THE first of these operations which we shall notice, is version, or the changing of one presenting part for another more favorable to delivery. There are two kinds of version: podalic, when we change the head for the feet; cephalic, when change the head in such a manner as to bring a more favorable part of the delivery. When the history of any given case of confinement reveals a probable malposition in the future, the case is to be met by the administration of such remedies as the symptoms may indicate. Cure the patient and the presentations will be natural. If a malposition be detected near the close of gestation, by means of auscultation or palpation, a dose of Pulsatilla, or of some other remedy, may rectify the abnormality. It is certainly worth while to make the effort.
Podalic Version. When it is deemed necessary to change the presentation of the child by bringing down the feet, there are certain rules which, under all circumstances, must be observed.
1. The patient should, by all means, be apprised of the nature of her case, and as simply and kindly as possible be made acquainted with the nature of the operation to be performed. When she is once made to understand that the proposed operation is for the safety of her child, she will the more cheerfully submit; her free consent must in the first place be obtained.
2. Her position must be upon the back, with the breech near the edge of the bed, her feet also near the edge of the bed, the thighs flexed at right angles with her body; the head and shoulders must be elevated to a reasonable height.
3. The accoucheur should slip off his coat as gently as possible, in such manner as not to make a great flourish, and thereby alarm his patient. The hand to be used in the operation should be rubbed with lard until perfectly smooth, that hand always to be employed whose palmar surface corresponds with the face of the child. For obvious reasons, care should be taken not to lubricate the palmar surface.
4. The os uteri must be sufficiently dilated, or dilatable, to admit the free introduction of the hand and the passage of the child. If there is the least rigidity of the fibres, we must defer the operation a little longer, otherwise we incur the risk of rupturing the uterus, or of badly injuring the patient in other respects. We must also be sure that the head has not passed through the os, else, in turning, we should be likely to cause a rupture.
5. The introduction of that hand whose palmar surface corresponds with the face of the child, can be easily effected after it s dorsal surface has been thoroughly lubricated with some unctuous material, by placing first the fingers and then the thumb within the vulva, at the same time bringing them all together into the form of an elongated cone. Now press carefully, slowly and steadily, from before backwards and from below upwards, and the hand will enter the vagina and soon come in contact with the child. Then the palmar surface must be spread out and kept upon the anterior surface of the child until we come in contact with one foot. If there is difficulty in finding the foot, carry, the hand upwards to the thigh, and then the hand can follow the thigh down to the foot. Having ascertained that it is really the foot, by its being articulated at right angles with the leg, make a firm grasp about the ankle close down to the foot. We may always proceed in this manner, whether acting before the membranes are ruptured, or at any succeeding period. If action is taken before the rupture of the membranes, these can be broken as the hand is about to enter the os uteri; all this stage can be accomplished from time to time, during the intervals of the pains. During each pain the hand should remain perfectly quiescent, no matter how much suffering the uterine contraction may occasion.
Having secured a foot as just described, the free hand must be placed upon the abdomen, in order to steady the uterus, or this office may be performed by an assistant, then, during the absence of a pain the hand should be gently and carefully withdrawn. If we have been careful to carry the hand upon the anterior surface of the child, and secure a foot there, we shall succeed in turning the child by doubling:it more and more upon its anterior surface, until the breech takes the place of the original position of the head, and the head that of the breech. By doubling the child upon its anterior plane we run no risk of breaking its back or neck, as in doubling it backwards. Moreover, by bringing down only one foot and allowing the other to remain in its usual position, we leave the breech to occupy a bulk nearly as large as the head, so that as it passes through the organs, more dilatation is effected, which the head requires in order to pass freely and with less compression upon the cord, and of course with less danger of strangulation.
Further, as one leg is left distended upon the abdomen of the child, it serves to protect the cord during the passage of the body; this is a self-evident fact.
After the turning of the child is fairly accomplished, the labor may be effected by the natural process alone, or we may continue to act as occasion requires. Wait by all means, if it will seem to answer to do so; but if not, make traction upon the leg, but act only in concert with the pains. Do not draw down the other leg; wait until it is fairly expelled, foot and all, for it may be the saving of the child’s life to do so the cord being in this manner protected. Now the chief danger arises from the strangulation of the cord, by its being compressed between the head and the bony walls of the pelvis. So long as we can feel the pulsation of the cord, all is well. Should the pulsation cease, a slight effort, may be made to draw it down a little. If this can be done, pulsation will often become re-established, and, all things being equal, we can still wait. If it cannot be drawn down, and pulsation ceases, we must hasten delivery as much as possible by making careful traction upon the body of the child. As soon as possible we must hook down the arms be placing the index finger in the bend of the elbow, and then, as soon as possible, hook the same finger into the mouth of the child and flex the head as strongly forward as possible; hold it thus, while with the other hand, placed upon the shoulders, make steady and strong traction, and the patient will soon be delivered. Manage all breech presentations in this way, when interference appears necessary in order to save child or mother; otherwise trust to nature.
It sometimes happens that the arms slip up by the sides of the head, when it will be necessary to disengage them, before the head can engage. This can be done by slipping two fingers up from the shoulder along the humerus and, allowing these fingers, to lie along on this line its whole length, we can pass them forwards and downwards on the child’s face, and in this manner run no risk of fracturing its arm, The posterior arm should be disengaged first and the sub pubic afterwards. In all cases of difficulty in the introduction of the hand to perform this operation, from rigidity of the uterine neck, the difficulty can be overcome by the administration of the proper remedies. See Labor. It should be further observed that complications from hemorrhages, &c., can all be controlled by suitable medication, and in this way time can be obtained for dilatations and other necessary advantages, without resorting to brute force or Allopathic measures. Let it not be forgotten that version must never be attempted until the os uteri is fully dilated or freely dilatable. It can then be safely performed, both to mother and child, whether the membranes are ruptured or not. If not ruptured, they must be, as the hand is passed into the uterus.
Mode of procedure in all cases, when the head face, breech, or trunk presents.
1) When the head presents never, under any circumstances, change it for the feet. If hemorrhage occurs, and there be placenta praevia, manage as before stated. If there is not placenta praevia, control the hemorrhage by medicine. See Hemorrhage.
Remove all other difficulties by medicine, if possible, (see Labor;) if not, apply the forceps, or resort to craniotomy, as the case may seem to demand. It is very unsafe plan ever to exchange the head for the feet, if it can possibly be avoided. It is much safer, in all respects, for the child as well as for the mother, to deliver by the aid of the forceps. We then run no risk; no possible contingency can drive us to decapitation after the body is delivered, and to perform the unsafe, the very difficult operation of craniotomy upon a floating head in the maternal organs, and that too up through the base of the skull. As a principle then, worthy of all confidence, never exchange the head for the feet.
If the face presents, and we are called before the face has become fairly engaged in the cavity of the pelvis, if it be in the right mentoiliac position, we must introduce the left hand, when the face will rest in the palm, and by proper manipulation with the fingers the face can be rotated upwards so as to flex the chin upon the sternum and thus bring the vertex in to the superior strait, when the labor can be abandoned to nature.
