Comparative merits of cephalic and podalic (or vertex-first and vertex-last) deliveries, through pelves narrowed in the conjugate diameter, by /

Stewart, R[enel].

Philadelphia : E. C. Markley & Son, Printers, 1875.

Description : [1] - 14p. ; ill., front., 23.5 cm.

Photographs : 2 uranium prints on 1 leaf.

Subject : obstetrics.

Cited : Cordasco 70-3458.

Notes :

When Stewart wrote this paper on childbirth in women with narrowed pelvic conjugates, caesarian operations were rare and usually fatal to the mother. In 1876 Edoardo Porro demonstrated that a mother's chances of survival were improved if the caesarian operation included excision of the uterus, but throughout the 1800's a complicated delivery usually ended with the obstetrician performing a craniotomy on the baby, sacrificing its life so as to save the life of the mother. To facilitate the procedure of craniotomy, should it become necessary, physicians preferred the vertex-first delivery which displays the baby's crown for an easy pierce. Stewart notes that in women with tortuous pelves or narrowed conjugates the baby's head will present obliquely, resulting in one blade of the forceps placed against the occiput and the opposite blade placed against the forehead, a "method taught and practiced by the Continental authorities" and goes on to affirm that "this mode of practice is incorrect" because only a biparietal positioning of the forceps will allow for compression of the cranium sufficient to pass the narrowed strait. Because of gaps in the fissures of the skull, he found that babies could tolerate a considerable amount of compression by the forceps.

I recently delivered a child at full time, whose measurement by the craniometer was three inches, easily reduced to two and three-quarters, and by harder pressure could be reduced to two and five-eighths inches.

As the result of compression, I have seen the child's eyes protruded from the sockets, and the head drawn out like a cone, and yet the child has survived.

Obstetricians preferred the vertex-first delivery should a craniotomy become necessary and so Stewart's colleagues practiced cephalic version in cases of breech representation. However, Stewart argues that podalic version should be considered and the greater portion of this paper is given to supporting his argument, clearly illustrated with the following table:


Vertex first.

Vertex last.
The head may be in a wrong position, which must be changed. The head at once assumes the correct position.
If the occiput is on the smaller side of the pelvis, it is hard to rotate. The difficulty is slight.
Difficulty in applying the forceps. The forceps not required.
Must make compression equal to the space taken up by the blades. Compression is unnecessary.
Loss of propulsive force which is directed at an angle to the superior strait. This force, being applied in a line perpendicular to the strait, no loss occurs, and the uterine contractions are stronger.
Traction must compensate for this loss. No compensation required.
Long continued pressure may produce vesical troubles, and injure the tissues. Delivery is necessarily rapid, and therefore these dangers are not so great.
Have time for traction. Have not, or will lose the child.
The forceps allowing unlimited tractile power to be used, the child's life is endangered by compression, of the brain &c. Being able to exercise the same power of drawing upon the neck like results may follow.
Traction is readily made. Traction is more difficult.
Have but little power applied from above. By pressure a force can be exerted upon the abdomen, equal to the tractile power.
The head cannot be moved except by the use of the forceps. By alternately flexing and extending the head, it can be made to pass the constricting points.
Craniotomy may be readily performed. This operation may be very difficult
No danger of irritating the uterus. In turning there is this danger.
No danger to be apprehended from pressure on the cord. There is danger unless the delivery be rapid.
The placenta will not be detached before delivery of the head. The child's life may be lost from this cause.

Regarding the ninth comparison in the table, Stewart maintains that the physical power of pulling on the baby's body in vertex-last deliveries is superior to the tractile power of the forceps in vertex-first deliveries. He further maintains that the neck can withstand a very large force from either direction :

I can bear testimony that on one occasion after having removed a great portion of the cranium of an infant and finding the shoulders apparently unable to pass the superior strait, one physician grasped the face and the remnant of the head, while another pulled upon a towel tied around its neck. These two, bracing themselves as best they could, used their combined strength to aid me in removing the shoulders, and yet the neck was not broken. If the neck of a dead infant will withstand such a force, will not that of a living, one, whose tissues possess the power of contractility, endure as much?

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