DYSTOCIA DUE TO ABNORMAL PRESENTATIONS OR POSITIONS.
I. Presentations of the Vertex.
The vertex may not present regularly with reference to the axis of the superior strait, that is to say, it may be inclined. When slight, this may be considered normal, but when exaggerated, it becomes a cause of delay during the first stage of labor.
If the inclined presentation does not correct itself, but persists, the forceps is indicated to terminate delivery. In case of the face, at times the forceps, at times version, are called for. In case of the breech, the foetus must be extracted, but intervention is absolutely dependent on the condition of the mother.
The presentation may be normal, and the position abnormal. Es pecially is this the case in posterior positions, whether of the face or the vertex, when rotation fails.
We must further study in detail those instances where the extremities prolapse in connection with one or another presentation.
a. Absence of Rotation.—Orcipito-poderior Position.—Occipito-posterior positions, which we have studied at length under the mechanism of labor (vide Vol. I.), are far from being rarities, as is proved by the following figures which we take from Sentex's monograph: The observations of Dubois, Velpeau, Villeneuve, Sentex, Wilson, Pajot, prove sufficiently that spontaneous labor is possible in persistent occipito-posterior positions. We are entitled then to wait on nature. But ought we to do so? Capuron and Macdonald argue for interference; Villeneuve, Sentex and the majority of authorities are guided by the condition of the mother and of the child, and we believe that this is the rule which should guide every accoucheur.
What are the means of intervention at our disposal ? Portal, Leroux, Guillemot advise abdominal pressure during the contractions of the uterus. Aside from the fact that this pressure is painful, it will fail, we believe, in the majority of instances, and further it may cause metritis, etc.
Smellie introduced the entire hand in the vagina, and endeavored to push up the head and to turn the face backwards, acting during the con tractions.
Burns recommends rupture of the membranes and pressure on the fore -head, during the contractions, to push it backwards.
Tarnier has lately proposed to act on the occiput by placing two fingers behind the ear, and thus endeavoring to bring the occiput forward. Sentex is also a partisan of internal manipulations.
In accord with Simpson, Burns, Cazeaux, Joulin, Depaul, we reject these internal manipulations as being inefficient and useless. Either
rotation will occur spontaneously, and we must have the patience to wait a little for this—for we must remember that in many instances rotation is not effected until the head reaches the perineum—or else rotation will not take place, and then both external and internal manipulations will fail, and we must deliver by the forceps, which we much prefer to version.
As to the forceps—for we would reject, with Tarnier, Leischmann and others, the lever—Millet, Levret, Astruc, Solayres, Capuron, Velpeau, NaegeM, Cazeaux, Barnes, Grenser, Schroeder, Sentex, and many others, advise the delivery of the occiput by it posteriorly, without attempting artificial while Pajot, Smellie, Baudelocque, Simpson, Joulin, Jacquemier, Ramsbotham, Blot, Tarnier and his pupils, advocate artificial rotation, We agree with them, and only in case this is absolutely im possible would we deliver with the occiput posterior. The objections raised against artificial rotation are not tenable, and the experiments of Tarnier and Blot prove that the occiput may be turned completely around without any appreciable lesion of the cord or of the fcetus being produced. (See Vol. 1V., under Forceps.) Unfortunately this rotation is not always possible, and then the occiput must be delivered posteriorly, at the great risk of the integrity of the perineum.
{This subject is considered at length in the next volume under the Forceps. We would simply state hero that in the majority of instances the absence of forward rotation is dependent on lack of flexion. Before resorting to artificial rotation, therefore, we would advocate an attempt at flexing the head either by the hand, or else by means of the valuable procedure advocated in particular by Richardson, of Boston, which con sists in flexing the head through the forceps applied inversely to the ordinary method, and then removing the blades. In case, after an inter val, varying according to the condition of the mother and the child, spon taneous rotation and delivery do not occur, artificial delivery of the occiput posterior by means of the forceps (and here Isaac E. Taylor's slender-bladed instrument is very valuable should be resorted to.—Ed.] b. this case artificial rotation should. always and absolutely be attempted. It often fails, however, and then our only resource is perforation, since version is not possible, unless the face is only slightly engaged, in which event, if it can be pushed up ver sion is indicated.