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Clinical consideration of the contracted pelvis
AMERICAN GYNECOLOGICAL SOCIETY
787
H. C. BuRGESS, Montreal, Que., (by invitation) presented a Clinical Consideration of the Contracted Pelvis. (For original article see page 739.)
DR.
DISCUSSION DR. W:IYI. E. CALDWEI..~L, l'tE\
7tJ8
THE _UiEitiCa:S ,JOURNAL 0£' 0B::\TETR1C::l 'eND SYSECOLOGY
,.±,uvv deliveries) whilst the .n1aLernal HH)I'tality .for ee;.;arean section is nearly _:J 'Jer cent. Our results from induction of labor in contracted pelves were so
DR. WM. C. DANFORTH, EvANSTON, !LL,,-The point which Dr. Burgess made l'i.;garding the great importance of prenatal exan1ination is ono which cannot be 'oo greatly emphasized. I have resorted to pushing the head into the pelvic inlet in order to determine v•hether or not the head would be likely to pass through, in our relatively con· tracted cases, but have not come to have quite the same confidence in it that ')r. Burgess apparently has. It is true that it will give us an idea as to the •_-elative size of the head as compared to the pelvis at the time at which th0 examination is made but it cannot tell us the degree of molding which we may 3xpect and upon this depends in many cases whether or not the head may pass 1:hrough. I agree entirely with Dr. Burgess' idea in regard to the management of case-; Di relative contraction so far as the labor is concerned. We have been accus· wmed to deliver those cases in which it seemed certain the head would not pass ihrough the pelvis by cesarean, using in these elective cases the classical section. In the borderline cases vre usually try a test of labor and this can be more e:ffe.e~ tively tried since the pel'fection of the cervical section which permits us to give :he patient an adequate trial of labor. Our experience with this operation has -:-,een linllted beeause our results with these cases have been quite like those Dr. !3urgess has spoken of; that is, 80 per cent of our relative eontractions deliver spontaneously or at least without the necessity of any abdominal interference. Dur recoveries after this operation have been very satisfactory. Ou:r experience with version ill the contracted pelvis corresponds with that which Dr. Burgess has described and we are not inclined to favor it. As to the induction of labor in contracted pelvis, I am not quite as enthusiastic. I take it that the primary reason for pregnancy and labor is ctd the essayist. ;hat a baby may be born which is not only alive but which may be brought up. T_t requires very careful judgment when induction of labor ahead of term is used uot to obtain s. certain percentage of babies which by reason of prematurity are Jompromised. We prefer therefore particularly in primiparae to allow labor to 'Jegin, using abdominal section in the minority which do not deliver normally. Dr. Burgess emphasized the value of a simpler classification of contracted pvlves. I agree thoroughly with this, and the shnp1er classification 1iVh:lch he gives c, CANADA.-! think as Dr. Bmgess does about the classification of pelves, for many students cannot learn the ordinary ~lassification and when they go out they never make any attempt to follow it. They steer clear of contracted pelves and the result is that many of these cases :tre not recognized and are not handled as they should be and after all, the proper ~umdling is the diagnosis early in the case.
DR. JOHN 0. POLAK, BROOKLYN.-A point which might probably be further 9mphasized, is the study of the individual patient, not only for stature, but for 0ther conditions. There are so many simple observations that suggest contraction; for instance, the length of the forearm, the shape of the thromboid, etc. As to fitting the head into the pelvis, it is not well understood what he really That can best be done, and should always be done where the l.lhJans by that.
AMERICAN GYNECOLOGICAL SOCIETY
789
dec1s1on is to be made between the infra-and supravaginal doliveiy, with the patient under an anesthetic, with the whole hand in the pelvis. Another point of importance is the incidence of craniotomies. Gradually in the East craniotomies have dropped out of use except in some of the larger clinics, and yet there is no operation that means so much to the mother in these neglected cases that are potentially Ol' fmnkly infected. I believe it is far better to do a craniotomy in those frankly infected cases than it is to take the risk of abdom· inal section.
