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[The Science and Art of Obstetrics, by Joseph B. DeLee, M.D. ]
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[These pictures were taken at the Chicago Lying-in Hospital in affiliation with the University of Chicago.]
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[…]
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[Dr. DeLee:] Ladies and gentlemen, today we will talk on the forceps operation,
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and we will begin with a brief pictorial history of the instrument.
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May we have the slides, please.
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Jan Palfijn, anatomist and surgeon-obstetrician of Kortrijk, Belgium invented a forceps in 1720.
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He walked the 180 miles to Paris to publish his blessing for womankind.
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True, an Englishman, son of a French Huguenot, named Peter Chamberlen, about 1580 devised a good forceps,
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but he and his descendants kept it a trade secret.
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Chamberlen has no monument, but Palfijn is remembered.
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In Ghent, a pregnant woman weeps on his tomb.
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And in Kortrijk, his birthplace, stands this heroic bronze.
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Next, please.
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Here is the crude instrument he contrived, a pair of heavy iron spoons, placed parallel and tied with a handkerchief when used.
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[…]
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Chamberlen’s forceps, a very practical instrument, discovered in an old garret in 1815.
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It is too bad the family did not give it to humanity.
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This round forceps dates 150 years before Christ.
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The Royal College of Surgeons and the Wellcome Historical Museum of London
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kindly let me photograph the forceps in their collection.
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Rueff forceps, 1522.
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Note impractical lock. The hook, probably for dead fetuses.
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Pugh’s forceps, an English forceps with the pelvic curve, 1740, the English lock.
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Levret’s forceps, a French long instrument.
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Levret also invented a pelvic curve, and the French screw lock.
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Busch’s forceps. Busch added the hook on the handle to facilitate traction,
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and introduced the German or pin lock.
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The great William Smellie of Scotland, about 1750, invented several forceps,
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a crude wooden affair and others both short and long. All covered with soft leather.
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Levret, a contemporary, objected to the leather, saying it could convey infection.
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A few bizarre models, hook for the breech.
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Anterior/posterior blade. Anterior/posterior blade, English lock.
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End is padded, like fingers for a rotation, possibly.
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Isometric blade.
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Ring for easier traction.
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Asynclitic blades for asynclitic heads.
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Barton forceps, 1928. See the hinge on the anterior blade.
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With this instrument you can pull down in the axis of the inlet.
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A three-bladed forceps with a hinge here.
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Don’t invent a pair of forceps until you have seen the 600 models published by Kedarnath Das of Calcutta.
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A vest pocket model, folded.
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A combination vectis sharp and blunt hook.
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The genial Simpson, who gave women anesthesia and did much else for obstetrics.
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I recommend his forceps presented in 1848.
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We now come to the important principle of axis traction.
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The pelvic floor curve prevents us from pulling down in the axis of the inlet with the ordinary forceps.
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Older obstetricians, in order to get around this pelvic floor curve, invented instruments that had crooked shanks or bent levers, like this.
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When you pull in the axis of the inlet with the ordinary forceps, part of the fork is exerted against the pubis, damaging the pubis,
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the head, the vagina, and cervix, and the bladder, particularly the bladder.
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When you use this kind of an instrument, you can secure axis traction, avoiding these damages.
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This is the first axis traction instrument.
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Pulled down through the handle, this pump arches the perineum.
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Note the hinges in the blade, this confers mobility on the head, lets it work up and down.
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This is a bent-lever forceps. This is the arch for the perineum.
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You pull on the handle here.
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Tarnier of Paris did the most for the axis traction principle and invented a hundred models of forceps.
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But now, hardly anybody uses them, because the high forceps operation is being done very little.
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This is his first model, a rather clumsy instrument, with numerous bends.
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This, his latest model.
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Force applied here at this joint, through this joint, to the head.
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A rather inartistic procedure, in my opinion.
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Lights, please.
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I will now show you how we can obtain axis traction with the ordinary or straight instrument.
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Here is the inlet. This is the axis of the inlet.
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This is the pelvic floor curve. We want to pull in this direction.
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First we do a deep episiotomy. That obliterates the pelvic floor curve and straightens the canal.
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Then, aided by Pajot’s maneuver, we can pull down, and around, and out, and make the head follow the path of least resistance.
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Saxthorpe in 1772 devised a movement by combining traction downward, outward, and upward at the same time.
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Pajot popularized it. And I will show it to you on this model.
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You pull down, here and you pull upward and out there.
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And with each traction, you fuse the two motions into one smooth movement, like this.
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In 1915, Kielland of Norway, over there it is pronounced Jelland, invented this instrument.
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Like all modern forceps, it embodies principles discovered by the pioneers.
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It is recommended for the high transverse head, in face and brow presentation,
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in occipital posterior as a rotator, and when the head is asynclitic.
