Frequency, etiology and practical significance of contractions of the pelvic outlet / by J. Whitridge Williams.

  • Williams, J. Whitridge (John Whitridge), 1866-1931.
Date:
1909
Catalogue details

Licence: In copyright

Credit: Frequency, etiology and practical significance of contractions of the pelvic outlet / by J. Whitridge Williams. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    ticularly in the earlier literature, only such cases were described as had given rise to serious dystocia; while in the second many of the cases had occurred in pre-antiseptic times and therefore were much more likely to suc- cumb to infection than at present. The cor- rectness of this supposition is borne out by Walther’s personal experience, as there were no foetal or maternal deaths in the seven cases which he observed. Turning to my own experience, 122 examples of outlet contraction were observed in 1,200 consecutive pregnant women, which were classified as follows: 83 typical, 34 generally contracted, and 5 irregular funnel pelvis. One hundred and three of the patients were delivered at or near full term without a death, while 7 of the children were lost. Five of them were born in a macerated condition and consequently their death could not be attrib- uted to the condition of the pelvis; while one of the other two children perished during ver- sion and extraction from an transverse pres- entation, and the other from craniotomy upon the after-coming head following an attempted, rapid extraction, necessitated by prolapse of the cord. Our results might be construed as indicating that the condition is practically devoid of dan- ger, but closer study of our material shows that such is not the case, as a large number of children would apparently have been lost had the condition not been recognized and appro- priate treatment instituted. Moreover I have indicated that the funnel pelvis is a potent factor in the production of complete perineal tears, a frequent cause of prolonged arrest of the head of the vulva, and occasionally may give rise to most serious dystocia. In the 69 full-term labors complicated by typical funnel pelvis, 9 low forceps operations and one pubi- otomy were rendered necessary by the con- traction of the outlet, while in the 29 cases complicated by generally contracted funnel pelvis, two pubiotomies, one low forceps opera- tion and one craniotomy upon the after-coming head were indicated. Moreover the histories of the multiparous women showed that in previous labors many children had been born dead, as the result of fracture of the skull or following craniotomy. Unfortunately, in the individual case, it is impossible to prognosticate the outcome of labor merely from the size of the antero-pos- terior or transverse diameters of the outlet, and it therefore becomes essential to take into consideration the length of the posterior sagittal diameter. On page 627, I have given the minimum length which it must present with varying degrees of shortening of the transverse diameter in order to render spontaneous labor possible. Accordingly it is only necessary to repeat in this place that a reduction to 8 cm. in the distance between the tubera ischii should be regarded as a danger signal, and as an ur- gent indication for the most thorough study of the pelvis before attempting any operative procedure, as neglect in this regard may con- vert what promises to be an easy low forceps delivery into a most difficult operation, which can be completed only by the sacrifice of the child and occasionally of the mother as well (Figs. 6 and 7). Generally speaking, it may be said that the prognosis is somewhat more favorably in black than in white women, owing to the smaller size and greater malleability of the heads of colored children. Likewise it is somewhat more serious in the generally contracted than in the typical type of funnel pelvis, for the reason that in the former dystocia may occur in all portions of the pelvic canal, while it is limited to the outlet in the latter. At the same time the prognostic import in the former con- dition may be less serious than the pelvic measurements would appear to indicate, as the imperfect general development which has resulted in the pelvic deformity may likewise manifest itself in a somewhat smaller-sized child. It should, however, be remembered that such considerations are merely of a general character, and while they hold good in a large series of cases, may nevertheless lead to erron- eous conclusions in the individual woman. Treatment. As has already been indicated, a reduction in the length of the transverse diameter to 8 cm. should be regarded as a danger signal, although the actual outcome of the case can be predicted only after taking consideration the size and malleability of the child’s head, and more particularly the length of the posterior sagittal diameter of the outlet.