Complications during labor may arise from abnormal positions of the head, such as face or brow; from abnormal presentations of the child, such as breech, transverse or shoulder; from twin labors; or from prolapse of a part like the foot, arm or cord.

The mother may be responsible for some of these abnormalities through having a contracted pelvis, a rigid os, or a rigid pelvic floor.

The uterus, too, may functionate abnormally by acting too vigorously, as in precipitate labor, or too slowly, as in uterine inertia. The membranes may rupture prematurely and produce a dry birth.

There may be hÆmorrhages before labor (ante partum hÆmorrhage) during labor (intra partum), and after labor (post partum hÆmorrhage), or the labor may be preceded, accompanied, or followed by that extreme example of toxÆmia known as eclampsia.

Face and brow presentations are rare and come to the attention of the nurse only when an operation is required for their relief. Further conditions may arise, such as danger to mother or child, which demand an acceleration of the labor.

If the head is engaged, forceps is the operation most commonly undertaken, and if not engaged, the problem may be solved either by an early version and extraction or by forceps later. The dangers to the mother are not usually difficult to diagnose if the case has been followed carefully.

Signs of danger to child must be looked for constantly. Such are:

(a) Alteration of the heart tones.

(b) Retardation of pulse in cord between pains.

(c) Escape of meconium is not significant unless occurring in the pain-free interval, when it may signify hypercarbonization of blood and a threat of asphyxiation.

The preliminaries for the performance of these operations may now be described, and the indications and conditions briefly tabulated.

The preparation should be standardized so that the same set-up of the room will do for all of the major obstetrical operations, except CÆsarean section.

The kitchen table is generally regarded as a satisfactory operating table. Its length is sufficient for delivery when the legs are doubled up. The table should be covered with a blanket or comfort on which it laid a clean sheet. A rubber blanket or piece of oil cloth is put on, so folded above the place for the patient’s hips, and so pinned at the sides, that all drainage will flow off into a bucket or jar at the foot.

In front of the table is placed a straight-backed chair with flat seat. To the right of the operator, as he faces the table, stands a bench, or two chairs, side by side; or, if possible, another table. This is covered with a clean sheet for the reception of the instruments. To the operator’s left, another table similarly prepared carries the solutions, sponges, etc. Every operation for delivery should have tape and cord scissors within easy reach, as well as facilities for the resuscitation of the child.

The light should come from behind the operator and fall full upon the field of operation. The room should be warm.

The patient is laid upon the table and her knees elevated in the exaggerated lithotomy position. If there are assistants enough, one can stand on either side and hold a knee, if not, a sheet sling can be made and slung round the patient’s shoulders and tied to the knees as previously described.

An anÆsthetic will be required. If a doctor can not be had, this duty will fall to the nurse.

A sterile douche bag hangs near the table. A bath tub of hot water must be provided and a tracheal catheter must be ready for the removal of mucus from the child’s windpipe. An abundance of hot and cold sterile water must not be overlooked. In the hospital the following synopsis for the placing of the linen may be found useful:

Sterile Linen for Operative Case.—

Bring patient to foot of bed.

Put in the stirrups. (For breech deliveries do not use stirrups.)

Same order as for normal case except that feet are put in stirrups instead of on bed.

Sterile sheet under patient extends now from basin under bed to buttocks.

Combination pad over field of operation.

Sterile sheet over abdomen.

The genitals of the patient are now cleansed with all care and attention described for labor. If this has been done within an hour, she need only be sponged off thoroughly with lysol solution (1 per cent). The feet and legs are covered with stockings, the body kept warm, and protected by sheets and blankets, if necessary.

Every operative delivery is preceded by catheterization.

All instruments are boiled for thirty minutes and brought to the table in the same container in which they are sterilized. The hot water has been poured off and a cool, weak solution of lysol (0.5 per cent) added.

Forceps.—Before using forceps it should be determined that the woman can not deliver the child unaided, or can not be permitted to do so without too great expenditure of physical and nervous energy. The exact conditions must be recognized as to the location and position of the head, the condition of the foetal heart tones and the size of the pelvis. When the head is high up, the axis traction instrument is employed and patient put in Walcher’s position for the traction.

Axis traction forceps are extremely dangerous to mother and child, and should be avoided wherever possible.

The following instruments are required:

Besides these instruments, the nurse will also have solution basins as described for normal labor. For operations outside of hospitals, the nurse need not be clean, as her duties will consist for the most part in changing solutions, refilling basins, handing towels, etc., all of which can be done with sterile forceps.

