McGeoch, Thomas

English

Glasgow Theses Service

MANAGEMENT OE OCCIPITQ-POSTERIOR PRESENTATIONS • IN MIDWIFERY PRACTICE*THOMAS McGEOGH,GIR7AN,AYRSHIRE.. B*, C.MvProQuest Number: 13915811All rights reservedINFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted.In the unlikely event that the author did not send a com p le te  manuscript and there are missing pages, these will be noted. Also, if material had to be removed,a note will indicate the deletion.uestProQuest 13915811Published by ProQuest LLC(2019). Copyright of the Dissertation is held by the Author.All rights reserved.This work is protected against unauthorized copying under Title 17, United States C odeMicroform Edition © ProQuest LLC.ProQuest LLC.789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 13461.MANAGEMENT OE OCCIPITO-POSTERIOR PRESENTATIONS IN MIDWIFERY PRACTICE.In Labour the proportion of cases of vertex presentations in which the head descends into the pelvis in the third and fourth positions is variously stated by different observers. Leishman* gives a table in which the percentage varies from 32.88 as given by Naegele the younger to 3.84 as given by Swayne. The proportion is usually stated as about 25 per cent.The condition is revealed early in labour by abdominal palpation, and after the os has dilated by the ease with which the anterior fontsnelle is reached.In the vast majority of occipito-posterior presentations when the occiput in the course of its descent reaches the floor of the pelvis it is directed forwards, and so rotates into the occipito-anterior position. In this termination the head rotates from a position in which there are greater mechanical obstructions to its passage to one in which these obstructions are lesser.In the occipito-anterior position of the head the sub-occipito- bregmatic diameter of the head, measuring 3i inches, has to pass the vulvar orifice, while in the occipito-posterior position the1A System of Midwifery 1880 page 348.2.occipito-frontal diameter, measuring 4| inches has to pass.This rotation therefore to the anterior position of the occiput makes for the safety both of the mother and the child.rotation does not take place. The main causes of failure to rotate are extension of the child’s head and defects in the pelvic floor.The proportion of occipito-posterior cases in which1the head does not rotate was found in Rotunda Hospital to beinto the mechanism of labour, that, if a case terminates;either by natural means or by the aid of the accoucheur^in an occipito- posterior position^ there is greatly increased danger of injury both to the mother and to the child. To the mother the greater risk arises chiefly from injuries to the soft parts, the perinaeum especially being liable to be torn to a greater or lesser degree. The increase of danger to the child arises from the extra pressure to which the head is subjected in its passage through the pelvis. Even in favourable presentations of the vertex, namely, the first and second positions, all authorities agree that in many cases a1Rotunda Practical Midwifery,1908, Tweedy and Wrench, page 193.2Operative Midwifery, 1908, page 28.In a minority of cases however this safety-makingt /j oJUL cklim /LUA.0.69 per cent^, Munro Kerr found it to be 7 perIn these difficult labours it is obvious, without goingcertain amount of laceration of the perinaeum is unavoidable.1According to Duncan this occurs in 60 per cent of first labours. How much greater then is the risk of injury in those cases which terminate occipito-posterior.A slight laceration of the perinaeum, extending to say an inch or so, as a rule heals well if the torn surfaces are brought together with a few stitches. A severe laceration however can be regarded in no other light than a serious one.If it is at once properly sutured the wound generally heals well, but occasionally it does not do so. Sven if it heal well, in the event of another pregnancy occurringythe cicatrix is very prone to give way. Occasionally there is failure of union and if the laceration has extended into the rectum proper control over the bowel is lost. There are many instances in which even skilled obstetric surgeons have failed to remedy this condition, which entails on the sufferer a life of misery. With a laceration there is always added the danger of the entry of septic organisms leading it may be to sapraemia or septicaemia.As illustrating one effect of a rupture of the perinaeum I may quote a case occurring in trry practice.Case I. Mrs. W. Age 25. Attended in first confinement 1st Sept., 1904. Antero-posterior diameter of pelvic outletSystem of Gynaecology, Albutt, Playfair & Eden, 1906^ page 719.slightlyjsontracted. Presentation was third cranial. I attempted pressure upwards on forehead during pains but the bead did not rotate. I administered chloroform and delivered the head with forceps in the occipito-posterior position, with considerable difficulty. In the operation the perinaeum was ruptured, the tear involving the rectum. This I stitched up carefully, and the wound healed completely, the control of the bowel being quite normal•I attended this patient in her second confinement on 20th Aug.!, 1908. The presentation was first cranial.The second stage was tedious, the patient desiring instrumental aid, which I refused to give. Whili® the head was distending the perinaeum the cicatrix in the latter suddenly gave way, tearing somewhat like a piece of wet paper. The rupture extended as far as the rectum, but did not involve the circular fibres.I administered chloi'oform and stitched the wound carefully.ItThe wound however only healed to one third or so of its extant.