In our opinion, therefore, once the labor has commenced, we must wait, watch the festal heart-beats with greater attention than ever, and, when the foetus is in danger. apply the forceps as soon as the dilatation permits, performing first artificial rotation of the chin, then extraction.
Even in cases where rotation takes place spontaneously, labor is some times prolonged, owing to exhaustion of the uterus and inefficiency of the contractions. Here again intervention should be subordinated to the condition of the foetus and the mother; but it must not be forgotten that excessive prolongation of the labor may have grave consequences for the mother. Hence we dare not wait too long before interfering, and although we advise, as a general rule, to await rotation, we do not hesitate to ter minate the labor by the application of the forceps when rotation has taken place, and the contractions become less frequent.
With reference to brow presentations, we are far from sharing the opinion of German authors as to their exceptional gravity. In harmony with French obstetricians, we look upon them as presentations interme diate between face and vertex presentations.
If we are wise enough to wait, we will always see them spontaneously transformed either into vertex presentations, which is by far the most fortunate circumstance, but it must be admitted rather rare; or else, into frank and regular face presentations. Then the accoucheur finds himself again in the ordinary conditions for intervention in face presentations.
Breech Presentations: Although breech presentations are not absolutely serious for the mother, they must nevertheless, as we have seen, render the prognosis more re served, since the mortality rises to one per cent., while it is only 0.57 per cent. in vertex presentations. For the child, however, the danger is much greater, since the mean mortality is 35 per cent. during labor and delivery. Five per cent. of the children born alive succumb within twenty four hours of their birth, while only two per cent. die during labor in vertex presentations, and but one per cent. of the children perish in the first twenty-four hours. It would seem, therefore, that the idea of trans forming breech into vertex presentations should have occurred to obste tricians long ago but this was not the case for two reasons: first, version by external manipulations was not known; second, when this form of ver sion was known, it was considered dangerous and impossible in these cases.
Mattei was the first who clearly formulated the idea of this transfor mation of breech into vertex presentation, who laid down the indications for it, and described the operative procedure. Although Goubelly had
tried it first, and without success; although Wig-and and Flamant had laid special stress on version by external manipulations, these proposals were rejected by Scanzoni and E. Martin, and accepted with a reserve border ing on repulsion by Dubois, Desormeaux, Chailly, and Devilliers. It was Mattei who first demonstrated that this operation, if it was to succeed, should be practised, not as formerly during labor, but at the end of preg nancy and before the onset of labor. But this applied chiefly to version by external manipulations in cases of transverse presentation. As re gards breech presentations, Jacquemier accepted version with hesitation, Petrequin of Lyons declared decidedly in its favor, while Herrgott re jected it before labor, and it is only when we come to the time of Hubert of Louvain and of Nivert that we see version by external manipulation applied to the transformation of breech into vertex presentations. Since then, Tarnier and his pupils, Pinard, Chantreuil, and Budin, have rea dopted the proposal, and in Germany, Heger considers it perfectly jus tifiable.
For our part, without absolutely rejecting the artificial transformation of breech into vertex presentations, we accept it only with great reserve, for the following reasons: lat. Although the prognosis of breech presentations is serious, this is the case mainly in primiparte, and not in multiparty. It would seem, therefore, that the partisans of this operation should practise it chiefly in case of primipane. Yet Pinard himself, in the chapter on contra-indica tions, particularly insists on primiparity, "and when the presentation is the result of an accommodation, when the presentation is always the same about the end of pregnancy, when, in one word, the variety exists which is termed frank, the evolution may be impossible. We must then desist after a few attempts, which may be repeated after some hours, or after some days, but which must always be practised with the greatest gentle ness and very slowly." Hence it is really in cases where version by exter nal manipulations could be of use that its most confirmed adherents re nounce it, because it fails, and this before labor. What if it were to be attempted during labor? In multiparty, version appears to us useless. The laxity of the soft parts, the lesser resistance of the cervix and the external parts, permit of an easy disengagement of the pelvic extremity, and we ourselves have always delivered living children in multiparty. The mothers never suf fered from any accidents.