The following summary may be serviceable for advanced study or reference:

Preparation.—

Thorough asepsis, both subjective and objective.

Patient should be pulled down to the foot of the labor bed with feet in the stirrups, or put upon the kitchen table or across the bed with the legs held in the lithotomy position. (For breech cases, legs should not be fastened.)

Bladder and rectum must be empty.

AnÆsthetic is necessary.

The position of the head must be accurately known.

Facilities for the treatment of asphyxia neonatorum must be at hand.

Conditions.—

Cervix effaced and os dilated, except when maternal or foetal life is threatened.

Bag of waters must be ruptured.

The head must be engaged.

The child should be living.

Indications.—

Insufficiency of the powers of labor.

Deep transverse arrest of the head.

Complications in labor, such as:

Eclampsia.

Fever.

Acute or chronic disease.

Hernia—especially if incarcerated.

Placenta previa.

Prolapse of the cord.

Face and brow presentations.

Contracted pelvis.

Occipito-posterior positions.

Dangers From Forceps.—

Injuries to Child.—Overcompression, especially with axis traction forceps or in contracted pelvis.

Crushing of soft parts, or such lesions as abrasions, pressure marks, hÆmatomata, swelling of face and eyelids.

Bone injuries: Spoon-shaped depression where the head has been dragged through a narrow inlet; fissures in the parietal or frontal bones; fractures. When axis traction forceps are applied antero-posteriorly, the occipital bone may be sprung inwards until it cuts the medulla.

Compression of the cord, especially if it is around the neck.

HÆmorrhage from the middle meningeal artery.

Injury to eye.

Erb’s paralysis.

Laceration of ears when the forceps are removed.

Facial paralysis from pressure of the blade.

Injury to Mothers.—

Infection.

Improper application of the blades outside the cervix uteri.

Soft parts torn by too rapid extraction. When os is not dilated, it is first pulled down and then torn. The tear may extend into the vaginal vault. FistulÆ may be produced.

Prolapse of the uterus from prolonged traction.

Vaginal tears from the blades or from malplaced head.

Slipping of blades. Traction must be not against the symphysis, but down.

The forceps commonly used in this country (Simpson or Elliott) are so made that the left blade must be introduced first on account of the lock.

The mortality for the child in forceps cases is about six per cent.

The axis traction instrument is used but seldom by good obstetricians, since the danger to mother and child in this operation is very serious and it should be reserved for emergencies of exceptional character. Pubiotomy may precede the operation with advantage in many cases. Asphyxia of the child and maternal hÆmorrhage must be prepared for.

Version (Turning).—Version is a maneuver for altering the presentation of the child while it is still in the uterus. A vertex may be converted into a breech, a breech into a vertex or a transverse into either a vertex or a breech.

Version usually means that a transverse or a vertex presentation is changed into a breech and is followed by the extraction of the child. The operation is serious and not to be undertaken without definite indications. There is always the risk of sepsis and rupture of the uterus as well as a high probability of a dead child. Perineorrhaphy is, if anything, more frequent after this operation than after forceps.

Preparations.—The room and patient are arranged as for forceps, except that the stirrups can not be put in. The legs must be held by assistants, for the delivery of the after-coming head may be complicated and require the Walcher position, which can not be quickly obtained if the legs are fast. Only eight minutes are allowed for the delivery of the child after the navel passes the vulva, if it is expected to live.

The bladder and rectum must be empty.

Asepsis must be rigid and both subjective and objective.

The dorsal position on a table is imperative.

The diagnosis must be accurate and the anÆsthesia carried to the surgical degree.

Facilities for treating asphyxia neonatorum must be provided.

The following summary of the indications and conditions may be convenient for reference.

Indications.—Contracted pelvis. (Consider pubiotomy.)

Abnormal position of the head. (Face position with chin posterior.)

Prolapse of cord or an extremity with a presentation of the head.

Placenta previa.

Transverse position after the seventh month.

Any condition requiring rapid delivery.

Conditions.—Cervix effaced and os dilated.

Uterus not in tetanus nor contracted down over the child.

The foetus must be movable.

The head should not be engaged.

The Walcher position is produced by bringing the patient down to the end of the table so that the sacrum rests upon the edge. The thighs and legs are allowed to hang down of their own weight and the patient is restrained from falling off by traction upwards on the axillÆ.

In the Walcher position the diameter of the pelvic inlet is increased from ? to ½ inch (1 cm.) and thereby the delivery of heads that otherwise could not pass becomes possible.

In addition to the Walcher position other measures may be required to help the head through. Thus, traction from below may be carried to the limit of safety and in spite of the Walcher position the head may not pass the inlet.