| Even if the wound left after incomplete union be only comparatively slight nevertheless the condition resulting is also unfortunate and serious. Most authorities on gynaecology’hold that rupture of the perinaeum predisposes to herniation of the pelvic contents.5.Simpson thinks that it is the main cause* Galabin attributes a leading part to rupture of the Perinaeum in the causation of prolapsus uteri* In the treatment also of prolapsus uteri if the perinaeum be not intact the most effective remedy^i^pelsary, cannot be used with effect*Any procedure;therefore;is of importance?which will tend to reduce the number of these unfortunate accidents*In the treatment of persistent occipito-posteriorpositions of the head different methods are advised bydifferent authorities* A few of these may be brieflysummarised herej 3Leishman recommends, if the head is free1System of Gynaecology, Allbutt, Playfair & gden, ii908, page 18 2.2Diseases of Women, ;1887, page. 75*3Op. Git* page 346.et the brim rotation with the long straight forceps.If the head is at the pelvic floor he advises that itsflexion be assisted by pressing up the forehead, and pulling1down the occiput with the vectis. He also recommends that when the head is at the pelvic floor rotation should be attempted with the forceps. This failing rotation combined with extraction should be employed. If this do not succeedthe head should be delivered in the occipito-posterior position.2 3 4Playfair quotes Bataillard and Fry as recommendingmanual rectification of occipito-posterior positions. He doesnot himself express an opinion on that treatment, but goes onto describe the method of delivery by forceps in the occipito-posterior ;position, stating that in this there is no special1Op. Cit. page 544SThe Science and Practice of Midwifery, : 1898, page 419.3Ann. de Gyn.i, Aug. 1889.4Amer. Journ. of Obstet., March 1897.7.difficulty, excepting tb© risk of rupture of the Perinaeum,1Galabin recommends that the vectis be used over theocciput to effect rotation in persistent occipito-posteriorcases. He admits that it capnot be so used if the headis pressing on the perinaeum and bulging the parts. If thehead has not descended into the pelvis he recommends thatit be brought down with the forceps, and then the forcepsremoved, and rotation attempted with the vectis. He also 2states that an attempt should be made to rotate with the forceps, either straight or double curved. These efforts failing he recommends that the head be extracted in the occipito-posterior position*1:A Manual of Midwifery, '1904, page 651,2ibid, page 6641Fothergill recommends that the head be delivered in the occipito-?posterior position* To avoid a deep central tear of the perinaeum often extending into therectum episiotomy may be performed*2Eden recommends manual rectification in thesepersistent occipito-posterior cases*3Munro Kerr also advises manual rectification*: 4'Tweedy Ji Wrench recommend leaving the case alone if there is no uterine inertia* If there is - uterine inertia they administer a sleeping draught, or morphia hypodermically* If the pulse or temperature of the mother rise, or the child shows signs of distress, they deliver with the forceps in the occipito-posterior position*Of the method of rotation with the forceps I have never made trial* In some instances I have found the head to rotate spontaneously in the process of attempting to deliver with the forceps in the occipito-posterior positian* ■This necessitates taking off the pelvic curved forceps and re-applying them*1Manual of Midwifery, 1907, page 320*2Manual of Midwifery, 1908, page 223*3Operative Midwifery, 1908, page 30.4Op. Git. page 193.To attempt rotation however with the forceps has always appeared to me bo he hazardous* Both hands I fancy.would be required to grasp the forceps, so thdb the left hand would not be available to apply to ths surface of the abdomen externally to assist in rotating the body of the child*In the-process there must be considerable risk of in.jury to the Pelvic structures.Neither have I tried rotation combined with extraction by the forceps* It seems to me to be haphazard work*|| Th9 method of Sxpectancy, as practised for instance in the Rotunda Hospital, appears to me to possess grave disadvantages* In the second stage of labour the head of the child is a foreign body in the pelvis, exercising great pressure on its walls and contents* To prolong thig pressure for an indefinite period must cause deleterious effects on the pelvic structures, and predispose