II. Presentation of the Trunk.
We have already passed in review the signs and the treatment of pre sentations of this nature, and we have pointed out that, while external version is easy during pregnancy, the presentation has always the ten dency to recur. To prevent this recurrence numerous means have been suggested, and their very multiplicity proves their inefficacy. Convinced that the position of the foetus is, in these cases, due to lessened resistance of the uterine and the abdominal walls, Pinard has endeavored to re enforce this by means of the following bandage. (Figs. 242, 243.) It consists of three pieces, a right and a left forming the body of the bandage, and an intermediate completing the bandage anteriorly. " When at the eighth month the head is not engaged, the bandage should be applied; when the presentation is of the breech or the shoulder, external version should be performed, and the bandage immediately applied. During the first day, compression should be moderate, and on the following days it should be increased by tightening the posterior buckles." We have used this bandage, even as has Pinard, Tarnier, Ribemont, Budin, Chantreuil, Champetier de Ribes, but we are not so optimistic in regard to it as is Pinard. It has its disadvantages, such as the necessity of removing it when palpation or auscultation is desired, the inability or unwillingness of many patients to wear it, the fact that, in many cases, since it must be worn night and day, it produces erosions and abrasions of the skin, and becomes a source of torture instead of relief. We would limit its utility, therefore, to the few days which precede the onset of labor.
III. Prolapse of the Limbs.
Under the term prolapse, we understand the presence at and above the superior strait of a part of the foetus which does not belong to the pre sentation, such as the cord and the extremities. Prolapse of the cord we have already studied.
The above definition eliminates the presence of one or both feet in case of presentation of the pelvic extremity, and of the arms in case of the shoulder. In these instances there is not true prolapse, but only exten sion of the limbs.
Where prolapse exists, it is usually of an upper extremity. We may meet, by the side of the head, a hand, an arm, the two hands, a foot, and, by the side of the pelvic extremity, a hand or an arm. In certain cases a foot, the two hands, and the cord are found. Frequently, indeed, the cord is prolapsed with the extremities. Rarely, the feet prolapse in case of presentation of the shoulder, although usually this is due to inex pert attempts at version.
The causes are about the same as for prolapse of the cord, except that, while procidence of the latter favors prolapse of the extremities, the reverse does not hold true. They are not very rare. Depaul, in 17,613 labors, noted prolapse of the extremities alone or with the cord 163 times; Lachapelle 45 times out of 15,652 labors, 11 of which were of the ex tremities. The difference is notable, Depaul 1 in 102, Lachapelle 1 in
1423.
Diagnosis.—We must recognize the fact of prolapse, and then deter mine which fcetal part it is. The diagnosis is only difficult when the presenting part is above or at the level,of the brim, and then careful ex amination should be made to avoid errors.
a. Prolapse of one or both Arms by the Head.—In this event very fre quently there is no difficulty. If the liquor amnii escapes but slowly, the hand will ascend as the head descends. If the arm is prolapsed, labor may still terminate spontaneously if the pelvis is normal, if the foetus is not very large, if the contractions are energetic. According to Crede, all depends on the degree of prolapse.
If the diagnosis is made before rupture of the membranes, the woman must stay in bed. After rupture, attempts at reduction must be made, and the prolapsed part held above until descent of the head. In case of prolapse of the arm reposition will often fail, and then, when dilatation is complete, the forceps should deliver, taking care not to grasp the arm in the blades. Where the pelvis is contracted, perforation may be re quired. If the head is not at all, or only slightly engaged, version may be resorted to.
b. Prolapse of one or of both Feet.—This is rarer than prolapse of the hand, although Depaul noted it 18 times in 278 cases. The attempt must be made to push up the foot, or else the head by traction on the foot, or else resort to the forceps.
c. Simultaneous Prolapse of the Superior and Inferior Extremities. — These instances are very rare, arid usually only observed in case of dead and macerated foetuses. Naegele, in a case where the right arm and the right foot were prolapsed, was able to push up the head, and by pulling on the foot, deliver a living child weighing 8f pounds. Monroe obtained a living child where one foot, the two arms and the cord were prolapsed. Hartmann succeeded where both feet and the right arm were down.
d. Prolapse complicating Presentations of the Face.—These are very ominous. Cazeaux saw a case where the presentation was M.I.L.P., the conjugate of the pelvis measured 3 inches, and where the left foot was prolapsed. The forceps failed, as well as attempts to push up the foot. Embryotomy was requisite for delivery.
In 1879 I saw two similar cases while substituting for Depaul at the Clinique d'Accouchemenls. In the one case I perforated. The mother recovered. In the other I performed embryotomy. The woman died. The pelvis in this case was contracted.
e. Prolapse of the Hand in Breech Presentations.—This is exceptional, and is not a complication of moment. We will consider it under version. (See Vol. IV.) It is much more common in these instances to see the arms extend over the head during extraction.
Joulin has reported a number of cases of dystocia determined by these different varieties of procidentia.