H. —31.

The Excessive Use of the Midwifery Forceps. The second subject of clinical interest is the abuse of the midwifery forceps. That any gross abuse is far from general is shown by the following table, in which is given the percentage rates of application for the past three years in the different classes of hospital : —

I think that 6 per cent, might not unfairly be regarded as the rate which ante-natal care and the proper management of the first and second stages of labour should render possible without causing unnecessary suffering or injury to mother or child. If so, then there is still room for a considerable reduction. It will be noted that, while the rate in hospitals with less than fifty confinements in the year is steadily increasing, the rate in the other hospital groups is steadily falling. It is probable that the patients who are confined in the first group of hospitals are those who receive the least amount of ante-natal care and first-stage supervision. There are various factors which suggest themselves to explain an unduly high rate. The first, and perhaps the most obvious, is lack of obstetrical experience. Then come such reasons as undue anxiety on the part of the medical attendant, undue pressure by the patient's relatives, unsatisfactory management of the first stage of labour, insufficient use of the various means of lessening pain during both the first and second-stage. It will be noted that all the reasons given in the last sentence might have been grouped under the head of obstetrical inexperience, but unfortunately they also are to be found existing separately when lack of experience should have ceased to exist. It is possible to suggest a remedy in such cases if the medical practitioners concerned will adopt it. Where actual inexperience is present it is more difficult to do so. I think that a quotation from a recently published repoit of the Louise Margaret Hospital at Aldershot by Lieut.-Colonel P. C. T. Davy, C.M.G., R.A.M.C., is pertinent to the matter under discussion. " That institutional midwifery is of immense advantage to the woman admits of little argument, but one is inclined to think that perhaps its most incalculable benefit lies (or should lie) in saving her from the obstetrical forceps. Removed from anxious relatives, under the constant observation of a staff to whom time is no object, and in the atmosphere of calm routine which prevails, Nature, who after all, is not a bad midwife, is allowed a hand. The ultimate good to the woman lies undoubtedly in patience. This counsel of perfection, of course, breaks down too often in other circumstances, but conscientious ante-natal examination should do much to preserve it." (Jour, of the R.A.M.C., Jan., 1928, p. 19.) Colonel Davy deals with 2,200 confinements, and the average rate of forceps application was 4 per cent. With the assistance of the different Medical Officers of Health through the country I have recently approached medical practitioners in whose practice very gross excess forceps application occurs. In the case of all hospitals in which the rate exceeded 40 per cent., the Medical Officer of Health has written to ask if any special reason or circumstances can be suggested for such excess. In most cases an answer has been received, some of which could not be regarded as satisfactory, whilst others showed that the medical practitioners believed they were really doing the best for their patients. I have written a short note on each answer, as well as a general note suggesting the lines of treatment which usually make instrumental interference unnecessary. As I have said, I have only considered this year instances of very gross excess. Next year I hope to consider all cases in which the percentage exceeds 30. I have always considered it to be my duty to draw your attention to any matter of nursing or medical education or practice which seems to increase the dangers of women in childbirth, and perhaps I have failed to emphasize equally the fact that there are other factors, for which medical practitioners and nurses have no responsibility. Such an omission is unfortunate because of the tendency of the lay press and the public to throw on the medical and nursing professions blame for happenings for which the latter are not responsible and which they are powerless to prevent. A single medical practitioner can give a patient advice which may save her life or health ; fifty practitioners cannot make her take it if her mental equipment is insufficient to enable her to appreciate its importance. Again, a medical practitioner single-handed can, if left unhampered, bring his patient successfully through a very difficult labour. If, on the other hand, his plans are obstructed and his mind confused by the injudicious interference of relatives and friends he can easily convert a normal case into a calamity. It is therefore very necessary that the public should remember that to the unavoidable consequences of disease and deformity, and of the sometimes avoidable consequences due to insufficient medical or nursing education, there must be added the wholly avoidable misfortunes resulting from misguided and clamorous relations, neglected advice, and unsuitable surroundings.

6—H. 31.

41

Number of Labours. Percentage of Forceps Deliveries. Hospitals of — 1925. 1926. 1927. 1925. 1926. 1927. 50 confinements and under .. 3,950 3,893 3,794 12-0 14-5 15-06 From 51 to 100 confinements .. 5,347 5,748 5,589 17-2 14-9 12-63 From 101 to 150 confinements .. 2,512 2,948 3,044 19-1 18-8 16-29 Over 151 confinements .. .. 3,556 4,024 4,229 8-7 8-02 7-35 All Hospitals .. .. 15.365 16,613 16,656 14-3 13-7 12-51