to their inflammation or sloughing, or to the entrance of germs, which are always presentin the vagina, into the tissues.1Drs* Hicks and Phillips have shown by their statistics that prolonged labour, and the prolonged pressure on the soft parts within the pelvis^was a more pofcsnt cause in producing thrombi, pelvic abscesses, peritonitis, and such like complications than the1Obst. Trans., 1872, 7ol. XIII. page 55*injuries produced in instrumental delivery.1Emmet also gives statistics which 3how that delay in delivery and the consequent pressure was a commoner cause of pelvic complications than In;juries from the use of instruments.The prolonged second stage must al30 have a reducing effect on the woman’s general condition. At that time as a rule she can take little or no nourishment. This lowering of her general powers must have a prejudicial effect on her recovery to health.Even if this treatment were the best it would be V8ry difficult to apply in general practice. In cases at a distance, say in the country, it would be almost impossible.In these latter cases too the presence of a trained nurse is the exception.During the last four years I hav^|employ ed the method of manual rectification in those persistent occipito-posterior presentations. I have employed it in all the cases I have encountered, fifteen in number, and in each instance it was performed with ease and success.The following is the manner in which I perform it.The patient, in the usual midvifery position, is put thoroughly under the influence of chloroform. The right hand, carefullyThe Principles and Practice of Gynaecology, page 33911.antisepticised is introduced into the vagina and the foebal head grasped babvreea the fingers and thumb. The head is flexed and gently pushed upwards. The left hand is applied to the surface of the abdomen and the anterior shoulder pushed forward with it, and at the same time with the right hand thehead is rotated into the occipibo-anterior position. Firmpressure is then made over the fundus uteri so as to force the head down again into the pelvis. It is well to have pressureover the fundus kept up by an assistant or nurse till the forcepsare applied in the usual way. Or if the operator decides not to use forceps he can himself maintain the pressure till the patient comes out of the effects of the chloroform, and the uterine contractions become re-established. Generally it is well to deliver with the forceps at once.The operation of course should not be performed too early, bub time given to see if spontaneous rotation will bake place.In these oases?in the second stage of labour after the head has been resting on the pelvic floor for two or three hours, for reasons above statedjl believe that manual rectification of the position is more in the interests both of the mother and child than further delay.Some of the authors quoted above giv9 cases in which they failed to effect rotation from impaction of the head or shoulders or other cause. These cases of failure should be few in number, and in th9m one is in no worse position than before in proceeding to direct methods of extraction.Formerly, in an experience of eighteen hundred cases, I followed the plan of delivering the head with forceps in the occipito-posterior position;in those eases where it did not rotate spontaneously. Though I have sometimes done so without in.jury to 9ither the mother or child, yet by far the worst lacerations of the perinaeum that have occurrsd in my hands have been in these position^* Indeed when I discovered an occipito-posterior presentation in a primipara, or even in a multipara, I had come to regard the case with some apprehension. Since adopting the manual rectification these, the most difficult cases, have so to spe been eliminated, to my great satisfaction.Statistics show that foetal mortality in this' method is 5 per cent as against 10 per cent in the expectant method of treatment.■The following two cases may be quoted as illustrating the value of thi3 mode of treatment:-Case II. Mrs. McC., age 30. Fourth Confinement.Th9 former confinements were normal and easy. Attended 20th Aug., 1909. On arrival the head was resting on the perinaeum, the pains being strong and fcrequent• I found that the presentation was the third position of the vertex.I tried upward pressure on the forehead during the pains.After two hours, as the head showed no signs of rotating,I administered chloroform and performed manual rotation.As the pains had been good I then allowed the patient to come out of the chloroform, and in the course of a few pains the child was born.Case III. Mrs. H., age 23. Primpara. I was asked by a brother practitioner to assist him in this case on 12th Dec., 1909. He was anticipating difficulty owing to the small size of the pelvis. The woman had been in labour for 30 hours.There was a large caput succudaneum, and the head was arrested in the pelvis. As there was great sensitiveness over thef abdomen the presentation could not be clearly made out. Under chloroform I found that the head was in the third cranial position.I performed