TWO DIFFICULT CASES OF Breech Presentation, WITH REMARKS. By CHARLES W. TOWNSEND, M.D. Reprinted from the Boston Medical and Surgical Journal of January 31 1889. BOSTON: CUPFLES AND HUliD, Medical Publishers. 1889. TWO DIFFICULT CASES OF BREECH PRES- ENTATION, WITH REMARKS.1 BY CHARLES W. TOWNSEND, M.D. Mrs. O., thirty-six years old, was taken in labor with her seventh child April 24,1888, at 10 a.m., and I was called to see her by her attendant at 6 the following morning. The history of her former labors was found to be as follows: first labor, twelve years ago, instrumental, child a girl, head presenta- tion ; second child a boy, delivery instrumental, head presentation; third child a girl, also instrumental; fourth, a boy, labor normal and easy; fifth, a girl, labor normal and easy; sixth, a girl, footling pres- entation, labor easy. The pains during the day of April 24th had been slight and infrequent until 3 in the afternoon, when the membranes ruptured spontaneously, after which the pains became strong and regular. At 1 o'clock the next morning, the os was fully dilated, with the exception that the anterior lip of the cervix was still to be felt. From that time till my arrival at 6 a. m., there had been little or no progress, although the pains were strong, coming at intervals of two or three minutes, and the woman was becoming nervous and tired, although her pulse remained strong at 80. Examination at this time showed considerable oedema of the vulva, with turgescence of the blood-vessels. This condi- 1 Read before the Obstetrical Society of Boston, Nov. 10,1888. 2 tion had developed during the night. On abdom- inal palpation the breech was found engaged at the pelvic brim, the back being on the right. The foetal heart was 142, and situated three inches above and one and a half inches to the right of the umbilicus. On vaginal examination the anterior lip of the cervix was found much swollen, caught be- tween the presenting part and the symphysis pubis, but was easily pushed up out of the way, leaving the os fully dilated. The breech presented at the superior strait, sacrum right anterior. Both but- tocks were greatly swollen, the caput succedaneum thus formed reaching nearly to the vulva. Pelvic measurements showed a slight general contraction, and were as follows: between spines of ilia, 9^ inches; between crests, 11 inches; external conju- gate, inches; internal diagonal conjugate, 4^ inches; height of symphysis, If inches, making the true conjugate about 4 inches. The patient was etherized, and repeated attempts were made to bring the breech down into the pelvis by traction with the index finger hooked into the anterior groin, but without avail. The blunt hook was also used, but with the same lack of success, as much force being applied as was considered j ustifi- able, a slight abrasion in the groin found after the birth of the child showing that this was the case. Miles' breech forceps were then applied three times over the sacrum and the posterior surface of the thigh, but each time slipped without advancing the breech. Dr. Edward Reynolds, who was present, and with whom I had the benefit of a consultation in the conduct of the case, then applied the forceps over the trochanters, with the same result. I then gradually inserted my right hand between the breech and the uterus, and seized and drew down 3 the right foot, which was found just above the brim of the pelvis, the knee being flexed, and using this as a handle the breech was soon brought into the world. The arms were extended above the head, but were delivered without much difficulty. The head, however, caught at the brim, occiput to the front, and refused to come after strong tractions by the Prague and Smellie-Veit methods and supra- pubic pressure. Forceps were applied, the head still being arrested at the brim, and even with their help there seemed to be no change in the position of the head. I then inserted Dr. Reynolds' axis- traction rods, and had the pleasure of feeling the head at once advance with moderate effort, much less than I had before expended unsuccessfully without the rods, and the child was speedily de- livered. After mouth to mouth insufflation and artificial respiration, the child gasped, and in the course of half an hour breathed and cried naturally, and afterwards did well. It was a girl, and weighed pounds. I have narrated this case at some length, believ- ing that it presented several points of interest for discussion, namely, the various methods for delivery in the case of an arrested breech, and also the treat"- ment of the high after-coming head. In ordinary cases of breech presentation our position should be one of watchful care, with avoidance of interference during the labor. When nature is unable to expel the breech, moderate traction with the index finger hooked into the anterior groin is in most cases sufficient, the strength of the other arm being added by grasping the wrist of the hand used for traction. This method failing, Lusk recommends, in the order given, the forceps, the fillet, and the blunt hook, and, if the child be dead, the cephalo- 4 tribe, the latter instrument giving us of course a firm hold on the presenting part. The ordinary forceps intended for the head have been used successfully for the extraction of the breech, and with reasonable care the danger of crushing the pelvis or lacerating the abdominal viscera of the foetus has been shown to be slight. A certain amount of compression of these parts to avoid slipping is of course required, but experience has shown that this compression is not harmful. Tarnier made careful examinations of still-born infants delivered by the breech with forceps, and in no case did he find any injury either to the pelvic or abdominal viscera. By guarding with the disen- gaged hand, the danger to the mother's soft