Then pressure from above is added. This maneuver will have to be executed in many cases by the nurse.

The fingers palpate the head above the pubes. Then one or both fists are placed upon the abdomen over the head and force is exerted to crowd the head down into the pelvis. This is known as the Wiegand compression.

For the operations destructive to the child, craniotomy or decapitation, the same arrangements are made.

Cranioclasis is the crushing of the foetal skull so that in its reduced condition the child can be delivered and the mother’s life spared. In addition to the solutions, the only instruments required are the Auvard cranioclast, a Naegele perforator, and a douche bag with glass, or any tip that can be sterilized.

In many of these cases, both mother and child could be saved if seen early enough to have a CÆsarean operation.

Decapitation is done to save the maternal life in cases of transverse or shoulder presentation. The preparations are the same as already described for forceps and version and the only instrument needed is a Braun blunt hook. (Fig. 73.)

CÆsarean section is the delivery of the child through an opening in the abdomen.

It is made necessary by contraction of the pelvic bones, or by the presence of a fleshy or bony mass which diminishes the size of the inlet. It may be required on account of the closure of the vagina or cervix by scars or on account of urgent conditions of the mother, such as eclampsia, heart disease, and sometimes placenta previa.

The technic is simple, but good judgment must be used in knowing when to do it. Many operators find it so easy that they prefer it to the harder but safer obstetrical operations.

The time of election is when the woman is at term but not in labor. This, of course, can be determined by the history, but more certainly by careful measurements of the child.

When it becomes necessary to operate on a woman who has been in labor a long time and especially if she has been examined frequently, the mortality is disproportionately high.

It is a hospital operation, but may be done in the house. If not an emergency, the bowels are emptied by a laxative and enema the day before. Regular preparations for laparotomy are made, plus the equipment necessary for tieing the cord and resuscitating the child. A table must be found large enough to hold the patient in the horizontal position at full length. Solutions of lysol 1 per cent and sterile water are placed on each side of the table. The instrument table carries towels and suture material as well.

On a stand behind the operator is placed the hot bath and tracheal catheter. This center is presided over by someone skilled in the treatment of respiratory difficulties in the new born. Altogether, five assistants are required for the operation: an anÆsthetizer, a clean nurse, and a nonsterile nurse to manage supplies, an operating assistant and one to take charge of the child.

Rubber gloves must be worn by the clean assistants.

If the woman has been examined, the vagina should be sponged out with tincture of iodine. The abdomen is shaved, scrubbed with green soap, nail brush, and hot water for five minutes. It is then rinsed with ether and painted with iodine.

The presentation of the child, the presence and location of the heart tones must be determined before operation.

The patient is anÆsthetized with ether, chloroform or gas.

The incisions are made; the child delivered to the proper assistant; the placenta and membranes removed; the sponges counted; and the uterus and abdominal wall sutured.

After-care.—The nurse watches the patient for sighing respiration, rapid pulse, pallor, and other symptoms of hÆmorrhage, either external or internal. Artificial heat is supplied. HÆmorrhage from vagina should be looked for. It is normal. Salt solution by hypodermoclysis may be required. Hot water by mouth in small sips or tap water by rectum (drop method) will relieve the thirst. Morphine may be given if pain is extreme. An enema may be given on the second day or calomel may be started in the morning of the second day. Distention from gas, with or without nausea and vomiting, hiccough and rise of temperature are all signs of danger. No milk should ever be given on account of the gas it causes.

The child is put to breast as usual after twelve hours.

The stitches are to be taken out on the tenth or twelfth day.

Symphyseotomy is a separation of the pelvis at the pubic joint and is done with a scalpel or a specially devised knife.

Pubiotomy is the division of the pelvis, three or four centimeters to the right or left of the pubic joint. The division passes through the pubic bone and is usually done with a serrated wire called the Gigli saw. It is introduced subcutaneously by a special instrument called a pubiotomy needle. Both symphyseotomy and pubiotomy are preparatory to delivery. Pubiotomy is the more desirable and successful operation. The ends of the severed bones separate from one and a half to two inches, and the child delivers easily through the enclosed opening. The after-care is usually simple.

The hips are strapped in circumference with zinc adhesive plaster to support the bones.

The danger of infection of the wound from the lochia is always present. The main difficulty is in moving the patient, who is more than usually helpless. The bony ring of the pelvis is broken and she can not raise her leg. The repair is cartilaginous at first, but solidifies in a few months so that locomotion is not impaired. Especial pains must be taken to avoid bed sores.