2. The manipulation is practicable as soon as the face presentation is recognized, during pregnancy as well as at the beginning of labor, until the end of the first stage of dilatation (Schatz believes it to be possible even later, when the bag of waters is intact). It will succeed more readily in proportion as it is practised earlier, but must be rejected when the face is engaged too far, and when the shoulders have passed the cervix.
3. This method requires no other precaution. If the membranes re main intact and the operation fails, the former condition will be repro duced; if it succeeds, the prognosis becomes favorable.
4. If this manipulation succeeds with the face, it will be all the more likely to do so in brow presentations.
Welponer has employed Schatz's procedure in one case with success; but, after having seen the occiput come down and descend, and this so forcibly as to rupture the membranes, he found the face presentation re produced, with the only difference that the face, at first in the first posi tion, was in the second position after the manipulation. The child was born living; the pelvis was generally contracted, and the conjugate diam eter measured three and three-quarter inches.
For our part, we do not see any objection to trying Schatz's procedure, but we advise not waiting till the beginning of labor. We would act toward the end of pregnancy, but this presupposes the existence of a primary face presentation recognized before the beginning of labor, and such are rare. Secondary presentations are the rule, and it is mainly during labor, when far enough advanced, that they are recognized. We believe, therefore, although this method may be tried without danger, it will often fail.
Schroeder, and other German writers, strictly discriminate between face and brow presentations. In the former, Schroeder says, when the face is completely engaged in the pelvis, we should wait as long as we can. and then resort to the forceps. If rotation is delayed, we might attempt first to lower the chin, then to inaugurate this rotation by exerting pres sure on the forehead iu a contrary direction. But when the face is not engaged, and the chin posterior, version is to be resorted to, and when this is no longer practicable, Pippingskold's procedure should be tried, so as to transform the face into a vertex presentation.
If, on the other hand, we have to deal with a brow presentation, ver sion should be practised if the orifice is sufficiently dilated and the brow still movable. If version is no longer possible, we must try to transform the brow presentation into a vertex or face presentation, by Hildebrandt's method. The latter consists in pressure exerted, during a contraction,
on the forehead, either in the direction of the face or in that of the ver tex. Playfair demonstrates that Hodge's procedure is nothing else but that of Baudelocque, but that it admits of attempts at transformation only in cases where the face remains above the superior strait and fails to descend into the excavation. On the whole, he prefers podalic version to all the other procedures. When the labor does not terminate, there is either uterine inertia or absence of rotation; then the forceps must be re sorted to.
Penrose attempts to cause rotation by the aid of the hand or the blade of the forceps; he claims to have succeeded several times.
As Playfair observes, rotation is often retarded until the face has reached the inferior portion of the excavation. Hence we must not interfere too soon.
What causes the real difficulty in face presentations is the absence of the movement of rotation, and, although we accept version by external manipulations at the end of pregnancy or the onset of labor, we carefully abstain from any manipulation as soon as the face engages and labor seems to progress. Then, in fact, Schatz's opinion to the contrary, version by external manipulations is impossible, and attempts to transform the face into a vertex presentation by internal manipulations seem to us injurious rather than useful. Delivery by the face must always and does take a longer time than delivery by the vertex; but we should not hasten to interfere, and must know how to wait. Only when we have become thoroughly convinced that rotation will not take place, or when it is in the interest of the mother or infant, should we interfere. Our preference is for the forceps. Unfortunately, as we will see, the applica tion of the forceps in face presentations does not always give the result we hope for. Artificial rotation of the chin does not succeed, and we are then forced to resort to embryotomy. We ourselves have had occasion to interfere eight times in face presentations in M. I. R. P. or M. I. L. P. with or without complications (procidentia of members or cord), in city and hos pital practice (we have never assisted at the beginning of labor, and have only been called as a last resort). Once only have we succeeded in bring ing the chin forward and delivering a living child (female); six times we have been obliged to resort to the cephalotribe. In one case (face, un successful attempts at version, prolapse of one foot, one hand, and funis), we were forced to extract the foetus piecemeal, the forceps and cephalo tribe having successively failed.