DR. W. H. VOGT, ST. Lours, Mo.-I want to endoTSie practically everything that Dr. Bm·gess has said, chiefly his method of classificatron; likewise his very excellent method of treating contracted pelvis. So far as the test of labor is concerned, I am always reminded of what my old teacher, Professor Leopold, used to say, that whenever you decide to do a high forceps, don't carry the forceps in your. pocket but go home and smoke a cigar and in the meantime, when you come back, perhaps the baby will be born. This is true in many cases of so-called contracted pelvis cases; we are often surprised to find the baby born. Only reCBntly I saw a normal delivery occur when an operator was getting everything in readiness to do a cesarean section. We are frequently surprised to see what the forces of labor will do even in severely contracted pelves. The baby, too, should be considered as well as the contracted pelvis and I think that is a thing that we are overlooking right along. I know the attempt is not generally made to obtain an exact idea of the baby's head. Personally, I believe one can get a real idea as to the baby's head in relation to the pelvis, when proper measurements are made, but when we speak, about the moldability of the baby's head, we speak of something we know nothing about. I do not believe> any of us know whether a baby's head is going to mold into the pelvis or not; therefore, I believe it is necessary to know what the size of the head is in relation to the pelvis. I am convinced that we can obtain very reliable working ideas of the size of the head by external measurements as advocated by Perret some years ago. I have been practicing that method and after considerable experience find that the difference between the estimated and the true biparietal diameters does not vary over three-quarters em. I am likewise convinced of the fact that there is such a thing as a postmature baby, even though it is generally denied. Some tell us that "babies who weigh over eight' and a half pounds, are suffering from hypothyroidism. I:E that is a fact then there are a lot of hypothyroid babies born. I am sure that we are no longer proud of bringing big babies into the world. We used to go around boast· ing of nine and ten pound babies; but now we are mther ashamed to admit that, for large babies are usually delivered at the expense of the mother's health and welfare and often sacrificing the baby's life. DR. BlTRGE.SS, (closing).~.A. s regards Dr. Danforth not having satisfactory results by a pelvic examination under an anesthetic, all I can say is that we have found it of the greatest benefit. I attempt manually to engage the head in the pelvis, and when it is a tight fit to wait for a period of six or seven days and then induce labor. We never think of inducing labor unless we feel that we ·have an excellent chance of getting a living, viable child; but when you have a borderline case, with a patient two or three weeks from term, the giving of pituitrin and castor oil, or the putting in of a bougie (which I prefer to a bag) recommends itself as a reasonable operation.
787
H. C. BuRGESS, Montreal, Que., (by invitation) presented a Clinical Consideration of the Contracted Pelvis. (For original article see page 739.)
DR.
DISCUSSION DR. W:IYI. E. CALDWEI..~L, l'tE\
7tJ8
THE _UiEitiCa:S ,JOURNAL 0£' 0B::\TETR1C::l 'eND SYSECOLOGY
,.±,uvv deliveries) whilst the .n1aLernal HH)I'tality .for ee;.;arean section is nearly _:J 'Jer cent. Our results from induction of labor in contracted pelves were so
DR. WM. C. DANFORTH, EvANSTON, !LL,,-The point which Dr. Burgess made l'i.;garding the great importance of prenatal exan1ination is ono which cannot be 'oo greatly emphasized. I have resorted to pushing the head into the pelvic inlet in order to determine v•hether or not the head would be likely to pass through, in our relatively con· tracted cases, but have not come to have quite the same confidence in it that ')r. Burgess apparently has. It is true that it will give us an idea as to the •_-elative size of the head as compared to the pelvis at the time at which th0 examination is made but it cannot tell us the degree of molding which we may 3xpect and upon this depends in many cases whether or not the head may pass 1:hrough. I agree entirely with Dr. Burgess' idea in regard to the management of case-; Di relative contraction so far as the labor is concerned. We have been accus· wmed to deliver those cases in which it seemed certain the head would not pass ihrough the pelvis by cesarean, using in these elective cases the classical section. In the borderline cases vre usually try a test of labor and this can be more e:ffe.e~ tively tried since the pel'fection of the cervical section which permits us to give :he patient an adequate trial of labor. Our experience with this operation has -:-,een linllted beeause our results with these cases have been quite like those Dr. !3urgess has spoken of; that is, 80 per cent of our relative eontractions deliver spontaneously or at least without the necessity of any abdominal interference. Dur recoveries after this operation have been very satisfactory. Ou:r experience with version ill the contracted pelvis corresponds with that which Dr. Burgess has described and we are not inclined to favor it. As to the induction of labor in contracted pelvis, I am not quite as enthusiastic. I take it that the primary reason for pregnancy and labor is ctd the essayist. ;hat a baby may be born which is not only alive but which may be brought up. T_t requires very careful judgment when induction of labor ahead of term is used uot to obtain s. certain percentage of babies which by reason of prematurity are Jompromised. We prefer therefore particularly in primiparae to allow labor to 'Jegin, using abdominal section in the minority which do not deliver normally. Dr. Burgess emphasized the value of a simpler classification of contracted pvlves. I agree thoroughly with this, and the shnp1er classification 1iVh:lch he gives c
DR. JOHN 0. POLAK, BROOKLYN.-A point which might probably be further 9mphasized, is the study of the individual patient, not only for stature, but for 0ther conditions. There are so many simple observations that suggest contraction; for instance, the length of the forearm, the shape of the thromboid, etc. As to fitting the head into the pelvis, it is not well understood what he really That can best be done, and should always be done where the l.lhJans by that.
