C. Forceps to the Breech.
If the child is dead, the blades are applied, after the German fashion, at the sides of the pelvis. But if the child is alive, the breech must be grasped in its bi-iliac or bi•trochanteric diameter. Exaggerated com pression must be avoided, and, therefore, the blades often slip. We must, hence make traction gently. Tarnier's forceps, not allowing variation in compression, is, according to his pupils, more advantageous than the classic. (Fig. 109.) [The following pages are inserted here instead of later on, as in the original, because here they are in natural sequence, and Charpentier would have done so, he tells us, had Olivier's thesis on the subject ap peared in time to have allowed him.—Ed.] This subject has been studied in detail by Budin, Pinard, Cantacnzene, Lefour and Olivier. Budin has, in particular, insisted on the fact that in a greater number of cases than is generally believed—we have ourselves observed three cases—the pelvic extremity is far more engaged than is gen erally stated, and that this deep engagement is met with exclusively in case of the decomposed breech. Palpation and touch suggest a cephalic presentation, and it is only when the woman assumes the lateral, or, if need be, knee-chest position, that we obtain the cephalic ballotement which is characteristic of a breech presentation. As for the touch, it is only by carrying the finger high up into the posterior cul-de-sac, and thus exploring carefully the fcetal presenting part; that we correct the error in diagnosis of cephalic presentation.
Lefour and Olivier look at the matter from a different standpoint. Both recalling the fact that breech presentations usually call for interven Lion, and that this interference, whether manual or instrumental, is dan gerous for the infant, have endeavored to find out not only the causes which render descent and expulsion difficult, but the instances in which intervention is most dangerous, and both have proposed different methods.
While Lefour rejects the forceps, except when the infant is dead, Olivier, on the strength of experiments made on the manikin, and clini cally, advises strongly the forceps, but applied after a peculiar manner.
Lefour counsels as follows: During pregnancy to beware of version by external manipulations, and to await the onset of labor. During labor to retain the membranes as long as possible, to wait until the cervix is dilated or dilatable, and then to introduce boldly the hand into the uterus and bring down one or two feet; in a word, to transform the breech into a foot presentation, and to deliver accordingly. If the membranes have ruptured prematurely, and the os is neither dilated nor dilatable, to wait for deep engagement of the breech. When the anterior hip is under the symphysis, and labor cannot be completed, because the posterior hip cannot pass the perineum, he rejects the finger, the blunt hook, the for ceps, except where the infant is dead, and advises the following method, which is none other than that of Ritgen, for delivering the head under the symphysis by extending it : He inserts the index and the middle fin ger, or the index alone, into the anus of the parturient, the pulp directed upwards, and he pushes on the thigh which is hooked and stopped by the perineum. The finger of the other hand may assist by making trac tion upward and forwards from the anterior groin.
Olivier, on the other hand, is a resolute partisan of the forceps, and concludes from his experience: The instrument is not only advantageous, but is inoffensive to the foetus, if it is applied, not as is ordinarily recom mended to the iliac crests, but to the festal limbs, and differently accord ing to whether the position is anterior or posterior.
If we use a filet, aside from the difficulty of placing it, we run the risk of fracturing the femur when making traction, and especially in poste rior positions.
"In anterior positions, that is to say, when the foetal sacrum is towards the right or left pectineal eminence, or the symphysis, the limbs, ex tended along the abdomen, make with the filet, the woman in the dorsal position, an angle the apex of which looks backward. If now we make traction in the axis of the groin we will not fracture the femur, because the greatest traction is at the most resisting part of the bone, the neck, the reverse of what holds in the adult, especially the aged.