DYSTOCIA DUE TO THE FIETAL ANNEXES.
Anomalies of the Cord.—We have already studied the anomalies (See Vol. I.) of the cord, which may interfere directly or indirectly with the foetus. We will now pass in review the most frequent cause which ren ders delivery dangerous to the infant, prolapse of the cord.
Prolapse of the Cord.—Under the name procidentia, prolapsus, falling of the cord, we mean the engagement of a portion in front of or near the portion of the infant, which is presenting. Naegel6 and Schure make two divisions, according as the membranes are ruptured or not. In the first instance, the cord presents, in the second it is prolapsed. The first is inevitably converted into the second, unless it corrects itself spontane ously. Jacquemier makes three divisions: Presentation before rupture of the membranes, incomplete prolapse when the cord lies in the vagina, complete prolapse when it hangs externally. As Depaul says, these sub divisions are of no moment, for the danger and the indications are similar in each. Deneux says that procidentia of the cord may be met with at and before term, but usually it occurs only when the cervix is notably dilated. It is rare when the fcetal part reaches the excavation, and rarer still, of course, at the inferior strait. Naegel6 has recorded a case. It varies with the length of the cord, and it usually occurs in the neighbor hood of the sacroiliac synchondroses, infrequently in front of the sacrum, or behind the symphysis. The cord may be tense or loose. The descent may further be complicated by the presence of the fcetal extremities, by knots, twists, placenta prwvia.
Frequency.—It is far from rare, and the figures given by the authori ties vary infinitely. Thus:— Etiology.—These have been well studied by Schur(, who divides them into four groups.
A. Every condition which renders the fcetus more movable. a. Abundance of liquor amnii. b. Small size of fcetus. c. Prolapse of a limb.
B. All causes which give rise to space where the cord may engage. a. Naegele has insisted strongly, in this connection, on want of con traction in the lower segment of the uterus, whence results lack of close approximation of this segment to the presenting part of the fcetus, and hence space into which the cord may fall. b. Anomalous positions of the fcetus which act either by making space for the cord, or else by bringing it nearer the cervix. In 124 cases recorded by Hecker, the cord was
beyond the normal in length in 92 per cent., having a mean length of 261 inches. Multiparity would seem to have a notable influence. According to Hildebrandt in 100 cases only 15 occur in primiparaz, and according to Hecker, in case of cephalic presentations, the proportion is 100 primipara3 to 226 multiparte. c. Deformities of the pelvis and displacements of the uterus.
C. All causes which bring the cord near the cervix.
D. Excessive length of the cord, premature rupture of the membranes, precipitate rupture, the woman being erect.
E. Finally, Depaul adds attempts at version by the inexperienced.
Diagnosis.—This is only difficult before the cervix is sufficiently dilated to allow the finger to reach the membranes. If the foetal part is deeply• engaged, and the lower uterine segment very thin, we may, exceptionally, feel the pulsations of the cord through this segment. These pulsations may be differentiated from those which are normally felt at the utero vaginal junction, by the fact that they are not isochronous with the ma ternal pulse. Where, on the other hand, the presenting part is elevated, the cervix dilated and a portion of the membranes accessible, the diag nosis is possible. Then, either during the contractions, or in the inter vals, a body is felt, not voluminous and floating, under the exploring fin ger. The nature of this body is recognized by the fact that it pulsates isochronously with the foetal heart. If the foetus is dead, this sign of course fails, but then the diagnosis is of no importance. The membranes once ruptured, the diagnosis is a simple matter, when the cord is in the vagina. Its pulsations, the possibility of hooking the finger in a loop, clear away any doubt. The same does not hold true when the cord slips to one side of the head, and remains there during the first stage. Then prolapse of the cord is often not diagnosticated, and Depaul says, with justice, that in certain cases where the fcetus dies during labor without appreciable cause, this should be attributed to an unrecognized prolapse of the cord, aside from the compression to which it is subjected in the uterine cavity.