B.    Warning in respect of vacuum extraction, face presentation and breech delivery

I regularly find a serious misalignment in the position of the head on the atlas in patients, where the atlas is displaced unilaterally under the head to such an extent that the transverse process of the atlas is positioned ahead of (ventral to) the processus stylohyoideus. This pulls the hyoid bone unilaterally in the dorsocranial direction, since the ligament to which the hyoid bone is attached is pushed away in the ventral direction by the transverse process of C-1. In this case, no translation is possible between C-0 (the head) and C-1; in other words, the joint between the head and C-1 is eliminated. When viewed from under the chin, the hyoid bone is then positioned somewhat obliquely in the dorsocranial direction with the patient in the seated position; in the dorsal decubitus position (while scanning) the hyoid bone is pulled away to one side (tongue bone phenomenon). Naturally, there are also cases in which the atlas is displaced to a slightly lesser extent in the ventral direction so that it stops just short of the tongue bone phenomenon. With the exception of violence (accident, uppercut) the case history frequently reveals a forceps or vacuum extraction as "birth trauma".

The rotation that spontaneously occurs when the baby's head is pushed out during birth is, of course, different to the rotation that is made during traction. After I had seen this abnormality in my own son (forceps delivery) I made a habit of checking children after an assisted delivery. In the majority of cases an abnormality was present as described above!

Recently my grandson was born by vacuum extraction. Since the suction force had caused all the fluid to be drawn from the neck and cranium to the caput succedanium, the infant's neck was very thin and you could easily see and feel the atlas. It was indeed oblique. I pointed this out to the attending gynaecologist, who also observed this. I then asked him to hold the baby's head between both hands, to support the chin with the ring fingers and to raise the baby by its head and hold it like that for a couple of seconds. After this the atlas had assumed the normal position! There is no point ir calling in a paediatrician in such cases since the abnormality can only be seen for about one hour after the delivery. As soon as the fluid has flowed back to the neck, the diagnosis can only be made by an experienced observer. The illustrated CT scan shows this abnormality, observed in an adult female.

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The simple and harmless manoeuvre described above prevents much distress. As my findings show, most of these children subsequently develop multiple ear disorders: owing to the swelling around this misalignment, the eustachian tube is compressed. These children also suffer severe earache when they are passengers in a plane that is taking off or landing.

It is not inconceivable that minor displacements also occur in the baby's neck after a breech delivery and this misalignment can certainly be found in a face presentation. In these cases too, for prophylactic treatment one can briefly raise the baby by its head: a perfectly harmless and often extremely curative manoeuvre!

In the event of whiplash injury later on in the life of a child born by abnormal vaginal delivery, with the associated displacement of C-2, C-3 and C-4, this may lead to severe disruption of the circulation in the brain with all the serious consequences that this entails, certainly if this second abnormality is on the same side. This occurs as a result of mechanical stimulation of the ganglion cervicale superior situated ahead of the two transverse processes of C-1 and C-2. I intend to devote a separate study to the combination of these two abnormalities as well as whiplash injury.

In adults and older children, giving extension alone is frequently not enough. In their case the atlas on the side in question should be pushed in the dorsal direction while in extension; this is necessary because when the abnormality has existed for a longer period, the ligament apparatus will have adjusted itself to the existing situation. The ligament apparatus, which is then asymmetrical, gives insufficient impulse for a full correction.