OPERATIONS
Complications during labor may arise from abnormal positions of the
head, such as face or brow; from abnormal presentations of the child,
such as breech, transverse or shoulder; from twin labors; or from
prolapse of a part like the foot, arm or cord.
The mother may be responsible for some of these abnormalities through
having a contracted pelvis, a rigid os, or a rigid pelvic floor.
The uterus, too, may functionate abnormally by acting too vigorously, as
in precipitate labor, or too slowly, as in uterine inertia. The
membranes may rupture prematurely and produce a dry birth.
There may be hæmorrhages before labor (ante partum hæmorrhage) during
labor (intra partum), and after labor (post partum hæmorrhage), or the
labor may be preceded, accompanied, or followed by that extreme example
of toxæmia known as eclampsia.
Face and brow presentations are rare and come to the attention of the
nurse only when an operation is required for their relief. Further
conditions may arise, such as danger to mother or child, which demand an
acceleration of the labor.
If the head is engaged, forceps is the operation most commonly
undertaken, and if not engaged, the problem may be solved either by an
early version and extraction or by forceps later. The dangers to the
mother are not usually difficult to diagnose if the case has been
followed carefully.
Signs of danger to child must be looked for constantly. Such are:
(a) Alteration of the heart tones.
(b) Retardation of pulse in cord between pains.
(c) Escape of meconium is _not_ significant unless occurring in the
pain-free interval, when it may signify hypercarbonization of blood and
a threat of asphyxiation.
The preliminaries for the performance of these operations may now be
described, and the indications and conditions briefly tabulated.
The _preparation_ should be standardized so that the same set-up of the
room will do for all of the major obstetrical operations, except
Cæsarean section.
The kitchen table is generally regarded as a satisfactory operating
table. Its length is sufficient for delivery when the legs are doubled
up. The table should be covered with a blanket or comfort on which it
laid a clean sheet. A rubber blanket or piece of oil cloth is put on, so
folded above the place for the patient’s hips, and so pinned at the
sides, that all drainage will flow off into a bucket or jar at the foot.
In front of the table is placed a straight-backed chair with flat seat.
To the right of the operator, as he faces the table, stands a bench, or
two chairs, side by side; or, if possible, another table. This is
covered with a clean sheet for the reception of the instruments. To the
operator’s left, another table similarly prepared carries the solutions,
sponges, etc. Every operation for delivery should have tape and cord
scissors within easy reach, as well as facilities for the resuscitation
of the child.
The light should come from behind the operator and fall full upon the
field of operation. The room should be warm.
The patient is laid upon the table and her knees elevated in the
exaggerated lithotomy position. If there are assistants enough, one can
stand on either side and hold a knee, if not, a sheet sling can be made
and slung round the patient’s shoulders and tied to the knees as
previously described.
[Illustration: Fig. 71.—Exaggerated lithotomy position. The legs are
held by a sheet sling. The vulva should be shaved. (Williams.)]
An anæsthetic will be required. If a doctor can not be had, this duty
will fall to the nurse.
A sterile douche bag hangs near the table. A bath tub of hot water must
be provided and a tracheal catheter must be ready for the removal of
mucus from the child’s windpipe. An abundance of hot and cold sterile
water must not be overlooked. In the hospital the following synopsis for
the placing of the linen may be found useful:
=Sterile Linen for Operative Case.—=
Bring patient to foot of bed.
Put in the stirrups. (For breech deliveries _do not_ use stirrups.)
Same order as for normal case except that feet are put in stirrups
instead of on bed.
[Illustration: Fig. 72.—Dorsal position when assistants are available.
(Hammerschlag.)]
Sterile sheet under patient extends now from basin under bed to
buttocks.
Combination pad over field of operation.
Sterile sheet over abdomen.
The genitals of the patient are now cleansed with all care and attention
described for labor. If this has been done within an hour, she need only
be sponged off thoroughly with lysol solution (1 per cent). The feet and
legs are covered with stockings, the body kept warm, and protected by
sheets and blankets, if necessary.
_Every_ operative delivery is preceded by catheterization.
All instruments are boiled for thirty minutes and brought to the table
in the same container in which they are sterilized. The hot water has
been poured off and a cool, weak solution of lysol (0.5 per cent) added.
[Illustration: Fig. 73.—Instruments for artificial delivery of the head.
