DIAGNOSIS OF FACE PRESENTATIONS.
Before Labor.
expresses himself thus: " In ice presentations, pel vic exploration shows the presence of a large tumor at the inlet, above the inlet, or below the inlet, according to the period of labor at which the examination is made. This tumor seems to occupy only one half of the true pelvis. It is very round, very large and very accessible, on one side, but seems lacking on the other. Placing the hand on tho fundus uteri, we find the breech generally on the side where the tumor is more promi nent. In order to easily follow and map out the resisting surface, it is necessary to depress the abdominal wall slowly and deeply, for the resist ing body seems to retreat into the abdominal cavity, while the small, superficial parts are readily felt by the hand. This results from the tor sion of the foetus on its dorsal plane. . In thoroughly exploring one of the lateral planes, we soon find that the most accessible part of the cephalic spheroid is in relation with the back. Moreover, particularly early in labor, there exists between the back and the head a deep furrow, into which the fingers sometimes easily penetrate." Thus, we have the pres ence of the cephalic extremity at the level of the true pelvis, and promi nence of this extremity on one side of the pelvis, the back, corresponding to this projection.. According to Budin, we may, in certain cases, feel on the side opposite to the accessible tumor a plainly perceptible, horse shoe-like swelling, the inferior maxillary bone. Pinard and Budin thus think that the diagnosis may be made by palpation alone. We hold the diagnosis by unaided palpation to be very difficult, since special conditions are necessary to thus make it, viz., great laxity of the abdominal walls, thinness of these walls and slight uterine irritability. We hold that, in the great majority of cases, palpation and auscultation must be combined. Palpation shows the presence of a cephalic presentation, the presence of extremities at the fundus, and the side upon which the back is located. But we think that auscultation, combined with palpation, best enables us to make the diagnosis. The foetus being higher in face pres entations than 'in vertex, the maximum of the heart-sounds is, as Devillier remarked, also higher, i.e., no longer below the line dividing the uterus into two equal parts, but on this line. But, while in flexed cephalic pres
entations the maximum is heard on the side where the back is, in face cases the maximum is transmitted, not by the back, but by the anterior fcetal surface. There will, therefore, be a lack of agreement between the signs furnished by palpation and auscultation, and this disagreement will not only enable us to recognize the face presentation, but to ascertain whether the chin be on the right or left, and thus to ascertain the posi tion.
To recapitulate: We find the characteristics of a head presentation, but while, in the presentation of a flexed head, we find the maximum of the heart-sounds on the left if the back be on the left, and the reverse if the back be on the right; in the face presentation, with extended head, we find, with the back on the left, maximum on the right, and the reverse. This disagreement between pilpation and auscultation suggests the existence of a face presentation, and va ginal touch confirms the suspicion. Vaginal touch is, indeed, the only true means of making the diagnosis of face presentations, and even with this, the membranes must be ruptured, the cervix sufficiently dilated, and the face sufficiently fixed. If labor has just set in and the membranes are intact, the engagement of the fcetus has hardly begun, because of its high position, and the extension of the head having just commenced, we reach the forehead, not the face. Now, since we may feel the anterior fontanelle, the coronal suture may be mistaken for the sagittal suture if we do not advance the finger as far as possible, and the face presentation may thus pass for one of the vertex. When the finger, introduced as far as possible, is made to follow the suture from the an terior fontanelle as a starting point, if the vertex is presenting, we will find that this suture is very long and ends at the posterior fontanelle. If it be a face presentation, the suture is shorter and leads to the root of the nose and to the superciliary ridges, not to the posterior fontanelle. Nev ertheless, if the membranes are intact and E little tense, and if the cervix is but little dilated, errors are not always avoidable. lf, however, the membranes are ruptured and the cervix widely dilated, the diagnosis is very easy.