[The above method will succeed very well in multiparm, but in prim', parce, where the integrity of the perineum is much more in danger, we believe the following to be far preferable: As soon as the occiput has been brought well under the pubes, and the perineum begins to distend, ad minister chloroform to the surgical degree, in order to abolish entirely involuntary expulsory efforts on the part of the patient, and then, remov ing with care the forceps, proceed to gradually shell out, as it were, the head, holding it back with one hand, and with the fingers of the other gradually relaxing and pushing back the perineum over the head. One finger in the rectum may be used to slowly extend the head, but this is not at all necessary. By this means it will often be possible to deliver without any laceration of the perineum whatsoever, and without resorting to episiotomy. It is at this stage that, for us, chloroform is of greatest utility in labor, but it must be pushed to the surgical degree.—Ed.] We cannot emphasize enough the fact that the best way to save the perineum is to extract the head very slowly, except of course where there is indication for haste in the interest of mother or of child. Here es pecially ip it wise to perform episiotomy.
When all that remains is to disengage the head, it suffices to seize the instrument in one hand, the left usually, (in case of Tarsier's forceps, the four branches together), and to lift the instrument slowly towards the mother's abdomen (See Fig. 91); the other hand may sustain the pen neum, or do episiotomy, if need be. Again, then, here no traction is to be made, and retain tne head, when necessary, to prevent too rapid exit.
When traction is made with the classic forceps, we must avoid great compression on the handles. Now this is, unfortunately, instinctive and.
involuntary. As we increase the traction, the hands involuntarily squeeze the handles and augment compression, and so it is advised to place be tween the handles a rolled napkin, which serves to limit compression. It is in order to fix the head, and avoid exaggerated compression, that Tar nier united his prehensile branches by a transverse screw, destined to make fixed and regular compression on the foetal head.
But as we have seen, this compression cannot be limited; for we are often obliged to screw tighter when the head has descended somewhat, diminished in size by the compression of the pelvic walls. In order to avoid this repeated tightening of the screw, Tarnier recommends that when the screw has first been tightened, the handles be pulled' on a little in order to mould the head, and then we may turn the compression screw firmly, and the head is tightly held and so retained.
All authorities are agreed in assigning to the forceps three methods of action. It is a tractor; it is a compressor; it acts dynamically, by awaken. ing uterine contraction.
These three methods are incontestable, but there is one above all which leads the others, and for which the forceps was constructed—it is an agent for traction. As for compression, it is a mere accessory, and may even become dangerous. We should never count on compression when we wish to end delivery by means of the forceps.
The Forceps as a order that it may be perfect in this re spect, the traction should be always directed in the axis of the pelvis, whether we use the ordinary instrument with great pelvic curve, or the straight forceps. Now all authorities are agreed that when the head is at the superior strait, and, therefore, of course, when above this strait, we cannot make traction backwards, since the perineum opposes. Even
at the inferior strait, and at the vulva, says Tarnier, traction is always badly made, on account of the form of the instrument. Therefore it is that all authorities are agreed in varying the traction according to the height of the foetal head. Make traction downward and backward when the head is above the superior strait; make traction downward in the cavity; make traction horizontally at the inferior strait; lift up the in strument as the head descends, and pull gently upwards when the head is at the vulva.
But, as said Pajot, in 1877, " to pull downwards does not mean, as all accoucheurs seem to think, to pull the entire instrument down by hang ing on the handles. It means to pull so that the upper extremity of the fenestrre shall come down and backwards, an impossible manoeuvre when we pull directly on the handles in this direction, for then the extremities of the fenestrfe, which should come downwards and backwards, tend downward and forward. But if the left hand seizes the instrument firmly near the vulva (Fig. 94), and if the handles are carried by the other hand, at first downward and a little forwards, and then, as the head descends, if the left hand depresses the blades, until both hands end by lifting up the instrument, never letting them touch the abdomen of the mother, if this manoeuvre is executed, we approach the true axis, and exact realiza tion could scarcely be more advantageous." "Tarnier says that the forceps, thus used, is no longer an agent of pure traction. It is transformed into a lever, the fulcrum of which is at the end of the handles, the force at the lock, and the resistance at the head. It acts, hence, according to the curve which the fenestrte tend to describe, and since this curve is first directed backwards, the force is also in this direction. The head, hence, is directed too far backward and it tends to flatten itself against the sacro-vertebral angle." Tarnier vehemently at tacks Pajot's method, and declares it impracticable when the head is at the superior strait, for the lock of the Instrument is between the labia majors. " When the centre of the head has reached the level of the superior strait, this manoeuvre, possible perhaps, although inconvenient, would be dangerous, because the fenestrre would cut the perineum each time the instrument slipped. Finally, at the inferior strait and the vulva, the extremities of the blades tend to tear the perineum." Although we accept the objections which Tarnier has brought against Pajot's manoeuvre at the superior strait, we reject them when the head has passed it, and has arrived in the cavity. Where the head, in occipito posterior position, is above the cavity, and resists direct traction, Pajot's manoeuvre may be of great service. It has assisted us in two cases. The forceps, if you please, no longer acts as a tractor, but it acts certainly as an agent for extraction, since it brings the head down which resists pure attempts at traction. But at the inferior strait, Pajot's manoeuvre neces sarily extends the head, and ruptures the perineum, and we much prefer to cause the head to rotate artificially; and then to reapply the instrument, and deliver the head, occiput to the pubes. We are, it is true, forced to make two applications of the forceps, but we avoid rupture of the perine um. Pajot's method, therefore, we believe, is only of use to bring the bead into the cavity, and thus to allow rotation of the head, which has not occurred spontaneously.