A CONTRIBUTION TO THE STUDY OF OCCIPITO- POSTERIOR POSITION OF THE VERTEX. BY JOHN O. POLAK, M.D., OF BROOKLYN, N. Y., INSTRUCTOR IN CLINICAL OBSTETRICS, NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL, AND THE LONG ISLAND COLLEGE HOSPITAL. THE MEDICAL NEWS, March 9, 1895. [Reprinted from The MEDICAL NEWS, March 9, 1895.] k CONTRIBUTION TO TH E STU0 Y 0F 0 C CIPIT0- POSTERIOR POSITION OF THE VERTEX. BY JOHN O. POLAK, M.D., OF BROOKLYN, N. Y., INSTRUCTOR IN CLINICAL OBSTETRICS, NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL, AND THE LONG ISLAND COLLEGE HOSPITAL. The notes forming the basis of this paper are the result of a detailed study of twenty-nine cases of vertex-presentation, with the occiput to the back. In each particular instance the diagnosis was con- firmed by other physicians after labor was fully established. A brief analytic study of the cases in question shows that twenty, or more than two-thirds of the entire number, rotated to the front, unaided by any manual interference whatsoever, and were delivered normally, with the occiput under the pubes. Of the nine in which spontaneous rotation did not take place, one was complicated by a pro- lapsed cord, demanding immediate podalic version and extraction. Another occurred in a pelvis hav- ing a conjugata vera of but three-and-a-half inches. In this case the occiput was twice manually rotated to the front and axis-traction forceps applied, but all efforts at delivery failed. Internal podalic version under complete narcosis was then elected, easily accomplished, and a successful extraction fol- lowed. 2 Of the seven cases not already considered, three were forceps-operations at the superior strait, with the head but partly engaged. In the remaining four the head had descended to the pelvic floor, with the occiput in the hollow of the sacrum. In all of these instrumental cases, save one, the occiput remained persistently to the back ; hence the frequent occur- rence of tears in the pelvic floor. These lacerations of the vagina, levator, and perineal body were imme- diately repaired, special care being taken to approxi- mate the deep muscular structures. Union by first intention occurred in 85 per cent, of the cases operated upon. In but one case was the child still- born. From the foregoing facts it will be seen that a large majority of posterior positions of the occi- put are delivered without the obstetrician's interfer- ence, after anterior rotation has taken place. In cases ending thus favorably there is but little added danger to either mother or child. Spontaneous rotation may occur at the superior strait, in the cav- ity of the pelvis, or on the pelvic floor. From a considerable experience in midwifery I am led to believe that this malposition-for such it is-is of much more frequent occurrence than is generally conceded by most authors, as many of these pos- terior cases remain unrecognized, owing to the diffi- culty in diagnosis during the early stages of labor. Again, a large percentage rotate to the front un- aided, and are recorded as anterior positions; hence the statistics on this subject are of little value. An existing disproportion between the head and pelvis is not infrequently met with, preventing proper flexion and engagement, so that dystocia follows, 3 and operative delivery is very often too late to be successful; hence the need of early and accurate diagnosis. Furthermore, the forceps should never be applied until such relations have been carefully determined and possible malpositions corrected. To recognize these conditions after labor is estab- lished and a caput formed presents no little diffi- culty ; hence I urge that when there is doubt as to the exact relation that a head bears to a particular pelvis, the patient be chloroformed and the aseptic hand passed into the uterus. This procedure will at once end any such uncertainty. With the hand thus introduced improper flexion of the head may be rectified or the occiput may be manually rotated to the front. It is well to remember, if such rota- tion be attempted, that it is necessary not only to rotate the occiput, but also to turn the body to the front. This is best accomplished by grasping the posterior shoulder with the internal hand and turn- ing the dorsum to the front; external aid facilitates this manipulation. Early diagnosis and postural methods in this class of malpositions are frequently all that is necessary to terminate labor normally. As rotation takes place at the brim, in the cavity, or on the pelvic floor, so the treatment of each indi- vidual case will differ as to the stage of progress in the mechanism. At the brim (before the head has engaged) the employment of postural methods frequently results in the normal termination of labor. The patient should be placed in the left or right latero-prone position, depending on whether the child's dorsum and occiput point toward the left or the right side of 4 the mother. In one of the cases making the basis of this paper, use of the Trendelenburg1 posture aided very materially in preserving the normal mechan- ism. This position offers all of the advantages of the genu-pectoral without the discomforts of the latter to both physician and patient. Should these methods fail, manual rectification or podalic version may be elected. The former procedure deserves consideration when the pelvis is ample, and the dorsum, as well as the occiput, can be rotated to the front. This failing, or should the occiput, after being once turned anteriorly, again rotate to the back, complete podalic version should at once be instituted, not waiting until the amniotic fluid has entirely escaped, and the operation be complicated by a spastic uterus. Should any disproportion exist between the head and the pelvis, version maybe elected. The extrac- tion of the after-coming head through a flattened pelvis of slight degree is more easily accomplished, by reason of the overlapping of the parietal and underriding of the occipital bones, than the delivery of the fore-coming head under like circumstances. The application of forceps to a head floating about at the superior strait, whether of an axis-traction model or not, is a procedure that deserves the con- demnation of careful obstetricians. In the cavity of the pelvis (when the head has entered the superior strait and is descending, the occiput being shunted to the back by the in- cline of the levator-ani muscle) rotation may be 1 As suggested by Dr. Fry, of Washington, in the management of mento-posterior cases, May, 1894. 5 promoted by keeping the patient in the latero-prone position, having her lie on the side toward which the occiput points. Since beginning this paper I have had two opportunities to utilize a method suggested by Penrose in the management of mento-posterior positions, i. e., the whole hand is introduced into the vagina, the palmar surface corresponding to the posi- tion of the occiput. The palmar surfaces of the fingers act as a lateral inclined plane, shunting downward, forward, and inward, while the thumb pushes the sinciput upward and backward, promoting perfect flexion and rotation. This manipulation should only be employed during the pains. Should im- paction occur, the axis-traction forceps may accom- plish delivery, the head rotating during its descent. I must take issue with the few who forcibly rotate the occiput to the front while the head is well down in the pelvic basin, as at this stage simul- taneous rotation of the shoulders is not apt to occur without a dangerous amount of torsion of the neck. When delivery is found to be impossible because of impaction of the occiput in the hollow of the sacrum, symphysiotomy or craniotomy may be elected according to indica- tions. With the head on the pelvic floor (at the vaginal outlet) the occiput can, in a very large proportion of the cases, be rotated to the pubes " by back- ward pressure with the fingers against the anterior temple, combined, if necessary, with forward press- ure upon the occiput." Should this method fail, rotation may usually be accomplished with a short pair of straight forceps. 6 Forceps to a posterior vertex as such, with the head on the pelvic floor, is not a difficult operation, though the mechanism and direction of traction must be very closely observed. Short, straight forceps accomplish delivery most readily. The traction is made directly forward until the root of the nose is immediately behind the pubic arch. The line of traction is then changed to the third position, perfect flexion of the head being preserved by upward pressure against the sin- ciput with the thumb, while a finger of the same hand in the rectum aids in shelling out the head by dislodging the occiput. The Medical News. Established in 1843. A WEEKL YMEDICAL NEWSPAPER. Subscription, $4.00 per Anmim. * The American Journal OF THE Medical Sciences. Established in 1820. A MONTHL Y MEDICAL MAGAZINE. Subscription, $4.00 per Annum. COMMUTA TION RA TE, $7.50 PER ANNUM LEA BROTHERS & CO. 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