There is, perhaps, no part of a medical man's duty which involves a higher degree of responsibility, than a decision as to whether the use of instruments be really required for the preservation of the life either of the mother or of the child. Many circumstances must be considered before a correct opinion can be formed: such as the length of time the female has been in labour; the cause which has given rise to the difficulty; the constitutional effect produced upon the mother, whether she be calm, tranquil, and disposed to sleep, or whether the system is getting into an irritable state, and shewing marks of fever or of inflammation: for a labour may in some instances be protracted for several days, and yet be safely trusted to the powers of nature, whilst, on the other hand, cases may occur in which the most prompt treatment is required in consequence of the effect produced upon the system. Where it is found that, although the pains continue severe, the head still remains fixed in its position for several hours, then it will afford a proof that there is more than the ordinary degree of difficulty, and the patient should be narrowly watched. The state of the bladder and rectum should not be lost sight of, lest, by the continued pressure of the head of the child, they become exposed to injury: as the pulse rises in frequency as soon as any internal part is suffering from this circumstance, the state of it (the pulse) may be regarded as an useful adjuvant in determining the propriety or impropriety of having recourse to instrumental interference.
The young accoucheur is particularly cautioned against an unnecessary multiplication of instruments, as they will only serve the purpose of confusing and perplexing him. The safety of these cases depends much more upon the head that directs, than upon the instrument which effects the delivery; and hence the reason why different men have argued so long and so loudly for the superiority of one instrument over the other.
Instruments are divided into two classes: 1st, those which are not necessarily destructive to either the mother or the child; and, 2d, those by which the child is destroyed for the purpose of saving the mother.
Of the first class are the forceps, both long and short, and the lever.
Of the second, are the perforator and the craniotomy forceps.
In all cases requiring the use of instruments, the bladder and rectum ought to be emptied previous to their introduction; the os uteri and external parts ought also to be well dilated, and the presentation and situation of the head correctly ascertained. The patient is to be placed near the edge of the bed, on her left side, the shoulders a little elevated, and the thighs separated by placing a pillow between the knees.
Long forceps. This valuable instrument has, until of late years, been too much neglected, and it is greatly to be feared that the lives of many children have been destroyed by the perforator, which might have been saved by the judicious employment of the long forceps. It is applicable in cases of deformed pelvis, wherein the deformity exists at the brim; the conjugate diameter, for example, being too straightened to allow of the passage of the head by nature's unaided efforts, and yet the contraction being too slight to warrant the mutilation of the child by lessening the size of its head; and, in fact, in all cases in which delivery is required with the head at the brim, and where, from any existing cause, turning may not be thought advisable; as, for example, in cases of hemorrhage, convulsions, &c.
In the more severe degrees of deformity however, where, for example, the distance from pubis to sacrum is under three inches, their use should not be attempted; for, as in these cases the child cannot be expected to be saved, it is better at once to use means by which the mother will be exposed to less risk. The length of these forceps is about fourteen inches; the perfectly straight ones are the best, the curve recommended by some answering no useful purpose. It is of great advantage that they be made according to the suggestion of Dr. Blundell, the talented lecturer at Guy's Hospital; viz. with a very loose lock: by which contrivance the blades may be joined together, and a very firm hold of the head obtained, even where they have not been applied in an exact line with each other.
Manner of applying the long forceps. In cases requiring the use of this instrument, the contraction is from before backwards, or from pubis to sacrum; it therefore should be so introduced that, when joined together and locked, the blades shall be lying in the side of the pelvis, embracing in their grasp the occiput and the forehead. For this purpose, after having warmed and anointed the blades, one is to be taken in the right hand, and carefully guarded to its place of destination by two fingers of the left hand previously introduced into the vagina. When applied, it is to be retained in its situation by an assistant, and the second blade introduced in like manner. When both blades have been properly introduced, viz. the one over the occiput, the other over the forehead, the handles are to be brought together and locked; great care being taken not to include any of the soft parts of the mother. After they have been united together, a very gentle degree of extracting force is at first to be made use of, in order to ascertain whether the instrument be properly applied, and a secure hold of the head obtained. It is better not to bind the handles together with tape, as formerly was recommended; for, by so doing, a constant and injurious pressure is kept up upon the yielding bones of the child's head. In delivering with the forceps, the force should be employed at intervals only; and, if pains are present, it may be used during a pain; the patient being examined from time to time, more especially as regards the state of her pulse, in order to be satisfied that no violent efforts are made use of, likely to endanger the soft parts, by producing contusion: it being well known that the pulse takes the alarm, and rises in frequency, directly the parts are injured by pressure. The situation of the axil of the brim (the part through which the head is first to be brought,) is strictly to be borne in mind, and the force employed in that direction. When the brim has been passed, end the head brought into the cavity of the pelvis, the forceps are to be removed; and, if the uterus be acting vigorously, the delivery will soon be accomplished. Where this is not the case, they may again be applied, the blades being passed over the sides of the head; or the short forceps may be employed, in the manner presently to be described.