_A_, Braun’s blunt hook; _B_, Cranioclast (Auvard); _C_, Axis traction
forceps (Webster); _D_, Low forceps (Simpson).]
=Forceps.=—Before using forceps it should be determined that the woman
can not deliver the child unaided, or can not be permitted to do so
without too great expenditure of physical and nervous energy. The exact
conditions must be recognized as to the location and position of the
head, the condition of the fœtal heart tones and the size of the pelvis.
When the head is high up, the axis traction instrument is employed and
patient put in Walcher’s position for the traction.
Axis traction forceps are extremely dangerous to mother and child, and
should be avoided wherever possible.
The following instruments are required:
The obstetric forceps.
2 eight-inch forceps.
6 artery forceps.
1 vulsellum forceps.
1 tissue forceps.
1 needle forceps and 6 needles.
2 vaginal retractors.
1 pair dressing forceps.
1 douche point.
1 silver catheter.
Suture material—both catgut and silkworm gut.
Besides these instruments, the nurse will also have solution basins as
described for normal labor. For operations outside of hospitals, the
nurse need not be clean, as her duties will consist for the most part in
changing solutions, refilling basins, handing towels, etc., all of which
can be done with sterile forceps.
The following summary may be serviceable for advanced study or
reference:
PREPARATION.—
Thorough asepsis, both subjective and objective.
Patient should be pulled down to the foot of the labor bed with
feet in the stirrups, or put upon the kitchen table or across
the bed with the legs held in the lithotomy position. (For
breech cases, legs should not be fastened.)
Bladder and rectum must be empty.
Anæsthetic is necessary.
The position of the head must be accurately known.
Facilities for the treatment of asphyxia neonatorum must be at
hand.
CONDITIONS.—
Cervix effaced and os dilated, except when maternal or fœtal life
is threatened.
Bag of waters must be ruptured.
The head must be engaged.
The child should be living.
INDICATIONS.—
Insufficiency of the powers of labor.
Deep transverse arrest of the head.
Complications in labor, such as:
Eclampsia.
Fever.
Acute or chronic disease.
Hernia—especially if incarcerated.
Placenta previa.
Prolapse of the cord.
Face and brow presentations.
Contracted pelvis.
Occipito-posterior positions.
DANGERS FROM FORCEPS.—
_Injuries to Child._—Overcompression, especially with axis
traction forceps or in contracted pelvis.
Crushing of soft parts, or such lesions as abrasions, pressure
marks, hæmatomata, swelling of face and eyelids.
Bone injuries: Spoon-shaped depression where the head has been
dragged through a narrow inlet; fissures in the parietal or
frontal bones; fractures. When axis traction forceps are applied
antero-posteriorly, the occipital bone may be sprung inwards
until it cuts the medulla.
Compression of the cord, especially if it is around the neck.
Hæmorrhage from the middle meningeal artery.
Injury to eye.
Erb’s paralysis.
Laceration of ears when the forceps are removed.
Facial paralysis from pressure of the blade.
_Injury to Mothers._—
Infection.
Improper application of the blades _outside_ the cervix uteri.
Soft parts torn by too rapid extraction. When os is not
dilated, it is first pulled down and then torn. The tear may
extend into the vaginal vault. Fistulæ may be produced.
Prolapse of the uterus from prolonged traction.
Vaginal tears from the blades or from malplaced head.
Slipping of blades. Traction must be _not against_ the
symphysis, but down.
The forceps commonly used in this country (Simpson or Elliott) are so
made that the left blade must be introduced first on account of the
lock.
The mortality for the child in forceps cases is about six per cent.
[Illustration: Fig. 74.—Forceps operation. The left blade, in the left
hand, is introduced first into the left side of the mother so that the
curve of the blade fits the child’s head (inside the cervix).
(Hammerschlag.)]
The axis traction instrument is used but seldom by good obstetricians,
since the danger to mother and child in this operation is very serious
and it should be reserved for emergencies of exceptional character.
Pubiotomy may precede the operation with advantage in many cases.
Asphyxia of the child and maternal hæmorrhage must be prepared for.
[Illustration: Fig. 75.—Forceps operation. The introduction of the right
blade. (Hammerschlag.)]
[Illustration: Fig. 76.—Forceps operation. Locking the handles.
(Hammerschlag.)]
[Illustration: Fig. 77.—Forceps operation. The way the blades should
grasp the fœtal head. (Hammerschlag.)]
[Illustration: Fig. 78.—Forceps operation. Traction on the handles.
