Delivery may be effected by the natural forces. After the birth of the trunk of the first twin the second is born, and then only the head of the first. As a rule, however, operative interference will be necessary. It is useless to attempt to push back the head of the second and to draw upon the trunk of the first. The second head must be extracted by means of the forceps, and the first then follows spontaneously. In case of failure the second head must be perforated, as the first cannot be reached.

It is far more rare for both heads to enter the pelvis together— the head of the second applied to the neck of the first. The impediment to labour is not so great in such a case, and it can scarcely be recognised before the birth of the first head. As both heads can be successively extracted by means of the forceps, this procedure appears to be most rational and quite sufficient.

II. ABNORMALITIES OF THE FETAL APPENDAGES

The birth of the foetus is rarely, and in a slight degree only, impeded by abnormalities of the membranes.

Great thinness of the membranes may favour their premature rupture. The consequence is that the greater portion of the liquor amnii escapes, whilst the presenting part is still movable above the brim. Usually, however, so much water remains within the uterus that the mechanical process of labour is not interfered with. But where labour is greatly protracted by complications and especially by a pelvic contraction-air may enter the uterus during the repeated manual examinations and displace the waters contained in it. The maternal soft parts may thereby become dry, the expulsion of the fœtus is delayed, and thus irritation and inflammation of the uterus, vagina, and vulva, are produced. In the narrow pelvis unnecessary examinations must therefore be avoided when the membranes have prematurely ruptured. A moderately filled caoutchouc bag should be placed in the vagina, and the woman should lie on her side or back. The rest of the liquor amnii is thereby pent up and only a small quantity escapes during a pain, and the uterine action is increased.

Great thickness of the membranes and their firm adhesion to the lower uterine segment may greatly impede the course of labour. The causes and treatment of this anomaly have been already mentioned.

Too small a quantity of liquor amnii will scarcely be able to delay labour under otherwise normal conditions, whilst too great a quantity may impede it in various ways. It especially favours malpositions of the foetus, and the contractions of the uterus are usually deficient.

Labour may be unfavorably influenced by a too short umbilical cord. This is either absolute or produced by coils around the foetal body. In head positions before the birth of the head, the cord can scarcely exert such an influence, because in each pain the contracting uterus follows the progress of the head. At least the symptoms, which are said to point to a short funis, as recession of the head in an interval, fixed pain, and discharge of blood, are not at all reliable. The head always recedes after a pain, when the soft parts

of the floor of the pelvis offer a great resistance, which is especially the case in primiparæ. A fixed pain at one spot of the uterus is not rare. It is probably due to an irritation of a circumscribed spot of the peritoneum, and it is very doubtful, indeed, whether it can be produced by dragging upon the umbilical cord. The escape of blood may proceed from lacerations of the os, but, independently of that cause, it is merely a sign of partial or complete detachment of the placenta, which is very rarely effected by a too short umbilical cord. If, however, the funis were too short prior to the birth of the head, it would rather tear or cause detachment of the placenta, than prove an impediment to labour. We admit that this anomaly of the cord may be instrumental in producing an abnormal rotation of the head as well as a short delay in labour. Usually, however, it is after the birth of the head, and especially of the shoulders, that the complete expulsion of the child, which is accomplished by the vagina, is delayed by a short funis, unless the placenta is detached. The tension of a coil will show that the shortness of the funis is due to it, and an examination will show if the cord is absolutely too short. In such cases the funis is divided before the child is completely expelled. The fœtal end is either ligatured or compressed by the fingers.

A too short cord is more frequently met with in breech positions, especially when it passes between the thighs (the child rides on it). After the birth of the breech it is often easy to push the cord aside over one buttock; but if this be neglected the funis may be so stretched along the perinæum of the child, that it must be divided before the trunk and head can be born. When the cord is in its natural position, it is rarely so short as to be stretched in cases where the breech presents. The treatment is here also the same; it is

evident that after the division of the cord the child is to be imme

diately extracted. We have spoken elsewhere of the delay in the labour caused by the retention of the placenta.

