252 



MIDWIFERY. 



OfParturi- state of the pelvis; for in the same period 1 woman in 

 tion. 1 1 died ; but the loss of children was rather less, 

 v " "V""' namely, I in 6'. In the range of the next 10 hours, that 

 is to say, if more than 40, and under 50, were allowed to 

 elapse, 1 woman in 13, and 3 children out of 10, were 

 lost. The conclusion is against delay. It is quite a 

 mistake to suppose, that the application of the forceps 

 by a careful practitioner is necessarily more painful or 

 more dangerous than the efforts made by nature for the 

 expulsion of the child in such cases. On the contrary, 

 the sufferings of the mother are both shortened and di- 

 minished, and her subsequent safety ensured, whilst the 

 life of the child is preserved, which otherwise would be 

 lost. Doubtless the unnecessary and wanton use of 

 instruments is strongly to be reprehended ; but much 

 and pretty long experience has convinced the writer of 

 this article, that of the two extremes of premature and 

 dilatory recourse to the forceps, the latter is by far the 

 most dangerous, and the most to be dreaded. He is 

 particularly happy to embrace the present opportunity 

 of expressing his concurrence in the sentiments main- 

 tained on this subject by Dr. Hamilton, the justly ce- 

 lebrated professor who fills the obstetric chair in Edin- 

 burgh, and to whom the profession is indebted for 

 many advantages, and for none more than his powerful 

 recommendation of early recourse to instrumental aid. 



To deliver precise rules for the time and manner of 

 applying the forceps, which ought decidedly to be pre- 

 ferred to the lever, would require a more minute detail 

 than is compatible with this work, nor is it perhaps ne- 

 cessary, as these are fully laid down in those elemen- 

 tary books which are in the hands of every practitioner. 

 The following observations, however, may be useful : 

 1st, In every instance where there is reason to appre- 

 hend a tedious or difficult labour, it is of importance to 

 prevent the first stage from being unnecessarily pro- 

 tracted. When the pains are regular, but productive 

 of little effect, the means already pointed out for procu- 

 ring dilatation of the os uteri within a limited period, 

 generally twelve hours, ought to be employed. 



2d, If the delivery can be accomplished by the for- 

 ceps, it is possible to apply the instrument whenever 

 the os uteri is completely dilated, but not sooner. 



3d, Although the last assertion be true, yet it is ge- 

 nerally found that the more the head has advanced in 

 the pelvis, the easier is the application of the instru- 

 ment, with the exception of those cases where the head 

 is firmly wedged in the pelvis. In such cases it has 

 been necessary to raise it up a little. When the ear of 

 the child can be felt behind the pubis, when a consi- 

 derable part of the cranium corresponds to the hollow 

 of the sacrum, and the perineum is touched, or a little 

 pressed by the head, the case may be managed with the 

 forceps without much difficulty. 



4th, A rule has been laid down, that before we apply 

 the instrument we should allow the head to rest on the 

 perineum for six hours ; that is, that we shall delay to 

 act for six hours after action has become easy. There 

 is no rule more absurd, and less to be depended on, 

 for we may sometimes delay much longer ; and in other 

 cases, be required to deliver much sooner. 



5th, We never ought to allow the head to remain 

 long impacted, that is, much pressure to continue for a 

 length of time on the soft parts, nor ought we to per- 

 mit the uterine action to become exhausted, far less the 

 general strength to be much impaired. If we do, ute- 

 rine hemorrhage succeeds delivery, or inflammation 

 comes on after it, or the uterus is ruptured ; and, in the 

 case of impaction, if the patient escape this risk, she is 



liable to sloughing of the soft parts, particularly of the Of Pariuri. 

 urinary organs. Continued pressure produces swell. tion. 

 ing of the soft parts in the pelvis, which impedes deli- s "* "> "' 

 very. It is preceded by heat and dryness of the vagi- 

 na, which indicate inflammation coining on, and, if 

 delivery be not resorted to, the case is likely to prove 

 fatal. ' 



6'th, Whenever we find that the head is remaining 

 stationary for several hours, and the uterine efforts do- 

 ing no good, although frequent and painful, and when 

 the ordinary means advised in tedious labour prove of 

 no avail, we are warranted to interfere. A prolonga- 

 tion of suffering would only endanger both mother and 

 child. It is no reasonable objection to this, that we 

 find women continue in severe labour for some days, 

 and yet not only bear the child without aid, but reco- 

 ver well. The fact is undoubted ; but, on the other 

 hand, it is no less certain that a great many such cases 

 end fatally. It is quite impossible to say where the 

 limits of safety end, or to lay down a general rule with 

 respect to time. Regard must be paid to the strength 

 and constitution of the patient, her age, to the circum- 

 stance of her being in labour for the first time, the fa- 

 tigue endured, the effect of the pains, and the ineffica- 

 cy of other means. Let us ascertain what the powers 

 of nature can do so long as we safely may wait, and 

 neither interfere rashly, nor delay dangerously. The 

 combination of other evils or accidents adds to the ur- 

 gency of the case. 



7th, When it is quite ascertained that the pelvis is 

 considerably contracted, we ought to deliver as soon as 

 the head comes into a favourable place. The patient, 

 in all probability, shall have had labour sufficiently 

 severe before the head have entered so far into the 

 pelvis, and permitting labour to continue longer is on- 

 ly adding unprofitably to her sufferings. 



8th, If the pelvis be contracted, and especially if this 

 state be combined with spasmodic action of the uterus, 

 the head may be very long of entering the pelvis, or 

 may never descend so low as is supposed in the third 

 remark. In such a case, it becomes necessary to deter- 

 mine whether the forceps can be applied, or the child 

 must be destroyed, by opening the head, and using the 

 hook or extracting pincers. In the middle of the last 

 century, long forceps was used by Dr. Smellie and 

 others, when the head was high. On the Continent, 

 the late excellent practitioner, Baudeloque, was, and the 

 present energetic Dr. Osiandcr is, successful in this 

 mode of using the forceps, which also has been advised 

 by Dr. Hamilton, who, like Smellie, uses both a long 

 and a short pair. In doubtful cases, an attempt certainly 

 ought to be made to save the child ; but repeated and 

 irritating efforts are to be discouraged ; nor, in any case, 

 are they admissible, when the conjugate diameter is de- 

 termined to be only three inches. The writer has seen 

 persevering efforts made with the best intention, but 

 ending at last in the use of the crotchet, and in the 

 accession of inflammation even before the delivery of 

 the child. 



9th, The blades of the forceps are to be successively 

 introduced along the opposite sides of the head, slid- 

 ing gently, and with the utmost tenderness. They are 

 to be accurately and cautiously joined, and having as- 

 certained that the application has been properly effect- 

 ed, and the fixture is secure, extraction during a pain, 

 or at intervals, if the pains have gone off, is to be made 

 in the direction of the axis of that part of the pelvis 

 through which the head is passing. In doing this, time 

 is to be considered as better than force. 



