OBSTACLES AND DIFFICULTIES TO VERSION.
Introduction of the Hand.
The causes of difficulty may lie in the vulva or vagina, (edema, nar rowness, rigidity), or be due to obstacles in ,the canal, (prolapse of the arm or the cord), in the cervix (resistance, rigidity, placenta pra3via), in the Uterus itself (retraction, tumors, etc.) a. N%rrowness, rigidity, of the vulva or vagina, are rarely so pronounced as to constitute genuine obstacles. Edema and traumatic swelling of the vulva and the external parts are the most frequent.obstacles.
Edema of the vulva may depend on albuminuria, and in certain cases it is necessary to puncture the labia in order to affect introduction of the hand. In such cases great care is necessary in order not to bruise the parts overmuch, and thus lead to gangrene.
b. Prolapse of the cord of itself is not an obstacle to version, but the life of the child is compromised, and, therefore, active intervention is called for, and extraction should at once follow version. If the foetus is dead, the only necessary precaution is not to pull on the cord and thus separate the placenta. If the cord be in the way it may be cut, the pla cental end being alone ligated, since the foetus is dead. But we must never forget that absence of pulsation in the cord is not a sure sign of foetal death, and that for absolute certainty we must listen for the foetal heart. If, on the other hand, the foetus is alive, we must particularly avoid compression of the cord. The best plan is to replace it in the uterus above the foetal part, and if it will not stay there, to terminate version as rapidly as possible.
c. In shoulder presentations, when labor is prolonged, and the liquor amnii has in great part escaped, the shoulder is pushed more and more into the superior strait, and the arm belonging to the shoulder extends, and prolapses into the vagina, often appearing at the vulva. At times the arm is brought down by the inexperienced operator, being mistaken for the leg. The arm thus prolapsed swells, becomes livid, and at times looks gangrenous.
The older writers often placed a piece of ice in the hand to cause it to retire. Mauriceau and others advocated efforts at replacement. Portal (1665) and Deventer (1701) first proved that such efforts were often un necessary. Smellie, Levret, Puzos, Lamotte, Van Hoorn, proved that such efforts were not only useless, but often dangerous.
To-day, this prolapse of the arm is considered an advantage, in the first place because we are enabled to make a correct diagnosis, and in the second place, because we may fix this arm and prevent it from extending along the head. We have already seen how, by looking at the band, or by following the arm up to the axilla, we may at once differentiate the presenting shoulder, and thus know exactly where to hunt for the feet.
We must not judge the infant dead by the condition of the arm, and, as has happened, amputate it; such amputation is never necessary, how ever swollen it be. Our efforts must be limited to passing a sling over the arm, and thus preventing its extension along the head during extrac tion.
There are instances, however, where the accoucheur's hand cannot be inserted, because during previous attempts at version the other arm or foot has been brought down. Then, in case of vertex presentation, de struction of the foetus is necessary. But first we must always assure our selves of the death of the foetus. If the foot, as well as the arm and the head, is in the vagina, we have seen that we may have recourse to the double manoeuvre, and if this fail, to perforation or cephalotripsy.
d. Obstacles in the cervix may be due to incomplete dilatation, to rigid ity, to spasmodic retraction, to placenta previa, or to tumors of one or another kind opposing dilatation.
1. Incomplete Dilatation and Retraction of the certain cases, the life of the mother or child depends on labor being terminated before complete dilatation; otherwise we must wait for complete dilata tion. Baths, hot injections, chloral, chloroform, belladonna ointment, will at the end of a few hours, overcome rigidity.