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The instrument is getting considerable vogue.
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And I use it occasionally, but not often.
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This is Sir James Y. Simpson’s forceps, the one that I recommend to you for general practice.
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I have made the shanks longer to keep the operating hand away from the infected anus.
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And also to make it a more universal instrument for high, as well as low operations.
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I also lightened the handle, so as to balance the instrument more evenly.
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Now, gentlemen, it is not the forceps, but it is the man behind the forceps that counts.
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And if you will know the anatomy of the pelvis, and the mechanism of labor,
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you will be able to do with this instrument, everything that it is safe to do with any other.
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Now, before going on to the forceps operation, I want to tell you about episiotomy, which I do in all primipari and many multipari.
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It not only saves the baby’s brain from compression and congestion, but it also
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preserves the pelvic floor and the connective tissue framework of the pelvis.
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And you know, damage to this structure often results in rectocele, cystocele, and descent of the uterus.
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You will watch an episiotomy on the living much more understandingly
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if you first see it done on these models.
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I prefer the medial lateral episiotomy. Squeeze the sphincter away.
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Begin in the middle line. I am cutting the skin and urogenital septum.
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This exposes the intercolumnar fascia.
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I am separating the vagina from the fascia.
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I am cutting the vagina.
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I cut the intercolumnar fascia on the levator ani pillar, higher up than the episiotomy,
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in order to leave a larger portion of the levator on the rectum. It is easier to sew.
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That is the urogenital septum. That is the other side. There is the cut fascia, and here the other side.
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I am now cutting the levator ani muscle itself, a little nick for a small baby,
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much deeper for a large baby, or a rigid pelvic floor.
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The levator flattens out as you cut it. Remember that when you sew.
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Here lies the sphincter ani, but in life you can’t see it unless it is torn.
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We will now do the repair.
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I use figure of eight silkworm gut. And I recommend it, because I believe it is the best for general practice.
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The first vaginal suture, sew the vagina high in the pelvis where it belongs.
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Take care to include the fascia.
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This is the holding stitch, it keeps the vagina out of the way.
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Now, lift up the intercolumnar fascia and the levator with Allis forceps.
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The finger goes into the rectum to push the rectum up into the pelvis and to prevent the needle
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from going through the mucosa of the rectum.
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The deep loop of the first suture is in, the second of the figure of eight stitches.
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The three figures of eight are now in.
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We cross the stitches, being careful not to lock them in the depth of the wound.
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Now, for the outer loop of the figure of eight.
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Pull out the urogenital septum from its retracted position.
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Get a good bite of the tissue so as to close off dead spaces in the bottom of the wound.
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Dead spaces breed infection.
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Pull out the tissue, take a little of the fascia here to close off the ischiorectal fossa.
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This is the second loop of the first figure of eight.
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[…]
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The second loop of the second figure of eight.
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Always take a little fascia here to close dead spaces.
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They fill with blood and breed infection.
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[…]
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The wound gapes a little at the bottom.
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Put in a stitch to close the ischial rectal fossa.
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Pull out the tissue carefully on the right, be a little careful of the sphincter.
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A traction diverticulum may be punctured.
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[…]
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Now, for the important crown feature. It prevents a gaping vulva.
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We will use a larger model here.
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Skin constrictor coming…pull it out. It retracts into the depths of the wound.
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[…]
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The fascia under the vagina…be careful, don’t puncture the vagina.
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[…]
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Now, the same on the right side.
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Pull the tissues out, take a good big bite.
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[…]
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Vaginal holding stitch. Twist all of the sutures into a bundle with a knot so they stand up away from the anus.
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Cut close to the knot so that the ends do not hurt the patient.
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[…]
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[Nurse:] Dr. Davis wishes you in the birth room please.
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[Dr. DeLee:] Thank you. A primipara, age 38, married 10 years, in labor.
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Membranes ruptured 20 hours,
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first stage 18 hours, second stage two hours, occiput right, 90 degrees.
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Station plus 2.
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Deep transverse arrest. No progress.
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Fetal heart tones 160, 120, 140.
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The heart rate does not always tell us what we would like to know about the baby.
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I think forceps is indicated. Davis.
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A second stage lasting two hours, that means that Davis
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has been waiting for spontaneous, anterior rotation to occur.
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It has not, and dangers are beginning to accumulate.
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Remember, prolonged labor has many harmful effects, both physical and biochemical.
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Some temporary, and some permanent on both mother and child.
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Let us adjourn to the birth room, and in the meantime, you might be thinking over the indications and the conditions for forceps.
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[…]
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Before deciding to operate, you must always make your own diagnosis.
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Uterus, rather rigid and tender. Occiput right transverse.
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The left round ligament, somewhat tender. Tense.