manual rotation, and delivered with the forceps with some difficulty. There was a tear of the perinaeum extending to an inch or so. Both woman and child did well.In the last case had extraction of the head been effected with forceps in the occipito-posterior position^I am certain that it would only have been done at the expense of very serious injury to the mother, and withincreased risk to the child.theIn dealing with occipito-posterior position of the after-coming head in foot and breech presentations there is no difficulty. When the pelvis is being born if it does notspontaneously rotate with the back to the front it is easyAto induce it to do so by rotating the pelvis. If the child's trunk b9 born before the arrival of the attendant, the head may be found in the occipito-posterior position. I have encountered th^idifficulty once. It is overcome by rotating the head and body together, so as to bring the head into the occipibo-ahterior position.In this country in dealing with fetes occipito-posterior presentations there is no doubt that the vast majority of general practitioners adhere to the older method of extraction by the forceps in the occipito-posterior position. This deliveryby forceps is effected too without much of a delay to allow of spontaneous rotation. There is an increasing demand too I believe among women to have chloroform administered, so as to avoid some of the irksomeness of the labour pains. The giving of chloroform even in small quantities generally has a weakening and retarding influence on the pains. All thi3 leads to an increased use of the forceps, and to their being used in an increased number of occipito- posterior caseSjwhich have not spontaneously rotated.It is not surprising thajb the older methods should be largely used seeing that writers on the subject appear to be about equally divided for and against manual rectification of occipito-posterior cases. I am convinced that its general adoption, in competent hands, would lead to reduced foetal mortality, and save parturient women from a great amount of risk and suffering.

Management of Occipito-Posterior Presentations in Midwifery Practice

Enlighten: Theses

MANAGEMENT OE OCCIPITQ-POSTERIOR PRESENTATIONS 
• IN MIDWIFERY PRACTICE*
THOMAS McGEOGH,
GIR7AN,
AYRSHIRE.
. B*, C.Mv
ProQuest Number: 13915811
All rights reserved
INFORMATION TO ALL USERS 
The quality of this reproduction is dependent upon the quality of the copy submitted.
In the unlikely event that the author did not send a com p le te  manuscript 
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.
uest
ProQuest 13915811
Published by ProQuest LLC(2019). Copyright of the Dissertation is held by the Author.
All rights reserved.
This work is protected against unauthorized copying under Title 17, United States C ode
Microform Edition © ProQuest LLC.
ProQuest LLC.
789 East Eisenhower Parkway 
P.O. Box 1346 
Ann Arbor, Ml 48106- 1346
1.
MANAGEMENT OE OCCIPITO-POSTERIOR PRESENTATIONS 
IN MIDWIFERY PRACTICE.
In Labour the proportion of cases of vertex presentations 
in which the head descends into the pelvis in the third and fourth 
positions is variously stated by different observers. Leishman* 
gives a table in which the percentage varies from 32.88 as given 
by Naegele the younger to 3.84 as given by Swayne. The proportion 
is usually stated as about 25 per cent.
The condition is revealed early in labour by abdominal 
palpation, and after the os has dilated by the ease with which 
the anterior fontsnelle is reached.
In the vast majority of occipito-posterior presentations 
when the occiput in the course of its descent reaches the floor 
of the pelvis it is directed forwards, and so rotates into the 
occipito-anterior position. In this termination the head rotates 
from a position in which there are greater mechanical obstructions 
to its passage to one in which these obstructions are lesser.
In the occipito-anterior position of the head the sub-occipito- 
bregmatic diameter of the head, measuring 3i inches, has to pass 
the vulvar orifice, while in the occipito-posterior position the
1
A System of Midwifery 1880 page 348.
2.
occipito-frontal diameter, measuring 4| inches has to pass.
This rotation therefore to the anterior position of the occiput 
makes for the safety both of the mother and the child.
rotation does not take place. The main causes of failure to 
rotate are extension of the child’s head and defects in the 
pelvic floor.
The proportion of occipito-posterior cases in which
1
the head does not rotate was found in Rotunda Hospital to be
into the mechanism of labour, that, if a case terminates;either 
by natural means or by the aid of the accoucheur^in an occipito- 
posterior position^ there is greatly increased danger of injury 
both to the mother and to the child. To the mother the greater 
risk arises chiefly from injuries to the soft parts, the perinaeum 
especially being liable to be torn to a greater or lesser degree. 
The increase of danger to the child arises from the extra pressure 
to which the head is subjected in its passage through the pelvis. 
