Since the time of J. Siegmundin, many instruments have been devised for carrying up the loop, analogous to those for the cord. For instance, those of Walbaum, Stein, Van Huevel, (Fig. 18), Wasseige (Fig. 19), Lambert (Figs. 20, 21, 22), Trefurt (Fig. 23), Hyernaux (Fig. 24), Morales (Fig. 25, 26), and all have about the same value.
The same is true of the forceps invented to carry the loop (Figs. 16 and 17), and those for seizing and bringing down the feet. (Those of Bang, Groning, Nevermann, Lazarewitz.) Of all the above instruments, the best is the hand. It is not often that the method by the hand fails, and the loop once in place we may make every necessary traction to extract the foot.
III Evolution.
Here the obstacles are dependent on foetal mobility. Whenever the obstacles to evolution are very great, we must desist from version, and resort to embryotoniy.
IV. Extraction of the Fetus.
We have already mentioned short and tense cord, and the means at our disposal. We must now study the difficulties offered by the arms and the head. If, indeed, uterine contractions are weak, if the cervix re sists delivery, if tractions are made in the pain-intervals, the arms are extended above the head, and this is a grave complication, seeing that the body of the foetus having been delivered, the infant may endeavor to breathe, and asphyxiates.
1. Extraction of the Arms.—The arms may be extended in two ways: either from above below, and from behind in front, or else from above below, and from in front behind, that is to say, crossing behind the neck. We must first determine in which of these two ways extension has oc curred, for we must always, in order to extract them, make them follow the same route traversed in extension. The angle of the scapula will tell us this. If the arms have extended from behind in front, the in ferior angle of the scapula will be at some distance from the vertebral column, while if extension has occurred from in front behind, then this an gle will be near the vertebral column.
Extraction of the arms must be performed gently, beginning with the posterior, for we thus gain space for the extraction of the anterior and more difficult arm. Often extraction of one arm is sufficient, for the other, as we have seen, may be in the vagina, and to prevent the ascent of this during evolution, a noose is slipped over the wrist and gentle traction made.
In order to extract the posterior arm, the body of the fcetns must be lifted upward by one hand, while the fingers of the other are gently in sinuated towards the axilla. The thumb is then placed on one side of the humerus, and the remaining fingers on the other; the fingers are slid along this bone to the elbow. Seizing this joint, the arm is pulled from behind to the front, passing successively over the face and the chest, out at the vulva. (Fig. 27.) In a word, traction should ever be made at the joint, in order not to fracture the bone, and the arm be made to fol low the inverse course it took during extension. Where the arm is ex tended from in front back, the same manoeuvre is indicated, except that the arm is passed over the occiput and the neck of the foetus. This latter form is rare.
The posterior arm disengaged, we turn to the anterior. The body of the foetus is depressed as much as possible'and the arm disengaged in the same manner. In general the left hand is used for the posterior arm, and the right for the anterior. Before extracting the arms, Baudelocque and Rossirth advise traction on the shoulders, thus approaching the arms One to another, and the neck is more readily accessible.
Hfiter recommends the following method: " He seizes with both hands the thighs, lifts them up and brings them together, drawing them more and more towards the maternal abdomen. Then introducing the hand, he finds the posterior shoulder so low, that he can readily reach the elbow and extricate the arm. He then seizes the thorax with both hands, and turns the fcetus on its longitudinal axis, so as to make the an terior arm posterior, and its extraction is easy. A necessary consequence of the elevation of the lower extremities is descent of the posterior shoulder, only we must be careful in lifting up the thighs not to pull so hard as to cause descent of the head, which would greatly complicate mat ters." This method, it is seen, is only a modification of Naegel6 and Grenser's.