THE INDICATIONS FOR THE FORCEPS.
The forceps being an instrument intended to be applied to the festal head, and for the extraction of the foetus from the mother, will be indi cated whenever, the head presenting and the sine qua non conditions for its application existing, any danger menaces the life of the mother or of the child during labor.
We have already seen that the instrument may also be used in case of • pelvic presentations, and the sphere of applicability of the instrument is thus widened.
The forceps thus is indicated: 1. Whenever, in head presentations, normal labor becomes difficult or impossible, owing to feebleness or absence of expulsory pains.
2. Whenever there exists disproportion between the size of the foetus and the dimensions of the pelvis, whether this disproportion depends on excess in foetal size, contraction of the pelvis, prolapse of a foetal part, extended vertex presentations, face presentations, or on resistance of the soft parts.
3. Whenever an accident supervenes compromising the life of the mother or of the child, such as hemorrhage, syncope, eclampsia, herniae, retention of urine not to be relieved by the catheter, rupture of the uterus' or of the vagina, short funis, absence of rotation, etc.—in a word, in every instance of dystocia, where, the head presenting, the termination of labor is called for in the interest of the mother or of the child.
4. Occasionally in pelvic presentations.
Of the above indications there are three, in particular, which most frequently necessitate resort to the forceps: a. Resistance of the perineum, and the inertia uteri which is a conse quence.
b. Persistent occiput posterior presentations.
c. The arrest of the head above, or at the level of the superior strait, by a contraction of the pelvis.
Of these three, the two first are the most frequent, particularly in primi para3. Where the forceps is called for in case of the urgent complica tions of labor, such as hemorrhage, the indication is often urgent, instan taneous so to speak. Not so, however, in case of the two indications we have just noted. Here we must, on the one hand, avoid too quick action, and, on the other, too tardy.
a. Resistance of the Perineum.—Our practice is entirely in accord with that of our teachers Pajot and Depaul. When the head reaches the peri neum, if, at the end of an hour and a half to two hours, it makes no pro gress, we terminate labor by applying the forceps, no matter what the intensity of the contractions. ITsually, however, in these instances, con tractions are absent or inefficient, so that we are in face of a two-fold in dication for the forceps, resistance of the perineum and insufficient pains. To act sooner seems to us useless, for frequently, within this interval, weak contractions become intensified, and the head is quickly expelled. To act later seems to us reprehensible, for arrest of the head means com pression of the maternal soft parts, and there may result gangrene, the consequences of which, aside from sepsis, will be fistulae, rectal or vesical, etc.
b. Absence of Rotation.—We give Nature here also a chance, but if within two hours the head does not rotate, we interfere at once by caus ing artificial rotation. In case of face presentation, we act a little sooner, in order to prevent deep engagement of the chin, which would complicate matters.
It goes without saying, that in these cases, particularly, the fatal heart should be listened for from time to time, in order that we may interfere sooner still, if the life of the child appears endangered.
c. Contraction of the Pelvis.—Here we never hurry. Labor is always longer. Before the head can pass the superior strait it must become moulded, and for this process time is requisite, relatively long. Without referring again to the degree of contraction calling for interference, (vide Deformities of the Pelvis, Vol. III.), it is above all the state of the mother and of the child which should be our guide.
As for the other indications, the time for interference varies, of course, according to the complication threatening the mother and the infant, and it is impossible to fix the limit. Finally we must not forget that the forceps is not the only means of terminating labor, and that frequently we may chose between forceps and version.