parts in case of slipping can be avoided. It is possible that in my case the use of axis-traction forceps would have succeeded. Special forceps intended for the breech alone have been devised by Miles. Lusk mentions some nineteen cases reported by different authors where the forceps were used suc- cessfully in the extraction of the breech. The fillet, when wet and twisted, as is almost always the case, may cut deeply into the tissues, and it seems to me that the blunt hook, which forms merely a strong index finger, is preferable. The blunt hook is, however, a most dangerous instru- ment, unless used with care; serious contusions and lacerations of the soft parts will occur unless the tip be guarded with the finger and its exact po- sition known. Of course, if the instrument be allowed to slip down on the thigh it may cause fracture. Leverage movements are particularly to be avoided. All of these methods failing, - it not being deemed expedient in my case to try the fillet after 5 the failure of the blunt hook. - the bringing down of a leg remained. The objection to this method at the first, and the preference of the other methods, is the danger to both mother and child, - of rupture of the uterus in the one case, or fracture of the leg in the other. The danger to the mother is espe- cially great where the membranes have been rup- tured for some time, and where from prolonged and ineffectual labor, the lower segment of the uterus has become thinned from retraction. Bear- ing these dangers in mind, the manoeuvre should be performed with the greatest care, the patient being completely anaesthetized. Tn the present case but little retraction had taken place, and no retraction ring was to be felt. The leg and foot were found just above the brim of the pelvis, and were not, as is often the case, extended up parallel with the axis of the foetus. In the latter case it is necessary to pass the hand up to the knee, and with the thumb in the popliteal space, to gradually flex with the fingers the leg upon the thigh, and draw it down into the world. As regards the extraction of the aftercoming head, I shall only repeat that without the axis- traction rods strong tractions with the forceps pro- duced apparently no effect, while with the rods the extraction was easy and immediate. Lusk says that "in extracting the after-coming head, the axis-traction forceps is particularly serviceable." One is often tempted, after considerable delay in the extraction of the after-coming head, to give up all hopes of saving the child's life and to rest awhile, for it is very exhausting work, and then begin more leisurely, but, as the event proved in this case, it was worth while to keep on and try every method, although the continued life of the child seemed 6 almost impossible. In another case, when the oper- ator, after a version, had been unable to deliver the head manually, he finally gave up after prolonged and repeated efforts, and requested me to apply for- ceps, the child's body hanging out apparently life- less. Delivery with the forceps proved easy, and to our surprise the child was resuscitated. The ten- acity of life displayed in some of these cases is certainly surprising, while in other cases its tenuity is, to say the least, disappointing. The following case of breech presentation differs entirely from the first, and the difficulty with the after-coming head was of an entirely different nature: - Mrs. H., twenty-eight years old, previous labors normal, was taken in labor with her sixth child, March 26th, 1888, at 5 a.m., and I saw her first at 4 that afternoon. At that time external examination showed the back of the child on the left, a large, soft, and apparently fluctuating mass at the fundus, and the breech at the brim. The foetal heart was 132, and heard loudest on the left side at the level of the umbilicus. On vaginal examina- tion the breech was felt engaged at the superior strait, S. L. A., the os two thirds dilated. The pains were moderate and the woman in good condition. The os became fully dilated at 8 p.m., and when I was again called by her attendant at 3 the next morning, the breech had made but little ad- vance, being still at the superior strait. Mother's condition good; pains poor; foetal heart 140. The breech was easily brought to the vulva by traction with the right index finger hooked into the ante- rior groin, and the child extracted all but the head, which remained high and could easily be felt above the pub as a large, fluctuating mass. As was to be 7 expected with a hydrocephalic head, the forceps slipped, although a careful attempt did no harm, and it was hoped might succeed. With Dr. Reynolds to as- sist in steadying the uterus, it was a simple matter to perforate with Smellie's scissors just above the edge of the occipital bone, and on dilating the aper- ture with the fingers about a pint of clear yellow serum gushed out. After this the child was easily delivered and the large hydrocephalic head was found to still contain a quantity of fluid. In the lower dorsal region there existed the condition of spina bifida, the spinal canal being covered with a thin membrane without a projecting tumor. I might have avoided craniotomy by inserting a catheter through this opening, forcing it up the spinal canal to the brain, and thus withdrawing the hydro- cephalic fluid, a procedure which has been success- fully carried out by Tarnier and others. THE BOSTON Medical and Surgical Journal. A First-class Weekly Medical Newspaper. This Journal has now nearly reached its sixtieth year as a weekly Journal under its present title. Such a record makes superfluous the elaborate prospec- tus and profuse advertisments as to enormous circulation, etc., etc., required by younger aspirants for professional and public confidence. 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