Literature.-Hhol, Die Geburten missgestalteter, kranker und todter Kinder. Halle, 1850.-Playfair, Obstetrical Transactions, VIII, p. 300.-Hohl, 1. c.— Joulin, Des cas de dystocie app. au foetus. Paris, 1863.-Denman, Londoner Medical Journal, Vol. V, 1785, Art. V, p. 371-Douglas, Explanation of the Real Process of the Spontaneous Evolution, &c., 2 ed. Dublin, 1819.--Gooch, Medical Transactions, VII. London, 1820, X, p. 230.-W. J. Schmitt, Rheinische Jahrb., B. III, St. 1. Bonn, 1821, p. 114.-Hayn, Ueber die Selbstwendung Würzburg, 1821.-D. W. H. Busch, Geburtsh. Abhandl Marburg, 1826.Betschler, Ueber d. Hülfe d. Natur z. Beendig. d. Geb. bei Schiefl. d. Kindes, Klinische Annalen, II, p. 197.-Birnbaum, M. f. G., B. 1, p. 321.-Haussmann. M. f. G., B. 23, p. 202 and p. 361.-O. Simon, Die Selbstentwicklung, D. i. Berlin, 1867.-Barnes, Obstetrical Operation, 2 ed., p. 107.-Kleinwächter, Arch. f. Gyn., B. II, p. 111.-Credé, Verh. d. Ges. für Geb. in Berlin, IV, p. 153.Pernice, Die Geb. mit Vorf. d. Extrem. neben d. Kopf. Leipzig, 1858.-Kuhn, Wiener Med. Wooch., 1869, Nr. 7-15.-Hohl, Nene Zeitschr. f. Geb., B. 32, p. 1-Joulin, Des cas de dystocie app. au Foetus. Paris, 1863, p. 83.-Kleinwachter, Lehre von den Zwillingen. Prag, 1871, p. 167.

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CHAPTER IV

ANOMALIES OF PARTURITION WHICH DO NOT IMPEDE THE MECHANISM OF LABOUR

1. COMPRESSION OF THE UMBILICAL CORD

WHEN the umbilical cord lies in the usual way, and we must consider its coiling round any part of the fœtus as usual on account of its very great frequency, it is very seldom so much compressed that the circulation in it is impeded, and the fœtus in consequence becomes asphyxiated and dies. As long as the membranes remain intact, as Lahs correctly observes, no such one-sided pressure takes place within the membranes. The general internal pressure of the uterus remains the same, whether it acts directly through the walls of the uterus or mediately through the liquor amnii. The form restitution power of the uterus exerts, indeed, a one-sided pressure, and although it may be able to compress the funis lying between the breech and the fundus, or between the head and the lower uterine segment, yet it is hardly strong enough to stop the circulation in the umbilical vessels; therefore, as long as the membranes remain intact, the cord is only exposed to compression when by the powerful action of the abdominal pressure the head, surrounded by the lower uterine segment, is forced into the small pelvis. The funis is then tightly squeezed between the head of the foetus and the pelvis covered by the wall of the uterus. If parturition has so far advanced that the head has passed out of the uterus into the vagina, the cord lying close to the head may also be compressed between the head and the pelvis by the force of the uterine contractions. This most frequently occurs in the stage of expulsion, when the funis is coiled around the neck, and this is pressed for some time against the posterior surface of the symphysis. Veit has shown that disturbances of the foetal respiration are two to three times more frequent when the cord is coiled than in any other position, but that death in such cases is only relatively rare, because the danger occurs a short time before birth.

The prolapsed funis far more frequently suffers such compression as to endanger the life of the foetus.

The funis is said to be prolapsed when, after rupture of the mem

branes, one or more coils are lying in the os, the vagina, or outside the external genitals. It is said to present when, before the rupture of the membranes, it can be felt lying in the os behind the membranes.

The prolapse of the cord is of varying significance, according to the presentation of the fœtus. It will, accordingly, be necessary to consider each separately.