Even in favourable presentations of the vertex, namely, the first 
and second positions, all authorities agree that in many cases a
1
Rotunda Practical Midwifery,1908, Tweedy and Wrench, page 193.
2
Operative Midwifery, 1908, page 28.
In a minority of cases however this safety-making
t /j oJUL cklim /LUA.
0.69 per cent^, Munro Kerr found it to be 7 per
In these difficult labours it is obvious, without going
certain amount of laceration of the perinaeum is unavoidable.
1
According to Duncan this occurs in 60 per cent of first 
labours. How much greater then is the risk of injury in those 
cases which terminate occipito-posterior.
A slight laceration of the perinaeum, extending to 
say an inch or so, as a rule heals well if the torn surfaces 
are brought together with a few stitches. A severe laceration 
however can be regarded in no other light than a serious one.
If it is at once properly sutured the wound generally heals 
well, but occasionally it does not do so. Sven if it heal well, 
in the event of another pregnancy occurringythe cicatrix is very 
prone to give way. Occasionally there is failure of union and 
if the laceration has extended into the rectum proper control 
over the bowel is lost. There are many instances in which even 
skilled obstetric surgeons have failed to remedy this condition, 
which entails on the sufferer a life of misery. With a laceration 
there is always added the danger of the entry of septic organisms 
leading it may be to sapraemia or septicaemia.
As illustrating one effect of a rupture of the perinaeum 
I may quote a case occurring in trry practice.
Case I. Mrs. W. Age 25. Attended in first confinement 
1st Sept., 1904. Antero-posterior diameter of pelvic outlet
System of Gynaecology, Albutt, Playfair & Eden, 1906^ 
page 719.
slightlyjsontracted. Presentation was third cranial. I attempted 
pressure upwards on forehead during pains but the bead did not 
rotate. I administered chloroform and delivered the head 
with forceps in the occipito-posterior position, with considerable 
difficulty. In the operation the perinaeum was ruptured, the 
tear involving the rectum. This I stitched up carefully, and the 
wound healed completely, the control of the bowel being quite 
normal•
I attended this patient in her second confinement on 
20th Aug.!, 1908. The presentation was first cranial.
The second stage was tedious, the patient desiring instrumental 
aid, which I refused to give. Whili® the head was distending 
the perinaeum the cicatrix in the latter suddenly gave way, 
tearing somewhat like a piece of wet paper. The rupture extended 
as far as the rectum, but did not involve the circular fibres.
I administered chloi'oform and stitched the wound carefully.
It
The wound however only healed to one third or so of its extant.| 
Even if the wound left after incomplete union be only comparatively 
slight nevertheless the condition resulting is also unfortunate 
and serious. Most authorities on gynaecology’hold that rupture 
of the perinaeum predisposes to herniation of the pelvic contents.
5.
Simpson thinks that it is the main cause* Galabin 
attributes a leading part to rupture of the Perinaeum in 
the causation of prolapsus uteri* In the treatment also 
of prolapsus uteri if the perinaeum be not intact the most 
effective remedy^i^pelsary, cannot be used with effect*
Any procedure;therefore;is of importance?which 
will tend to reduce the number of these unfortunate 
accidents*
In the treatment of persistent occipito-posterior
positions of the head different methods are advised by
different authorities* A few of these may be briefly
summarised herej 
3
Leishman recommends, if the head is free
1
System of Gynaecology, Allbutt, Playfair & gden, 
ii908, page 18 2.
2
Diseases of Women, ;1887, page. 75*
3
Op. Git* page 346.
et the brim rotation with the long straight forceps.
If the head is at the pelvic floor he advises that its
flexion be assisted by pressing up the forehead, and pulling
1
down the occiput with the vectis. He also recommends that 
when the head is at the pelvic floor rotation should be 
attempted with the forceps. This failing rotation combined 
with extraction should be employed. If this do not succeed
the head should be delivered in the occipito-posterior position.
2 3 4
Playfair quotes Bataillard and Fry as recommending
manual rectification of occipito-posterior positions. He does
not himself express an opinion on that treatment, but goes on
to describe the method of delivery by forceps in the occipito-
posterior ;position, stating that in this there is no special
1
Op. Cit. page 544
S
The Science and Practice of Midwifery, : 1898, page 419.
3
Ann. de Gyn.i, Aug. 1889.
4
Amer. Journ. of Obstet., March 1897.
