Madame Lachapelle, Simpson, Cazeaux and Barnes, have especially drawn attention to the arm behind the head. Barnes believes that it is often the result of inexpertness, while Dues and Cazeaux believe that this accident may be produced in two ways: either the arm crosses the neck, after it has extended above the head, or else the arm extended along the back and was stopped at the occiput.
When the ventral surface of the fcetus has remained forward until the delivery of the shoulders, extraction of the hands is no longer difficult, as is pointed out by Dubois and Madame Lachapelle. The shoulders are still oblique, and it suffices to extract the posterior arm first. If it is not possible to bring the arm in front of the face and the thorax, NaegeIC. and Grenser advocate pushing back the elbow to the outside and behind, and at once to extract the anterior arm first.
2. Extraction of the Head.—The first obstacle which may offer, is the retraction of the cervix around the neck. If energetio traction is made, the result may be separation of the body from the head. If we do not act rapidly, the child will die. When the fcetus is dead, we can wait for the cervix to relax, but otherwise we must try every means, baths, inunc tions of belladonna on the cervix, chloroform, venesection to syncope, etc., to overcome the spasm. If the spasm is limited to the external os, we may try incision of the cervix and the forceps. IL however, the spasm is at the internal os, and we cannot reach it with the fingers to dilate, we must wait till the fcetus is dead, and then resort to perforation or the cephalotribe. Even wfien we resort to incision and the forceps, we rarely save the foetus, for, however quick our actions, the infant has time to make efforts at inspiration, and dies.
Besides this obstacle, there are four difficulties dependent on the man ner in which the head engages: 1. Occiput in front, and head flexed.
2. Occiput in front, and head extended.
3. Occiput behind, and head flexed.
4. Occiput behind, and head extended.
1. The head is extracted without the least trouble. It suffices to lift the body towards the maternal abdomen, in order to extract the head. The perineum calls for special care.
2. The first thing to do is to flex the head. In 1668 Mauriceau de.
scribed at length the operative method which, to-day, bears the name of Smellie, or of Veit, and which should in reality be called after Ilaariceau.
(Fig. 28.) The method consists in lifting the body of the foetus upward with one hand, and applying the index and the middle finger of the other hand each side of the nose, on the superior maxilla, and pulling the face downward the head is flexed. If we do not thus obtain flexion, one or two fingers are introduced into the mouth to the base of the tongue, and using the inferior maxilla as a fulcrum, the face is pulled down. The head once in the excavation, the two fingers are again placed on the superior maxilla, and while by them we seek to lower the face, the occi put is pushed upward by the index and the middle finger of the other hand, so as to assist in flexion. This once accomplished, the body is lifted towards the abdomen of the woman, and, as in the preceding in stance, the fcetns is delivered with its back to the mother's abdomen. Traction should always be made backwards.
Under the name of the Prague method, Kiwisch and Seyfert have de scribed a process which varies but little from that already advocated by Puzos, and used by P. Dubois. It may be performed in two stages: 1. When the head is high up, the body of the fcetus is carried backward towards the perineum, the fingers are applied over the shoulders, and traction is made downward and backward. If uterine contractions are defective, Kiwisch adds to this traction pressure exercised over the head through the abdominal walls.
Once the head in the peliis, the other hand seizes the limbs of the fcetus, and lifting the body rapidly towards the body of the mother, keep ing up traction through the fingers applied over the shoulders, the fcetus is delivered.
If this method do not succeed, forceps must be applied and the head extracted.
While this method often does succeed, it nevertheless frequently ex poses the infant to serious accidents, such as dislocations, fractures of the vertebrae, etc. Hecker, Martin, Gusserow, have cited examples of frac ture of the vertebral column, and of decapitation, and Ruge, in his mon ograph on the foetal lesions following on extractions in pelvic presentations, reports a number of accidents to which this method exposes the foetus. Scanzoni, nevertheless, is greatly in favor of a method which saved the lives of 117 infants out of 152 delivered at the Prague Maternity.