In head presentation in primiparæ the lower uterine segment normally surrounds the head, which at the commencement of labour has already entered the small pelvis, so closely that a prolapse of the cord is actually impossible. The entrance of the head into the pelvis, and the accurate adaptation to it of the lower uterine segment, are, in some cases, impeded by an abundant quantity of liquor amnii or by twins, most frequently, however, by a contracted pelvis. Consequently prolapse of the cord in head presentations in primiparæ is almost always dependent upon a contracted pelvis. In pluripare the head is often at the commencement of labour still high up and easily movable, even over the normal inlet, and it consequently happens that in pluriparæ the cord is often projecting behind the membranes. When there is not too much liquor amnii and the membranes rupture at the proper time the presenting cord is, as a rule, pushed aside by the head entering the pelvis; but the presenting cord prolapses if there is hydramnios, which retards the entrance of the head, or if the membranes rupture too early, before the head is closely surrounded by the lower uterine segment. The same occurs when, for some other reason, as an upper extremity lying close to the head, the lower uterine segment is prevented from closely surrounding the head, and thus allows the necessary space for the prolapse of the cord by the side of the head. Shortness of the cord and loops in it hinder its prolapse, and this the more easily the higher up in the fundus the placenta is inserted. On the contrary, low insertion of the placenta plays an important part in the causes predisposing to prolapse of the funis. As a rule the cord prolapses when several of the predisposing causes occur at the same time; for instance, when the membranes are ruptured the head is situated on one side of a contracted pelvic inlet, the cord is long and without loops, and inserted low down in the uterus.

Diagnosis. When the membranes are tightly stretched it may not be possible to feel the presenting cord, but in the interval between the pains the soft pulsating cord can almost always be detected behind the membranes. Prolapse of the funis is, of course, much more easily detected, yet it may also be overlooked in an insufficient examination, when, for instance, only one coil projects close to the periphery of the head.

Except in those rare cases where the projecting cord is so tight that the advancing head exerts considerable traction on the placental insertion, prolapse of the funis is without the slightest consequence to the mother. To the child it is one of the most dangerous complications, and in head presentations, without suitable assistance, it almost always causes its death. The danger to the child does not follow from the abnormal position of the cord, but because the prolapsed cord is much more frequently and more easily than one in a normal situation exposed to pressure, which stops the circulation.

In head positions the head is so closely applied to the pelvis, that the cord lying between them is always compressed; moreover, the passage of the head through the pelvis takes, as a rule, so long that the child dies during the time from the impediment to the placental circulation.

The treatment varies greatly, according to the progress of the labour.

If the cord presents behind the membranes, everything must be done to delay the rupture of the membranes as long as possible. For, as long as the membranes are intact, the cord can still be pushed aside, and when prolapse has actually taken place it is much less dangerous when the os is fully dilated than when it is only slightly so. The examination must be made gently, and not at all during a pain. A moderately filled caoutchouc bag is to be placed in the vagina in order to offer counter-pressure to the membranes. Much is gained if the rupture of the membranes is delayed until the os is sufficiently dilated. For usually the presenting cord spontaneously retires when the head enters the pelvis. Exceptionally it does not retire, and it is then exposed to dangerous pressure between the head and the pelvis. If the membranes are still intact, attempts must be made to push the cord back, or the head must be pushed to one side in order to remove the pressure from the cord. If all these attempts fail, nothing remains but to rupture the membranes, and to act upon the principles about to be given.

Matters are worse when the cord is prolapsed after the premature rupture of the membranes, and the os is only slightly dilated. Immediate delivery is impracticable without the greatest danger to the mother. The preservation of the child depends alone in protecting the cord from dangerous pressure until the woman is delivered by the forces of nature or by art.

Reposition of the cord is the most natural way of preventing the pressure. Under these circumstances this may be very difficult. If the os will admit only one or two fingers the cord may be pushed back a little, but on withdrawal of the fingers it always comes down again. It must therefore be carried higher up into the uterus by means of instruments, in the expectation that the cord will adhere to something, or that the head may in the meantime be firmly impacted in the inlet, or that the cord by a suitable posture of the woman may be prevented from again coming down. To effect reposition a number of instruments have been devised, of which Braun's is the most simple and the most practical. It consists of a small caoutchouc rod, with a hole at the thinner end, through which a double cord passes. The coil of the funis is placed in the latter, and the loop of the cord is put over the tip of the rod. The rod with the umbilical cord is now introduced high up into the uterus. In withdrawing the rod the loop of the cord is displaced from the tip of the rod, and the coil of the funis falls out. In the dorsal position of the woman, however, the funis only remains in the uterus when it happens to fall over one of the extremities, or when in the meantime the head has firmly entered the pelvis. Roberton's instrument appears to be more effective, because by it, as in similar older methods, the funis is permanently retained at the fundus. It consists of a thin caoutchouc tube about forty centi