(Hammerschlag.)]
[Illustration: Fig. 79.—Forceps operation. The delivery of the head.
(Hammerschlag.)]
[Illustration: Fig. 80.—Version. Seizing a foot. (Hammerschlag.)]
=Version (Turning).=—Version is a maneuver for altering the presentation
of the child while it is still in the uterus. A vertex may be converted
into a breech, a breech into a vertex or a transverse into either a
vertex or a breech.
[Illustration: Fig. 81.—Version. The child rotates as pressure is made
upon the head and traction upon the foot. (Hammerschlag.)]
Version usually means that a transverse or a vertex presentation is
changed into a breech and is followed by the extraction of the child.
The operation is serious and not to be undertaken without definite
indications. There is always the risk of sepsis and rupture of the
uterus as well as a high probability of a dead child. Perineorrhaphy is,
if anything, more frequent after this operation than after forceps.
[Illustration: Fig. 82.—Version is complete when the knee appears at the
vulva. (Hammerschlag.)]
PREPARATIONS.—The room and patient are arranged as for forceps, except
that the stirrups can not be put in. The legs must be held by
assistants, for the delivery of the after-coming head may be complicated
and require the Walcher position, which can not be quickly obtained if
the legs are fast. Only eight minutes are allowed for the delivery of
the child after the navel passes the vulva, if it is expected to live.
The bladder and rectum must be empty.
Asepsis must be rigid and both subjective and objective.
The dorsal position on a table is imperative.
The diagnosis must be accurate and the anæsthesia carried to the
surgical degree.
Facilities for treating asphyxia neonatorum must be provided.
The following summary of the indications and conditions may be
convenient for reference.
INDICATIONS.—Contracted pelvis. (Consider pubiotomy.)
Abnormal position of the head. (Face position with chin
posterior.)
Prolapse of cord or an extremity with a presentation of the head.
Placenta previa.
Transverse position after the seventh month.
Any condition requiring rapid delivery.
CONDITIONS.—Cervix effaced and os dilated.
Uterus not in tetanus nor contracted down over the child.
The fœtus must be movable.
The head should not be engaged.
The _Walcher position_ is produced by bringing the patient down to the
end of the table so that the sacrum rests upon the edge. The thighs and
legs are allowed to hang down of their own weight and the patient is
restrained from falling off by traction upwards on the axillæ.
In the Walcher position the diameter of the pelvic inlet is increased
from ⅓ to ½ inch (1 cm.) and thereby the delivery of heads that
otherwise could not pass becomes possible.
In addition to the Walcher position other measures may be required to
help the head through. Thus, traction from below may be carried to the
limit of safety and in spite of the Walcher position the head may not
pass the inlet.
Then pressure from above is added. This maneuver will have to be
executed in many cases by the nurse.
The fingers palpate the head above the pubes. Then one or both fists are
placed upon the abdomen over the head and force is exerted to crowd the
head down into the pelvis. This is known as the _Wiegand compression_.
For the operations destructive to the child, craniotomy or decapitation,
the same arrangements are made.
[Illustration: Fig. 83.—The Walcher position. (American Text Book.)]
=Cranioclasis= is the crushing of the fœtal skull so that in its reduced
condition the child can be delivered and the mother’s life spared. In
addition to the solutions, the only instruments required are the Auvard
cranioclast, a Naegele perforator, and a douche bag with glass, or any
tip that can be sterilized.
In many of these cases, _both_ mother and child could be saved if seen
early enough to have a Cæsarean operation.
=Decapitation= is done to save the maternal life in cases of transverse
or shoulder presentation. The preparations are the same as already
described for forceps and version and the only instrument needed is a
Braun blunt hook. (Fig. 73.)
[Illustration: Fig. 84.—The Wiegand compression of the child’s head to
force it into the pelvis. (Hammerschlag.)]
=Cæsarean section= is the delivery of the child through an opening in
the abdomen.
It is made necessary by contraction of the pelvic bones, or by the
presence of a fleshy or bony mass which diminishes the size of the
inlet. It may be required on account of the closure of the vagina or
cervix by scars or on account of urgent conditions of the mother, such
as eclampsia, heart disease, and sometimes placenta previa.
The technic is simple, but good judgment must be used in knowing when to
do it. Many operators find it so easy that they prefer it to the harder
but safer obstetrical operations.
[Illustration: Fig. 85.—The Naegele perforator. (Hammerschlag.)]
