT DORSO-POSTERIOR.
CHAPTER XVIII.
THE TREATMENT OF TRANSVERSE POSITIONS ; VERSION.
IN transverse positions, the treatment of such conditions con-
sists in turning the child about so that its long axis shall co-
incide with the axis of the birth-canal. This may be accom-
FIG. 74.
COMBINED VERSION (First Stage).
plished, first, by external manipulation only ; second, by external
and internal manipulation combined ; and third, by turning the
child within the womb.
To accomplish the first of these procedures, the membranes
should not have ruptured, and the patient should not be in active
labor. If she is sensitive and the abdominal muscles irritable,
123
124 MANUAL OF PRACTICAL OBSTETRICS.
she may be partially anaesthetized with ether or chloroform. The
practitioner can usually outline the two extremities of the foetus,
and by pressing upward upon one of them and downward upon
the other by a series of gentle sliding movements, either the head
or the breech can usually be brought to the brim of the pelvis.
This procedure is known as " External Version."
FIG. 75.
COMBINED VERSION (Second Stage).
By "Combined Version," we understand a method by which
one hand of the physician is placed upon the abdomen, while two
fingers of the other inserted within the vagina and cervix endeavor
to lift up the presenting shoulder, thus dislodging it and favoring
the turning. The external hand, by pressing upward upon the
breech, favors the descent of the head. This method is often
known as that of Braxton-Hicks. It is appropriate for cases in
which the membranes have not ruptured ; when the os and cer-
vix are partly dilated, and uterine contractions are not strong.
To perform this successfully, anaesthesia may be, but often-times
is not, required (Figs. 74, 75 and 76).
" Internal Version," or turning the child within the womb, is
the procedure necessary in cases in which the membranes have
THE TREATMENT OF TRANSVERSE POSITIONS; VERSION. 125
raptured, or are ruptured by the operator, 'and in which there is
not sufficient time to perform either of the other manipulations.
Internal Version consists in introducing a hand within the uterus,
grasping the feet of the child and bringing them down, thus con-
verting a transverse into a breech presentation. Although a seri-
ous procedure, it is one of the most valuable expedients in the
FIG. 76.
COMBINED VERSION (Third Stage).
obstetric art, and when skillfully performed, is very safe for
mother and child. The patient should always be anaesthetized
and placed across a bed, with her hips projecting over the edge.
A preliminary antiseptic douche should be given, and, as in all
obstetric operations, the bladder and rectum should be empty.
Before proceeding to turn, the operator should carefully palpate
the abdomen to determine the presence or absence of excessive
126
MANUAL OF PRACTICAL OBSTETRICS.
distension of the lower uterine segment. A clear diagnosis of the
position and presentation should be made, and from such diag-
nosis the situation of the feet of the foetus can be readily deter-
mined. The operator will then select for introduction the hand
which will pass most readily to grasp the feet (Figs. 77 and 78).
FIG. 77.
INTERNAL VERSION (Grasping the Lower Foot).
Referring to our original example, in a right-dorso anterior posi-
tion and presentation, the head of the child is in the left iliac-fossa
of the mother, the feet and legs of the foetus lying at the brim of
the pelvis and posteriorly upon her right side. As the obstetrician
sits before her, his left hand can be introduced most readily to grasp
THE TREATMENT OF TRANSVERSE POSITIONS; VERSION. 127
the feet. His arm should be uncovered to the elbow, rings upon the
fingers should be removed, and the nails cut short and carefully
cleaned. The hand and arm should then be thoroughly antisepti-
cized ; the back of the hand may be slightly smeared with some
antiseptic . ointment. To introduce the hand, the patient being
anaesthetized, the thumb and little finger may be folded toward
FIG. 78.
INTERNAL VERSION (Grasping the Upper Foot).
each other, thus reducing the width of the hand very considerably.
The hand should be brought in such relation with the vulva that
its greatest diameter of width will be parallel to the greatest di-
ameter of the vulva. The right hand should palpate the abdo-
men externally, endeavoring to push up the foetal head while the
128
MANUAL OF PRACTICAL OBSTETRICS.
other hand brings down the breech. The internal hand the
left, in the case which we are considering should be gently
FIG. 79.
INTERNAL VERSION (Grasping both Feet).
pushed on until the feet of the foetus can be grasped. This sim-
ple manoeuvre of grasping the child's feet should be so done
that the finger nails of the operator are turned away from the
THE TREATMENT OF TRANSVERSE POSITIONS; VERSION. 129
uterine wall and toward the centre of the uterine cavity. To
accomplish this, the feet should be seized between the index and
middle finger, and the thumb folded over upon them grasping
them firmly in the palm of the folded hand, as shown in the ac-
companying illustration (Fig. 79). Traction by the internal hand
should be slow, gentle, but strong. When the limbs of the foetus
FIG. 80.
THE NOOSE m VERSION.
have fully descended, the external hand should endeavor to push
up the head, thus favoring version.
When the feet have been brought down, if haste is not neces-
sary, it is well to delay the extraction of the child, allowing time
for the mother's uterine contractions to expel it. If there be a
fear lest the foetal limbs should recede within the uterus, a loop of
gauze or bandage should be slipped around a foot or hand. When
version is accomplished, the subsequent course of the labor will
be simply that of an ordinary breech presentation (Fig. 80).
