2d. The prognosis is not alike in all presentations. Presentation of the buttocks is the gravest of all. In such cases, therefore, we could, and by rights should, practise version by external manipulations, but this pre supposes that the diagnosis be made before the onset of labor; yet this is next to impossible. The pelvic extremity is readily recognized, but neither palpation nor auscultation nor the touch enables us to make the diagnosis of the variety of the presentation before labor. Yet during labor this version is impossible, and hence it is useless to attempt it.
3d. In our opinion, the dangers for mother and infant depend perhaps less on the presentation as such, than on the inexperience and the med dlesome intervention of the obstetrician. In fact we believe that, in a fair proportion of cases, intervention is useless and can only have bad effects; and on the other hand, when this intervention is necessary, there is, as it were, a moment of election which we must take advantage of, in order to arrive at a satisfactory result. • Three instances may be encountered. The child may present: 1, by the complete pelvic extremity (buttocks and feet); 2, by the incomplete pelvic extremity; 3, by the buttocks, the members extended over the anterior plane.
1. Buttocks and is the simplest of all; the entire first por tion of labor proceeds regularly, and it is only when the breech is about to be delivered that dangers arise for the child Since intervention may nevertheless become necessary at a given mo ment, the accoucheur must have in readiness whatever may be indispen sable, warm water for the child's bath, vinegar, laryngeal tube, forceps, and cord; he must attentively watch the festal heart-beats, and from the moment when the breech appears at the vulva, or better still, from the moment that it has descended to the pelvic floor, have the patient placed in the operative obstetrical position, i.e., across the bed, the buttocks at the edge of the bed, the feet resting on two chairs, the limbs held by two assistants. The accoucheur then places himself on a low chair, facing his patient, and holds himself in readiness to supervise the evolution without leaving the patient for a single instant. If everything proceeds normally, the breech with the feet, is disengaged slowly from the vulva, then the hips appear, and at last the funis. It is only necessary to take the cord between the fingers to assure one's self of the integrity of its beats, and hence of the life of the foetus. If the funis seems strained at the level of the umbilicus, it is eased by bringing forward a portion of its length.
Then the foetal extremity needs only to be sustained without exercising the least traction, and the rotation movement, which the trunk performs in its •iisengagement, favored. While the accoucheur sustains the Leta' extrem ity, one of the assistants rubs the fundus uteri during its contraction so as to re-enforce the latter. We then see, even without any friction if the contractions are vigorous, the trunk and the arms appear, the latter re maining applied to the trunk; and finally the head is disengaged in its turn. Nothing remains but to tie and cut the cord.
Depaul is in the habit, if the contractions are not vigorous, of admin istering to the woman, at the moment when the breech appears at the vulva, thirty grains of ergot in three doses given at ten minutes' intervals. We believe that this practice, although harmless in the hands of our ex perienced professor, may become dangerous if generally resorted to, and we uphold Pajot's law—never to give ergot unless the uterus is empty.
We much prefer frictions over the fundus uteri, and, if necessary, direct pressure exercised upon the head through the abdominal walls. We pro hibit traction which, if the contractions are at all feeble and far apart, lead to but one result, extension of the arms, possibly extension of the head, arrest of the rotation movement of the head, and will thus become cause of disaster which would have been avoided if it had been left un done.
But if the disengagement takes place too slowly, if the uterine contrac tions are not vigorous enough to effect the disengagement, if the arms are elevated, if the head is extended or fails to turn, we must interfere, and this resolutely.
If the contractions are merely slow and feeble, wait as long as the con dition of the mother or of the child permits; then extract as rapidly as possible.
If the evolution progresses too slowly, intervention is likewise called for, but the precise time is difficult to determine. If traction be made too soon, before the trunk has emerged, while the contractions are fee ble, the arms are very liable to be extended. If traction be too long de layed, the arms may have become spontaneously extended, and, since the trunk of the child is delivered, inspiratory efforts might be made which would jeopardize its life. In our opinion, the time for intervention is when two-thirds of the trunk are delivered—in other words, when the greater part of the thorax is outside, and the trunk achieves its movement of rotation.