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The right round ligament, also.
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That is the retraction ring, near the navel, that’s normal.
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You can count the heartbeat.
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[Sound of baby’s heartbeat]
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About 100, strong, regular. But we know her heart is normal, and her other organs too.
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She has been given good prenatal care and has been prepared physically and mentally for her ordeal.
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The doctor must know the exact condition of his patient, as she stands on the threshold of her labor.
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Has she been having been pains like that very long?
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[Dr. Davis:] Yes, over two hours, but she is discouraged, her pains do no good, and her efforts are getting weaker.
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[Dr. DeLee:] It looks like a good size baby, I’d guess about 9 pounds.
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High up, I feel a rim of cervix left. Only a rim.
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The vaginal suture is in the transverse diameter.
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Small fontanelle on the right, large fontanelle on the left.
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Synclatism perfect.
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Deep transverse array.
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Oh, yes, dehydration. Tongue is rather dry.
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I thought I’d missed a beat, but no.
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Her color is good.
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I’d like to wait for a complete rotation, but progress has stopped.
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The woman is 38, and we must think of the baby too.
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The conditions are all satisfied.
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There is no disproportion between the head and the toes.
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The bag of waters is ruptured.
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The child is living. The cervix is dilated, fully.
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The head is engaged, well-engaged.
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We do not wait to see what the woman can endure, but what she can accomplish,
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Barnes of London said that.
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We will start the anesthetics when we are nearly ready.
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Use as little anesthesia as possible.
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We often use pudendal, or local.
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Watch the heart tones, there is a tendency to abruptio placentae at this time.
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Primum non nocere.
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First of all, do no damage.
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Non vi sed arte.
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Not with force.
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[Baby crying ]
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There are seven things to do before leaving the house.
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Don’t forget them.
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One, two, three, four, five, six, seven.
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One, see that the uterus is hard and not inverted.
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The uterus is firm below the naval.
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Examine both broad ligaments.
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You may find a hematoma or a twisted ovary. Rare, but worth thinking about.
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See the contraction of the uterus beginning.
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Two, see that there is no hemorrhage, external or internal.
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No, the pad is dry.
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Three, see that the placenta is complete.
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Well, we’ve done that.
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Four, see that all lacerations are attended to.
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We’ve done that.
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Five, see that the bladder is empty.
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We have emptied it.
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Six, see that the mother is in good condition.
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Her pulse is good,
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better than it was at the beginning of the operation.
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Her color is good. She has not lost much blood.
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Seven, see that the baby is in good condition.
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Miss Carman says it is.
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Everything is fine.
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How much did the baby weigh?
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[Nurse:] Eight pounds, nine ounces.
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[Dr. DeLee:] You see the head is drawn out, Dolichocephalus.
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Typical molding for ODT.
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Those marks on the baby’s head, those red streaks,
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will disappear in a few days.
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They show that the forceps were lying in the proper position.
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The right parietal lies a little bit under, uh, over the left.
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It is a boy, and since we have delivered him without damage to his brain, he ought to make a good citizen.
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Ladies and gentlemen, I will meet you tomorrow and we will discuss this case further. In the meantime, ponder over what you have seen.
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Good morning. Our patient of yesterday is doing very well, and so is the baby.
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The older obstetricians, when they reported their cases, used to write down their reflections.
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What they did right, what they did wrong, and what they would do if they had the case to do over again.
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Let us review some of the things we did yesterday. First the rotation.
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The baby lay occipital right posterior, occipitodextra 135 degrees.
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Nature had brought the occiput into the transverse, where the rotation was arrested.
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I simply completed the rotation, bimanually, and applied forceps like this.
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Occiput right 135 degrees.
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The small fontanelle must travel 3/4 of a half-circle.
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[…]
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Push the head up out of its embedment in the narrow pelvic region.
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Turn it by combined manipulation.
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[…]
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Hold the head by either hand, or a light clamp such as an Allis forceps, affixed to the scalp while you apply the blade.
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I always try to do with my hands everything possible. The fingers have eyes.
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A few words about the key and lock maneuver. Nature, when she advances the head through the birth canal,
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forces it down, turns it a little to the front, and relaxes.
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The head lowers in the pelvis, rotates a bit, and then retreats.
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And thus, in gradual stages, the occiput is brought to the front under the pubis.
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When we try to imitate nature in persistent occiput posterior, and fail with our fingers, we have to use forceps.
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And the movements we impart to the instrument, resemble those we use when we try to turn a key in a stubborn lock.
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That is why I called it the key and lock maneuver. Perhaps some of you will give me a better name for it.
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Let us do the little operation on this half pelvis.
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Occiput, right posterior. You may have to apply the forceps obliquely.
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Push up a little, twist a little, pull down a little. Readjust the blade.