The time of election is when the woman is at term but not in labor.
This, of course, can be determined by the history, but more certainly by
careful measurements of the child.
When it becomes necessary to operate on a woman who has been in labor a
long time and especially if she has been examined frequently, the
mortality is disproportionately high.
It is a hospital operation, but may be done in the house. If not an
emergency, the bowels are emptied by a laxative and enema the day
before. Regular preparations for laparotomy are made, plus the equipment
necessary for tieing the cord and resuscitating the child. A table must
be found large enough to hold the patient in the horizontal position at
full length. Solutions of lysol 1 per cent and sterile water are placed
on each side of the table. The instrument table carries towels and
suture material as well.
On a stand behind the operator is placed the hot bath and tracheal
catheter. This center is presided over by someone skilled in the
treatment of respiratory difficulties in the new born. Altogether, five
assistants are required for the operation: an anæsthetizer, a clean
nurse, and a nonsterile nurse to manage supplies, an operating assistant
and one to take charge of the child.
Rubber gloves must be worn by the clean assistants.
_Instruments.—_
2 scalpels.
2 scissors.
8 eight-inch forceps.
10 six-inch artery forceps.
4 sponge carriers.
4 tenaculum forceps.
2 rat-toothed tissue forceps.
4 full curved round needles for uterine wall.
4 smaller needles for the fascia.
2 Hagedorn needles for the skin.
2 needle holders.
1 dressing forceps.
Plenty of suture material, both catgut (No. 3 and 4) and
silkworm gut for the abdominal wall.
_Supplies.—_
1 doz. laparotomy sponges with metal rings sewed in or
a long tape attached.
6 large laparotomy pads.
1 large pillow slip full of sterile cotton.
Sponges.
1 laparotomy sheet.
1 dozen towels.
1 pair of leggins.
Gowns and head dressings (gauze will do) for the operator and
assistants; rubber gloves, basins and accessories. All are
sterilized.
If the woman has been examined, the vagina should be sponged out with
tincture of iodine. The abdomen is shaved, scrubbed with green soap,
nail brush, and hot water for five minutes. It is then rinsed with ether
and painted with iodine.
The presentation of the child, the presence and location of the heart
tones must be determined before operation.
The patient is anæsthetized with ether, chloroform or gas.
The incisions are made; the child delivered to the proper assistant; the
placenta and membranes removed; the sponges counted; and the uterus and
abdominal wall sutured.
_After-care._—The nurse watches the patient for sighing respiration,
rapid pulse, pallor, and other symptoms of hæmorrhage, either external
or internal. Artificial heat is supplied. Hæmorrhage from vagina should
be looked for. It is normal. Salt solution by hypodermoclysis may be
required. Hot water by mouth in small sips or tap water by rectum (drop
method) will relieve the thirst. Morphine may be given if pain is
extreme. An enema may be given on the second day or calomel may be
started in the morning of the second day. Distention from gas, with or
without nausea and vomiting, hiccough and rise of temperature are all
signs of danger. No milk should ever be given on account of the gas it
causes.
The child is put to breast as usual after twelve hours.
The stitches are to be taken out on the tenth or twelfth day.
=Symphyseotomy= is a separation of the pelvis at the pubic joint and is
done with a scalpel or a specially devised knife.
=Pubiotomy= is the division of the pelvis, three or four centimeters to
the right or left of the pubic joint. The division passes through the
pubic bone and is usually done with a serrated wire called the Gigli
saw. It is introduced subcutaneously by a special instrument called a
pubiotomy needle. Both symphyseotomy and pubiotomy are preparatory to
delivery. Pubiotomy is the more desirable and successful operation. The
ends of the severed bones separate from one and a half to two inches,
and the child delivers easily through the enclosed opening. The
after-care is usually simple.
_Instruments.—_
1 scalpel.
2 Gigli saws.
1 pubiotomy needle.
6 artery forceps.
3 eight-inch forceps.
1 needle holder.
2 retractors.
Suture material and sponges as usual.
The hips are strapped in circumference with zinc adhesive plaster to
support the bones.
The danger of infection of the wound from the lochia is always present.
The main difficulty is in moving the patient, who is more than usually
helpless. The bony ring of the pelvis is broken and she can not raise
her leg. The repair is cartilaginous at first, but solidifies in a few
months so that locomotion is not impaired. Especial pains must be taken
to avoid bed sores.