7.
difficulty, excepting tb© risk of rupture of the Perinaeum,
1
Galabin recommends that the vectis be used over the
occiput to effect rotation in persistent occipito-posterior
cases. He admits that it capnot be so used if the head
is pressing on the perinaeum and bulging the parts. If the
head has not descended into the pelvis he recommends that
it be brought down with the forceps, and then the forceps
removed, and rotation attempted with the vectis. He also 
2
states that an attempt should be made to rotate with the 
forceps, either straight or double curved. These efforts 
failing he recommends that the head be extracted in the 
occipito-posterior position*
1
:A Manual of Midwifery, '1904, page 651,
2
ibid, page 664
1
Fothergill recommends that the head be delivered 
in the occipito-?posterior position* To avoid a deep 
central tear of the perinaeum often extending into the
rectum episiotomy may be performed*
2
Eden recommends manual rectification in these
persistent occipito-posterior cases*
3
Munro Kerr also advises manual rectification*
: 4
'Tweedy Ji Wrench recommend leaving the case 
alone if there is no uterine inertia* If there is - 
uterine inertia they administer a sleeping draught, or 
morphia hypodermically* If the pulse or temperature of the 
mother rise, or the child shows signs of distress, they 
deliver with the forceps in the occipito-posterior position*
Of the method of rotation with the forceps I have 
never made trial* In some instances I have found the head 
to rotate spontaneously in the process of attempting to 
deliver with the forceps in the occipito-posterior positian* 
■This necessitates taking off the pelvic curved forceps and 
re-applying them*
1
Manual of Midwifery, 1907, page 320*
2
Manual of Midwifery, 1908, page 223*
3
Operative Midwifery, 1908, page 30.
4
Op. Git. page 193.
To attempt rotation however with the forceps has always 
appeared to me bo he hazardous* Both hands I fancy.would 
be required to grasp the forceps, so thdb the left hand would 
not be available to apply to ths surface of the abdomen 
externally to assist in rotating the body of the child*
In the-process there must be considerable risk of in.jury to the 
Pelvic structures.
Neither have I tried rotation combined with extraction 
by the forceps* It seems to me to be haphazard work*|| Th9 method 
of Sxpectancy, as practised for instance in the Rotunda Hospital, 
appears to me to possess grave disadvantages* In the second stage 
of labour the head of the child is a foreign body in the pelvis, 
exercising great pressure on its walls and contents* To prolong 
thig pressure for an indefinite period must cause deleterious 
effects on the pelvic structures, and predispose to their inflammation 
or sloughing, or to the entrance of germs, which are always present
in the vagina, into the tissues.
1
Drs* Hicks and Phillips have shown by their statistics that 
prolonged labour, and the prolonged pressure on the soft parts 
within the pelvis^was a more pofcsnt cause in producing thrombi, 
pelvic abscesses, peritonitis, and such like complications than the
1
Obst. Trans., 1872, 7ol. XIII. page 55*
injuries produced in instrumental delivery.
1
Emmet also gives statistics which 3how that delay in delivery 
and the consequent pressure was a commoner cause of pelvic 
complications than In;juries from the use of instruments.
The prolonged second stage must al30 have a 
reducing effect on the woman’s general condition. At that 
time as a rule she can take little or no nourishment. This 
lowering of her general powers must have a prejudicial effect 
on her recovery to health.
Even if this treatment were the best it would be 
V8ry difficult to apply in general practice. In cases at a 
distance, say in the country, it would be almost impossible.
In these latter cases too the presence of a trained nurse is 
the exception.
During the last four years I hav^|employ ed the method 
of manual rectification in those persistent occipito-posterior 
presentations. I have employed it in all the cases I have 
encountered, fifteen in number, and in each instance it was 
performed with ease and success.
The following is the manner in which I perform it.
The patient, in the usual midvifery position, is put thoroughly 
under the influence of chloroform. The right hand, carefully
The Principles and Practice of Gynaecology, page 339
11.
antisepticised is introduced into the vagina and the foebal 
head grasped babvreea the fingers and thumb. The head is 
flexed and gently pushed upwards. The left hand is applied 
to the surface of the abdomen and the anterior shoulder pushed 
forward with it, and at the same time with the right hand the
head is rotated into the occipibo-anterior position. Firm
pressure is then made over the fundus uteri so as to force the 
head down again into the pelvis. It is well to have pressure
over the fundus kept up by an assistant or nurse till the forceps
are applied in the usual way. Or if the operator decides not 
to use forceps he can himself maintain the pressure till the 
patient comes out of the effects of the chloroform, and the uterine 
contractions become re-established. Generally it is well to 
deliver with the forceps at once.