I 3
MANUAL OF PRACTICAL OBSTETRICS.
It will be observed that version by external manipulation can
be performed only before the membranes have ruptured, and no
considerable degree of dilatation of the os and cervix exists.
FIG. 81.
THE OBSTETRICIAN ANESTHETIZING THE PATIENT AND PERFORMING
VERSION WITHOUT ASSISTANCE.
Version by combined manipulation requires sufficient dilatation to
permit at least the introduction of one or two fingers. The
membranes may or may not have ruptured. In combined version
it is often advantageous to introduce the four fingers through the
THE TREATMENT OF TRANSVERSE POSITIONS; VERSION. 13!
os, thus grasping the head or breech, and bringing it at once to
the desired position. To perform internal version, the membranes
must have ruptured, or must be ruptured, and dilatation should
be at least almost complete Fig. 81).
Version is further divided into Cephalic and Podalic, accord-
ing as the head is brought to the brim of the pelvis, or the feet
are brought down, as in internal version. Version as an opera-
tion will be further considered in treating of labor in contracted
pelves, when we shall find that in transvere presentations in
highly contracted pelves it may be necessary to lessen the size of
the foetal body by emptying the trunk of a portion of its con-
tents or, in rare cases, by cutting through or dividing the trunk.
So far as nomenclature of these presentations goes, we have, first,
and far most common, right-dorso-anterior ; second, and next in
frequency, left-dorso-anterior, the dorso posterior positions being
rare.
CHAPTER XIX.
LABOR WHEN THE CHILD AND THE BIRTH-CANAL OF THE MOTHER
ARE DISPROPORTIONATE IN SIZE.
A CONSIDERABLE number of cases of difficult labor arise from
the fact that the child and the birth-canal of the mother are not
of proportionate size. In successive pregnancies, it is common
to find a slight increase in the size of children born after the
first. Again, conditions affecting the mother's nutrition may
also influence the growth and size of her child. Thus, children
born during a period of famine are naturally smaller than chil-
dren born amid plenty. The most potent influence in determin-
ing the size and type of the foetus is found in the size and type
of the father. For example, marriage between a large and finely
proportioned man and a small and ill-developed woman may
result in children larger proportionately and better developed
than the mother, although rarely attaining the stature and perfec-
tion of the father's form. On the other hand, a large and finely
shaped woman, if married to a man inferior in size and develop-
ment to herself, may give birth to children far inferior to her own
excellences of form and feature. The influence of this law may
be illustrated by reference to an actual case : an ill-developed,
badly-nourished woman, married to a man as weak and poorly
developed as she, gave birth to a small, ill-nourished child after
a short and easy labor. The first husband dying, the mother
married a large and well developed man, and became the second
time pregnant. The size and proportions of the child were such
that labor was so prolonged and difficult that the Caesarean Sec-
tion was seriously contemplated by the obstetrician in attend-
ance.
Cases of disproportion between the size of the foetus and the
132
LABOR WHEN DISPROPORTION EXISTS.
133
birth canal may be conveniently divided into those in which the
size and development of the child exceed comparatively those
of the mother, and, second, those cases in which the birth-canal
of the mother is contracted either by a deformity in the bony
pelvis, or by a foreign growth, or previous pathological process in
the mother's soft tissues. In cases where the disparity is that of
size and development, pelvic measurements will reveal the fact
that the pelvis is symmetrical in form, although often below the
average in its diameters. Pelvimetry then gives us no informa-
tion regarding the amount of disproportion in the size of the
mother and child, but simply indicates that the mother is either
of average size, or slightly below. There is no practical method
available for measuring the child in the uterus, and any estimate
as to the relation between its size and that of the mother's birth-
canal must be reached by some method of practical comparison.
In cases in which the head is presenting, an effort should be
made to fit the head into the bony pelvis as a head is fitted into
a hat. To accomplish this, the patient should lie upon her back,
the thighs flexed, and should there be such sensitiveness or irri-
tability of the abdominal muscles as to cause spasmodic contrac-
tion upon pressure, an anaesthetic should be administered. The
obstetrician then endeavors to press the head of the child gently
into the pelvis of the mother. For this purpose, a hand should
be placed transversely behind the pubes, while with the other, an
internal examination is made, and the descent of the head is
appreciated. If an assistant is available, he should place one
hand upon the fundus of the uterus, the other above the pubes,
and make pressure gently as already described.
By engagement is understood the fitting of the head into the
brim of the pelvis; if it is found that the head enters the pelvis,
or engages, its size is such that a favorable termination of labor
may be expected in the usual way. If, however, the head fails
to engage, but remains above the entrance to the pelvis, some
abnormality exists which should be investigated.
In presentations other than those of the head, we have no
practical method of estimating the relative size of the child and
134 MANUAL OF PRACTICAL OBSTETRICS.
the birth-canal. Thus, if the breech presents, a head too large
to pass easily through the pelvis may be found at the fundus of
the uterus, and yet no accurate idea of its comparative size can
be obtained by palpation. Excessive distension of the abdomen,
the complaint of the mother of excessive weight, and projection