Once rotation effected, the only obstacle the head can encounter is the descent of the anterior lip of the cervix, which we have explained above. As to the perineum, we have likewise indicated what is to be done. It sometimes happens, as Jacquemier has pointed out, that the shoulders fail to turn, and thus oppose an obstacle to the passage of the trunk; this constitutes a veritable form of dystocia which we shall consider here after.
Face Presentation.
Face presentations have long been considered as so grave by most writers as not to permit the normal termination of labor; they hold that every effort should be made to change them into vertex presentations, and where this fails, to resort to version. Portal, indeed, recommended to leave the case to Nature; but Dionis, Smellie, Viardel, de la Motte, Baudeloc que, and Capuron still advise early intervention, and only when we come to Mme. Lachapelle do we find the principle laid down that delivery by the face is at least as easy as delivery by the vertex. Without admitting this proposition of Mme. Lachapelle, which in this form is too absolute, all modern obstetricians, headed by Depaul, at least in France, have ad vised to remain inactive, unless absolutely forced to interfere.
Schroeder, and other German writers, strictly discriminate between presentations of the face and those of the brow, and their procedures vary accordingly. Still, some among them have returned to early inter vention, and seek to transform the face into a vertex presentation, by in ternal, external, or combined manipulations.
Pippingskiild advises to change the face into a vertex presentation. In one case, after vainly trying the forceps and lever, he succeeded by pressing one hand on the chin, theh on the alveolar border of the superior maxilla, and lastly on the borders of the orbits, while the other hand exerted counter-pressure on the occiput through the external abdominal walls. He was thus able to flex the head, and the application of the for ceps at once terminated the delivery.
This transformation of the face into a vertex presentation has been ac cepted by Osiander, Rosshirt, E. Martin, Hildebrandt, Fasbender in Ger many, and by Baudelocque in France, but rejected by Mme. Lachapelle, Chailly, Dubois, Depaul, and Cazeaux.
Schatz resorts to external manipulations. According to him, it was solely at the beginning of labor, and exceptionally at the end of preg nancy, that he had occasion to attempt a change of the presentation; he assails the transformation by internal manipulations as practised by Fritsch and Baudelocque, and that by combined manipulations performed by Pip pingskold, and, after indulging in a series of geometrical and mechanical demonstrations in which it is very difficult to follow him, he proposes this procedure: He does not touch the head directly, all the more because he advises intervention after the onset of labor, and the rupture of the membranes, and because tho head, consequently, can only be grasped incompletely.
Instead of acting on the head, he seeks to grasp that part of the back which is nearest the head—that is to say, the shoulders and the top of the thorax (through the abdominal walls)—and, in the interval between two contractions, he crowds them first upward, and from the side where the back of the foetus lies. As soon as the shoulders and the chest have been thus brought into the vertical axis, they are no longer pushed upward, but toward the back of the foetus. In this movement, and by this pres sure, not only the shoulders and chest of the foetus, but the uterus like wise, are twisted to one side (the right, for instance); therefore the other hand should fix and hold in place the fundus uteri and the breech of the fetus, or at least push them back from the opposite side; that is, from the side where the thorax lies. The shoulders and chest are thus brought into the vertical axis, but led away from the left side; in short, while the trunk is given an impulse from one side, it is drawn away from the other side through action on the podalic extremity of the Rails. If, notwith standing,the head does not leave the border of the superior strait, it is forced to do so by exerting with the hand pressure on the corresponding side of the pelvis, or by having an assistant do so. In this way the move ment the head is to go through is completed.
According to him, the advantages of this method may be summarized in the following propositions: 1. The manipulation is harmless for both mother and infant. The only thing to be feared is, that the face presentation may be transformed into a brow presentation; but the latter will soon again change into a face presentation.