The practitioner should first decide whether Cmsarean Section is indicated. The indications are—(i) A history of embryotomy in previous labours; (2) a contracted pelvis, with a true conjugate of less than 3f inches if the child is alive, or less than 21 inches if the child is dead; (3) the presence of an ovarian cyst or a myoma blocking the pelvis, or of a carcinoma of the cervix, or of dense cicatricial adhesions narrowing the vagina. When the operation has been decided upon, no further vaginal manipulations should be made, for fear of septic infection. The patient should be prepared for operation (see Operations, Treatment of). The operation may be done without an assistant other than the chloroformist. An incision is made from the umbilicus to the pubes, exposing the uterus. A 6 to 8 inch incision is then made through the uterine wall and the foetus pulled out by the legs. The membranes and placenta are then peeled off the interior of the uterus, which is brought out through the abdominal wound for convenience in suturing. A continuous catgut suture unites the mucous membrane, and a second row of catgut sutures is employed to close the remainder of the wound. The haemorrhage from the uterine incision is not excessive, and may be neglected, even if the placental site is opened; the sutures completely control it. The abdominal wound is then sutured with silkworm-gut; some operators recommend that these sutures should include the superficial layer of the uterus so as to fix that organ to the back of the anterior abdominal wall and prevent general peritonitis should the uterine wound become infected from the vagina. The whole operation may be completed in about 15 minutes. In favourable cases, where the patient has not been allowed to go on to the point of exhaustion, and where repeated vaginal examinations and attempts at delivery have not been made, the mortality is very low and the results very good.
The second question that the practitioner should settle is whether pubiotomy or symphysiotomy should be done. These operations are eminently useful in the type of case where contraction exists to such a degree that delivery has been previously effected through the natural passages, but at the expense of the life of the foetus. The increase in the conjugate gained is usually enough to permit of the delivery of a living child. The operations are easy of performance, but the after-results depend so much on the nursing that they cannot be recommended to the general practitioner, and are better left to specialists.
In the minor degrees of contraction above 3+ inches the choice of the practitioner lies between forceps and turning. If forceps are chosen,
plenty of time should he allowed for the head to mould, as many failures are due to want of this precaution. \Valcher's position, with the patient on her back on a high table and the thighs hanging down over the edge of it, with the feet clear of the ground. is of great assistance. It may be used at intervals during the period of waiting to assist the head in entering the pelvis. Should the head refuse to enter, the idea of applying forceps must be abandoned and some other means of delivery adopted. Turning permits of the head moulding itself more easily to the pelvis. It exposes the child to very considerable risk, increasing enormously with the degree of obstruction, as the delivery of the after-coming head becomes more difficult and lengthy. The practitioner should be prepared to apply the forceps on the head the instant the body is delivered, as the usual methods are fairly certain to be ineffectual and only waste valuable time. Turning should not be attempted when labour has been in progress for a long time and the waters have drained away.
Finally, perforation may be called for. It should be looked on as a last resource, and a confession of failure on the part of the obstetrician. It is, of course, the best method in a contracted pelvis when the child is dead, unless the degree of contraction absolutely indicates Caesarean Section (true conjugate under 2 inches). It is also indicated after repeated and in effectual attempts at forceps delivery, or when turning has been done and the head cannot be brought through the pelvis. It may be the only method open to a practitioner who is confronted with a case which he cannot deliver and who is without the necessary assistance or appliances for a Cmsarean Section. If perforation has been decided upon after a fruitless attempt at forceps delivery, it is wise to leave the forceps on the head and allow the nurse to hold them, as in this way the head is steadied and the perforation made easier. The perforator should be thrust into the most prominent part of the head, and no endeavour need be made to find a suture. The after-coming head may be perforated through the occiput or through the roof of the mouth. The brain is washed away with a stream of sterilised water, and the craniotomy forceps applied. The smaller blade goes inside the skull, the larger over the face or occiput. The blades are screwed tight and traction made. It is well to keep a finger in the vagina while this is being done, as a piece of the cranium may be pulled away and laceration of the vagina may be caused by the jagged edges unless the accident is noted.—R. J. J.