2. " The head is in the upper segment of the uterus, the breech below.— We must first mobilize the fcetns, by either pressing down the head laterally, or by lifting up the breech on a finger in the vagina, and press ing down the head in the opposite direction; the two poles being now accessible, slow and sustained pressure must be made so as to make the head ascend, and the breech descend by the shortest route. The pressure on the breech has always seemed more effective than that on the head." External Version during Martin manipulates as follows: " The woman lies on her back, the pelvis slightly elevated, the operator sitting by preference with his back to the woman's face. One hand is applied over the inferior portion of the abdomen so as to push towards the superior strait the foetal pole nearest it, whilst the other hand is ap plied above, and pushes towards the fundus the higher foetal pole. These manoeuvres are applied only between the pains. During a pain, the ob ject is simply to retain the ground gained. After an interval the manoeuvres are repeated. If the hands tire the nurse may be entrusted with the uterus during a pain. At times it is advantageous to make the woman lie on that side towards which the inferior extremity is deviated, usually the head, and pressure is applied to it either by the hand or by a cushion. Once the head engaged, the woman should retain her position, or else the membranes may be ruptured, and the fatal part thus fixed." According to Playfair, " external version should never be resorted to, except where the abnormal presentation has been recognized before labor, or at least before rupture of the membranes. It is only applicable to transverse presentations, for we must not expect to obtain complete evo lution of the foetus, but only a substitution of the head for the lower ex tremity." It is thus seen that we are in complete accord with the opinion of the English acconcheur.
Combined External and Internal Version.—Bi-polar Version.— This consists in acting with one hand externally on one foetal pole. while the finger in the vagina acts on the other. In the hands of d'Outrepont, Esterle, Rigby, Simpson, Robert Lee, it was a method ap plicable to cephalic version, and Hohl, according to Naegel6 and Grenser. practised it as follows: " The parturient lies horizontally, until the head has engaged. When the uterus is inclined to one side, the woman re clines on the opposed side. The uterus is steadied by an assistant, whose hands are applied flat against the lateral superior sides of the uterus. At the moment when, by manipulation, the head is brought towards the superior strait, the assistant gently pushes the uterus towards the same side, for example, to the left, when the head is deviated to the left. Then we place the left hand above the horizontal rami of the pubes on the side of the head, while the index and the middle finger of the right hand, in the vagina, rest on the foetal shoulder. These fingers gently lift the
body and push it towards the mother's right, during the intervals of a pain if the membranes are intact, constantly if they have ruptured, while with the left hand the head is pushed towards the superior strait. The head once engaged, we rupture the membranes, but only when the liquor amnii is abundant." Braxton-Hicks applies these manoeuvres to every variety of version, both cephalic and podalic, whatever the presentation, and this not only when the presenting part is above the brim, but also after the waters have escaped, even though the foetus is deep in the cavity, and the cord or an arm have prolapsed. (Figs. 3 and 4.) He thus describes his method: " Introduce the left hand into the vagina, place the right hand on the abdomen, in order to recognize the position of the foetus, and the direction of the head and the feet. If, for example, the shoulder presents, it should be pushed by one or two finger€ in the direction of the feet; at the same time pressure is exercised with the other hand on the pelvic extremity of the child. (Fig. 3.) "This pressure will bring the head towards the orifice. It is received on the ends of the internal fingers, and it may be placed in any desired posi tion. If the breech do not rise easily towards the fundus, after the head has been applied over the brim, the hand should be withdrawn from the vagina, and applied to the breech to cause it to rise. The head should be steadied gently for a while, until the pains have fixed the child in its new position, and until the uterine walls have accommodated themselves to the new form. If the membranes are intact, it is useful to rupture them as soon as the head is over the internal os. The head will then retain its position." This method, which requires a certain degree of cervical dilatation and consecutive rupture of the membranes, is applicable only to the begin ning of labor; for we doubt its success when the waters have escaped, the uterine contractions are energetic, and the uterus has contracted down on the foetus.
To resume then: Perform cephalic version at the end of pregnancy, and at the beginning of labor, in every case of transverse presentation; at the end of pregnancy retain the head in its position by means of Pinard's birider, whenever it is borne; if not, await the onset of labor, do cephalic version, and rupture the membranes to fix the head; such is our advice. Abstain from cephalic version in case of presentation of the pelvic extrem ity, for it is often impossible in primiparm, and it is useless in multiparre. Nevertheless, since it is not injurious, the accoucheurs who try it are not to blame.