The operation of course should not be performed too early, 
bub time given to see if spontaneous rotation will bake place.
In these oases?in the second stage of labour after the head has 
been resting on the pelvic floor for two or three hours, for 
reasons above statedjl believe that manual rectification of the 
position is more in the interests both of the mother and child 
than further delay.
Some of the authors quoted above giv9 cases in 
which they failed to effect rotation from impaction of 
the head or shoulders or other cause. These cases of 
failure should be few in number, and in th9m one is in no 
worse position than before in proceeding to direct methods 
of extraction.
Formerly, in an experience of eighteen hundred 
cases, I followed the plan of delivering the head with 
forceps in the occipito-posterior position;in those eases 
where it did not rotate spontaneously. Though I have 
sometimes done so without in.jury to 9ither the mother or 
child, yet by far the worst lacerations of the perinaeum 
that have occurrsd in my hands have been in these position^* 
Indeed when I discovered an occipito-posterior presentation 
in a primipara, or even in a multipara, I had come to regard 
the case with some apprehension. Since adopting the manual 
rectification these, the most difficult cases, have so to spe 
been eliminated, to my great satisfaction.
Statistics show that foetal mortality in this' method 
is 5 per cent as against 10 per cent in the expectant method 
of treatment.
■The following two cases may be quoted as 
illustrating the value of thi3 mode of treatment:-
Case II. Mrs. McC., age 30. Fourth Confinement.
Th9 former confinements were normal and easy. Attended 
20th Aug., 1909. On arrival the head was resting on 
the perinaeum, the pains being strong and fcrequent• I found 
that the presentation was the third position of the vertex.
I tried upward pressure on the forehead during the pains.
After two hours, as the head showed no signs of rotating,
I administered chloroform and performed manual rotation.
As the pains had been good I then allowed the patient to come 
out of the chloroform, and in the course of a few pains the 
child was born.
Case III. Mrs. H., age 23. Primpara. I was asked by a 
brother practitioner to assist him in this case on 12th Dec., 
1909. He was anticipating difficulty owing to the small size 
of the pelvis. The woman had been in labour for 30 hours.
There was a large caput succudaneum, and the head was arrested 
in the pelvis. As there was great sensitiveness over thef abdomen 
the presentation could not be clearly made out. Under chloroform 
I found that the head was in the third cranial position.
I performed manual rotation, and delivered with the forceps 
with some difficulty. There was a tear of the perinaeum 
extending to an inch or so. Both woman and child did well.
In the last case had extraction of the head 
been effected with forceps in the occipito-posterior position^
I am certain that it would only have been done at the 
expense of very serious injury to the mother, and with
increased risk to the child.
the
In dealing with occipito-posterior position of the 
after-coming head in foot and breech presentations there is 
no difficulty. When the pelvis is being born if it does not
spontaneously rotate with the back to the front it is easy
A
to induce it to do so by rotating the pelvis. If the child's 
trunk b9 born before the arrival of the attendant, the head 
may be found in the occipito-posterior position. I have 
encountered th^idifficulty once. It is overcome by rotating 
the head and body together, so as to bring the head into the 
occipibo-ahterior position.
In this country in dealing with fetes occipito-posterior 
presentations there is no doubt that the vast majority of 
general practitioners adhere to the older method of extraction 
by the forceps in the occipito-posterior position. This delivery
by forceps is effected too without much of a delay to allow 
of spontaneous rotation. There is an increasing demand 
too I believe among women to have chloroform administered, 
so as to avoid some of the irksomeness of the labour 
pains. The giving of chloroform even in small quantities 
generally has a weakening and retarding influence on the 
pains. All thi3 leads to an increased use of the forceps, 
and to their being used in an increased number of occipito- 
posterior caseSjwhich have not spontaneously rotated.
It is not surprising thajb the older methods should be largely 
used seeing that writers on the subject appear to be about 
equally divided for and against manual rectification of 
occipito-posterior cases. I am convinced that its general 
adoption, in competent hands, would lead to reduced foetal 
mortality, and save parturient women from a great amount 
of risk and suffering.


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Management of Occipito-Posterior Presentations in Midwifery Practice

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