OBSTRUCTED LABOUR.
The practitioner will diagnose obstruction when strong, regular and frequent pains are present, and yet the head either refuses to engage in the pelvic inlet, or, if it has engaged, ceases to advance. Treatment will largely depend on the diagnosis of the nature of the obstruction to its progress. If assistance can be procured it is wise to obtain it, as it is not easy to manage a case of obstructed labour single-handed.
r. Malpresentation with a Normal Palms and Pelvis.—A common cause of delay is the persistence of an occipito-posterior presentation. Rotation of the occiput forwards would probably occur in the majority of these cases if left alone, but when labour has already lasted a long time and the patient is becoming exhausted with her efforts, it is good practice to interfere. An attempt should be made under chloroform to rotate the head by means of a hand introduced into the vagina, and forceps may be applied immediately before the hand is withdrawn. Should the attempt fail, forceps may be applied and traction made downwards and backwards at first. The head may be delivered with the occiput posterior, hut the perineum is very apt to suffer extensive laceration, and traction should be made as gently as possible so as to save it. As the head is brought down the normal rotation often occurs. When this has happened the forceps must be removed and reapplied.
Breech presentations are normally slower in delivery than vertex presentations, and plenty of time should be given. If it is decided to attempt to hasten matters an attempt may first be made to bring down a foot if the breech is not fixed. If it is fixed the forefingers of both hands should be hooked into the child's groins, and traction made. If this fails forceps may be applied over the trochanters. A fillet may be passed, or in the last resort the blunt hook may be used. The after-coming head often gives trouble, especially if the pelvis is rather narrow. After the arms are brought down, it is always wise to take the child by the shoulders and carry the body strongly backwards towards the mother's perineum, so as to unhitch the occiput from the pubes. When a certain amount of
descent of the head has thus been gained, delivery is easily completed by carrying the body of the child forwards over the mother's abdomen.
Face presentations often cause delay through persistence of an occipito anterior presentation. If the head is not fixed, an attempt should be made to convert this into a vertex presentation by pushing up the chin with two fingers in the vagina, while the child's breech is carried towards the chin, so as to promote flexion. If the chin cannot be dislodged plenty of time should be given, as the chin often rotates forwards quite suddenly at the last and the labour is speedily over. Failing this, an attempt may be made to rotate the head with forceps, and should this fail perforation must be done.
In brow presentations an attempt should be made to convert into a vertex or mento-anterior face presentation, whichever is easiest, if the head be not fixed, and, failing this, version should be done provided the waters have not drained away and the uterus is not retracted. If the head is fixed, an attempt at forceps delivery may be made. That failing, the only resource is perforation or symphysiotomy or Cxsarean section.
2. Want of Normal Proportion between the Fretus and the Passages.— This may be due to an abnormally large or deformed foetus, or to a narrow pelvis, and much less frequently to tumours blocking the pelvic cavity, or to stenosis of the natural passages caused by injury or disease. In the treatment of these cases it is important to recognise the cause and degree of obstruction.
If the patient is a multipara, the history of her previous labours is of importance in deciding on the proper measures to be taken. If she is a primipara, an anaesthetic should be given and the dimensions of the passages ascertained either by the aid of a pelvimeter or by the introduc tion of the hand into the vagina. It is hardly necessary to say that the strictest antiseptic precautions must be observed both during the examina tion and subsequent treatment.