Short forceps. This instrument can only be employed when the head of the child has descended considerably into the cavity of the pelvis; and, indeed, not until an ear can be distinctly felt by the ringer, without the introduction of the hand into the vagina. In consequence of this situation of the head, delivery is more readily accomplished by the short than by the long forceps, and the risk of injuring the soft parts of the mother proportionally lessened. When about to operate, the bladder and rectum should be attended to, as before recommended; the instrument to be guided carefully up the vagina, and over the ears of the child, until the lock reaches the external parts. In a vertex presentation with a natural situation, viz. with the occiput to the acetabulum, and the face to the sacro-iliac symphysis, very little difficulty will be experienced in the application of tin instrument. When both blades have been carried along the sides of the head, they are to be brought together and locked; and, when the pains come on, a gently extracting force employed, at first downwards and backwards, till the head nearly reaches the perineum; a half turn is then to be given, so as to throw the face into the hollow of the sacrum, and the occiput under the arch of the pubis. The line of motion must now be altered: fur, instead of being downwards and backwards, it should be downwards and forwards in the axis of the outlet. Great care is required in the delivery of the head; it should be brought through the external parts in the most cautious and slow manner, the perineum being supported by an assistant, in order to prevent laceration.
The head being born, the instrument is to be removed, and the delivery completed as in ordinary circumstances.
The bandage around the abdomen ought to be particularly attended to, for, in cases requiring the use of instruments, there is frequently a tendency to hemorrhage.
Where the face is towards the pubis, or where it is the presenting part, the forceps are still to be applied over the ears of the child. A more than ordinary degree of care is in these instances required in delivering the head, as the perineum will be put greatly upon the stretch.
Lever. The lever, or tractor, is applicable in every case to which the forceps may be used, and although a most valuable instrument in some hands, yet it is not so easily managed, nor upon the whole is it so safe, as the forceps; and therefore the latter is recommended in preference to the former.
Perforator, and craniotomy forceps. As, in the use of these instruments, the life of the infant must be sacrificed, the actual necessity for their employment ought to he well and clearly ascertained before recourse is bad to them. It has before been noticed, that if the conjugate diameter of the pelvis be less than three inches, it would be better not to attempt the delivery with the forceps, because the life of the child, under such circumstances, is not likely to be saved, and the soft parts of the mother would be in danger of suffering from the contusion which they must of necessity undergo; but, as it is not always easy correctly to ascertain the dimensions of the living pelvis, it will be right, in every doubtful case, to make a gentle and steady attempt with the long forceps, before the head be opened; taking, however, especial care not to make use of an undue degree of violence, for fear of contusing or lacerating.
It unfortunately happens that the operation of craniotomy is a very easy one, much more so than the application of the forceps; and is, perhaps on this account, in many instances, too hastily resorted to.
When, after due deliberation, it is judged expedient to open the fetal head, the rectum and bladder having been attended to, the patient is to be placed in the same position as before recommended; the left hand of the operator is to be carried along the vagina, until the fingers rest upon the head. These will serve as a director for the perforator, which is nothing more than a long pair of sharp-pointed scissors, which are then to be introduced with their points carefully guarded by the forefinger of the right hand, until they reach the presenting part. An opening being made by passing the instrument through the cranium with a sort of boring motion, and this opening having been enlarged to a sufficient extent, the perforator is to be withdrawn in the same cautious manner with which it was introduced. The brain should be thoroughly broken uown,-either by the ringer or by the introduction or any convenient instrument for ths purpose.
The next part of the operation consists in extracting the head by means of the cranicotomy forceps, a pair of which were invented some time ago by Dr. Davis. These are, however, quite inadequate in the Beverer cases of this kind, and will ere long be completely superseded by those of Mr. Holmes; the invention of which entitles tins gentleman to the thanks of every obstetric operator. His (Mr. Holmes's) instrument is one of much greater power, and may be used with more certainty than that of Dr. Davis, which, from the arrangement and small size of the teeth, is very apt to slip, in consequence of the scalp alone being transfixed by them. With Mr.H.'s, this accident cannot lake place: the vast superiority of which instrument has, indeed, been acknowledged by all who have used it; more, therefore, need not be said in its favor.
A secure hold of the head having been obtained by the instrument, the convex blade of which is passed on the inside of the cranium through the opening made by the perforator, and the concave on the outside, the operator gradually draws down; making use at first of a moderate degree of force only, and gradually increasing it till the head has passed through the contracted brim; after which there is usually but little difficulty. The long diameters of the pelvis, and of the head and shoulders of the child, must be borne in mind, that, in the progress of the delivery, they may be made to correspond with each other.
When the child is born, a suture is to be passed through the torn edges of the scalp, in order that it may be brought together, the cranial bones having been previously pressed as nearly as possible into their usual form.
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From Charles Waller
Elements of Practical Midwifery: Or, Companion to the Lying-in Room, 1829
