Asphyxia may, according as the compression is rapid or slow, occur rapidly or slowly, and hence the two conditions of apparent death in which the infant may appear. Post-mortem, indeed, congestion of the brain, heart and lungs have been found, as also anemia; but these differences are only apparent, and the same lesions are to be detected in the nervous, circulatory and respiratory centres.
In case of compression of the cord, sudden death occurs but rarely, and usually the accoucheur may, so to speak, follow the progress of asphyxia by means of auscultation.
Finally, compression may occur within the membranes before rupture, and in Depaul's opinion, which seems rational, where the liquor amnii is greenish and tinged with meconium, notwithstanding the integrity of the foetal heart, the explanation is probably to be found in transient compres sion of the cord.
Treatment.—The treatment varies with the case, and whilst in certain instances only rapid intervention can save the child, in others, on the contrary, haste would be only harmful, and expectancy is indicated.
If the prolapsed cord is diagnosticated within the membranes, we must above all keep these intact as long as possible. The woman should lie down, the buttocks elevated, and but few vaginal examinations should be made. The progress of labor should, not be hastened, however prolonged. Birnbaum advocates the introduction of the colpeurynter to sustain the membranes. A Gariel pessary might be used for the like purpose. By means of the colpeurynter, according to Birnbaum, the vagina is dis tended; if the membranes rupture the waters can escape but slowly, the uterine contractions are intensified. Abegg approves this procedure, but we do not grant it any special advantage, for it is not in the vagina, or in the cervix, but at the level of the superior strait that the cord is subject to compression, and hence the tampon cannot relieve or moderate it..
As soon as the membranes rupture, an examination should be made to gain whatever information is possible as to the state and the condition of the cord.
When prolapse of the cord has been diagnosticated before rupture of the membranes, Ritgen has advocated placing the woman in the knee chest position, or in the lateral position on the side opposed to that where the cord has prolapsed. Birnbaum, Ritgen's pupil, aiRrms that this
manoeuvre alone has never resulted successfully.
When the membranes rupture and we have assured ourselves of pulsa tion in the cord, three methods are at our disposal: 1. Abandon the labor to nature, and simply direct and second her efforts; 2. End the labor as soon as possible; 3. Attempt reduction of the cord.
Labor can only be left to the efforts of nature under the following circumstances: where the infant is dead, where the pains are good. We are dealing with a multipara, and where, consequently we may expect the end of labor in a few minutes. If, however, the pains are few and irregular, the pelvis is deformed, the foetal heart is troubled, the os is rigid, we must interfere. Where the cervix is dilated or dilatable, we should resort to the forceps or to version. Where such interference is impossible, we must try to reposit the cord and maintain it above the presenting part.
Reduction of the cord may be attempted by the hand or by instruments. Manual reduction was employed by Mauriceau, Amand, Deventer, Rcederer, Siebold, d'Outrepont, Busch, Kluge, Michaelis, and others. The latter in 35 cases succeeded 21 times, Lachapelle 14 out of 16. Lamotte, Smellie, Baudelocque, Boer, reject the method, whilst Ritgen, Kiestra, Leopold, Simpson, and others, recommend reposition by posture.
The cord, grasped in the palm of the hand, is to be carried above the internal os and the presenting part, and held there until engagement of the foetus has taken place, and further descent prevented. Now, when the cervix is sufficiently dilated to allow this manoeuvre, it is much more simple to deliver at once by version. When the cervix is not sufficiently dilated then manual reposition of the cord becomes, as Boer has well pressed it, a labor of the Danaids—it is carried up by the fingers and it_ falls down again. As for the advice to sling the cord around one of the foetal limbs, it does not seem to us acceptable, for where the cervix is sufficiently dilated to allow of the procedure version is also possible, and this is preferable; in the event of the cervix not being dilated or dilatable, neither method is practicable.