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Push up a little, twist a little, move down a little, readjust the blade.
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You adjust, you bring the occiput around in easy stages, 10 or 15 degrees of the circle each time.
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The rotation being completed, from now on the case is the usual low forceps operation.
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[Observer:] Doctor? Is it always so easy to locate the head?
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[Dr. DeLee:] Oh, no. Sometimes it is very hard.
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You may have to push the head up out of the pelvis, and rotate the back to the front, or even to the opposite side of the abdomen, like this.
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[…]
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Left occiput posterior this time. Raise the head above the inlet.
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Gently! Force is dangerous. Spread the fingers over the shoulders and back.
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This is the back.
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Turn the back to the front. Carefully.
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Lead the head down into the pelvis with both hands
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or draw it into the pelvis with forceps, perhaps leaving the case then to nature.
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Rarely, in transversely contracted pelves, the anthropoid type,
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It may be better to deliver the occiput posterior as such, over the perineum. But as a rule, it is best to do the rotation.
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Again, it may be impossible to effect delivery with the forceps.
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And then, you should not use dangerous force, but consider the three alternatives.
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First, version. Now, version is an unorthodox procedure, after you have tried the forceps.
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Second, craniotomy.
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Third, laparotrachelotomy.
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[Observer 2:] Doctor, why do you prefer silkworm gut?
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[Dr. DeLee:] Some of you may think I am old-fashioned, because I use and recommend
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the figure of eight silkworm gut stitches in the perineum.
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But, long experience has convinced me that it is the safest for general practice.
00:31:49 – 00:31:54
True, catgut makes prettier wounds and does not hurt the patient so much.
00:31:54 – 00:32:03
But remember, we obstetricians are working in an infected field, between feces and urine.
00:32:03 – 00:32:09
Remember too that catgut is treacherous. It sometimes is absorbed too quickly.
00:32:09 – 00:32:12
And furthermore, the knots uncurl.
00:32:12 – 00:32:18
Third, I use catgut, but only in a perfectly aseptic environment.
00:32:18 – 00:32:20
Fourth, drainage.
00:32:20 – 00:32:27
If you have sewn a wound with catgut, and it becomes infected, it is very hard to drain.
00:32:27 – 00:32:33
Whereas, if you have used silkworm gut, you cut the stitches and then you can lay the wound wide open to the bowel.
00:32:34 – 00:32:38
[Observer 3:] Doctor, why did you forbid Kristeller expression?
00:32:38 – 00:32:44
[Dr. DeLee:] Kristeller expression interferes with the mechanism of labor and may hurt the baby.
00:32:44 – 00:32:52
Second, it mashes the placenta, and disturbs the mechanism of the placental delivery.
00:32:52 – 00:33:00
Third, it bruises the uterus, and bruises invite infection, thrombosis, and embolism.
00:33:00 – 00:33:03
Fourth, it is unnecessary.
00:33:03 – 00:33:10
To me, it appears brutal, midwifery, not obstetrics.
00:33:10 – 00:33:19
I have yet to take up forceps in cases of face and brow presentation and other mechanisms.
00:33:19 – 00:33:25
But today I will show you a case of forceps on the aftercoming head.
00:33:25 – 00:33:32
Mrs. L, age 29, primipara sacral left, transverse.
00:33:32 – 00:33:37
I did a complete extraction. The film, please.
00:33:40 – 00:33:47
Anyone wants a more convincing demonstration of the indispensability of the tracheal catheter,
00:33:48 – 00:33:52
and of the value of the forceps on the aftercoming head.
00:33:52 – 00:33:55
Now, ladies and gentlemen, in conclusion.
00:33:56 – 00:34:05
This instrument is one of the most beneficent gifts that the art of medicine has given to humanity.
00:34:05 – 00:34:12
Correctly indicated, and skillfully applied, it fulfills its primary function,
00:34:12 – 00:34:19
which is to deliver the baby, by the head, without injury to it or its mother.
00:34:19 – 00:34:26
Indeed, we may go a little further. In expert hands, and in a proper environment,
00:34:26 – 00:34:37
it may be used to diminish those injuries which even natural labor sometimes inflicts upon the mother and child.
00:34:37 – 00:34:43
And this is what I tried to do with the prophylactic forceps operation.
00:34:43 – 00:34:50
On the other hand, if the instrument is used indiscriminately, without proper indication,
00:34:50 – 00:34:58
and before the conditions are all satisfied, it can work irreparable damage on both mother and baby.
00:34:58 – 00:35:05
The operation of forceps itself, can be developed to the highest point of technical beauty and safety.
00:35:05 – 00:35:10
And this will help to raise the art of obstetrics to a high level
00:35:10 – 00:35:16
and confer upon it that dignity which the science of obstetrics has prepared for it.