AMERICAN GYNECOLOGICAL SOCIETY
789
dec1s1on is to be made between the infra-and supravaginal doliveiy, with the patient under an anesthetic, with the whole hand in the pelvis. Another point of importance is the incidence of craniotomies. Gradually in the East craniotomies have dropped out of use except in some of the larger clinics, and yet there is no operation that means so much to the mother in these neglected cases that are potentially Ol' fmnkly infected. I believe it is far better to do a craniotomy in those frankly infected cases than it is to take the risk of abdom· inal section.
DR. W. H. VOGT, ST. Lours, Mo.-I want to endoTSie practically everything that Dr. Bm·gess has said, chiefly his method of classificatron; likewise his very excellent method of treating contracted pelvis. So far as the test of labor is concerned, I am always reminded of what my old teacher, Professor Leopold, used to say, that whenever you decide to do a high forceps, don't carry the forceps in your. pocket but go home and smoke a cigar and in the meantime, when you come back, perhaps the baby will be born. This is true in many cases of so-called contracted pelvis cases; we are often surprised to find the baby born. Only reCBntly I saw a normal delivery occur when an operator was getting everything in readiness to do a cesarean section. We are frequently surprised to see what the forces of labor will do even in severely contracted pelves. The baby, too, should be considered as well as the contracted pelvis and I think that is a thing that we are overlooking right along. I know the attempt is not generally made to obtain an exact idea of the baby's head. Personally, I believe one can get a real idea as to the baby's head in relation to the pelvis, when proper measurements are made, but when we speak, about the moldability of the baby's head, we speak of something we know nothing about. I do not believe> any of us know whether a baby's head is going to mold into the pelvis or not; therefore, I believe it is necessary to know what the size of the head is in relation to the pelvis. I am convinced that we can obtain very reliable working ideas of the size of the head by external measurements as advocated by Perret some years ago. I have been practicing that method and after considerable experience find that the difference between the estimated and the true biparietal diameters does not vary over three-quarters em. I am likewise convinced of the fact that there is such a thing as a postmature baby, even though it is generally denied. Some tell us that "babies who weigh over eight' and a half pounds, are suffering from hypothyroidism. I:E that is a fact then there are a lot of hypothyroid babies born. I am sure that we are no longer proud of bringing big babies into the world. We used to go around boast· ing of nine and ten pound babies; but now we are mther ashamed to admit that, for large babies are usually delivered at the expense of the mother's health and welfare and often sacrificing the baby's life. DR. BlTRGE.SS, (closing).~.A. s regards Dr. Danforth not having satisfactory results by a pelvic examination under an anesthetic, all I can say is that we have found it of the greatest benefit. I attempt manually to engage the head in the pelvis, and when it is a tight fit to wait for a period of six or seven days and then induce labor. We never think of inducing labor unless we feel that we ·have an excellent chance of getting a living, viable child; but when you have a borderline case, with a patient two or three weeks from term, the giving of pituitrin and castor oil, or the putting in of a bougie (which I prefer to a bag) recommends itself as a reasonable operation.