3. Pelvic deformity.
a. The indication is absolute in case of transverse presentations which could not be remedied before labor, or which were not recognized, after the seventh month. Up to six months, the fetus is small enough to allow us to count on spontaneous evolution. Before resorting to podalic version, the diagnosis must be exact, that is to say, we must know not only that the shoulder presents, but which shoulder, and consequently, the location of the head, and the ventral surface of the foetus.
b. Here version only aims at rescuing the mother and the infant from threatened danger, and not alone to modify the foetal presentation. In many instances, then, the forceps will answer, and the accoucheur must decide as to which method of interference will answer the best for the individual case.
c. We have already spoken at length of version in case of contracted pelvis. Although authorities here differ on certain points, they all agree in favor of version in case of oblique contraction, since then the ac coucheur may direct the foetal part towards the greater pelvic space.
Finally, we must not forget that extraction is not necessarily the im mediate consequence of version, and that, in many instances, the change of foetal position having been obtained, it is possible, advantageous at times, to leave the case to Nature.
Conditions necessary for the successful Performance of Version.—Cer thin ones are absolutely indispensable, and others only favorable.
The indispensable conditions are: 1. The dilatation, or at least com plete dilatability of the cervix. 2. Festal part not firmly engaged. 3. Pelvis not too contracted. 4. Uterus not too contracted.
A favorable condition, if not absolutely indispensable, is the integrity of the membranes, or at least the presence of enough liquor amnii to allow of festal motion, and thus prevent too great contraction of the uterus.
1. Dilated or Dilatable Os.—By complete dilatation is understood that condition where the walls merge with those of the vagina, so that the uterine, cervical, and vaginal canals are one; by dilatibility is understood such softness that the cervix may readily be converted into the state of dilatation. We are thus opposed to Schroeder, who claims that it is not
absolutely indispensable that dilatation should be such as to allow the introduction of the hand, and that version is most likely to succeed when attempted early. Podalic version, through an undiluted os, is very diffi cult and very dangerous, for it is like accouchement force, and, therefore, except under stringent necessity, it should never be resorted to unless the cervix is dilated or dilatable. Otherwise we may lacerate the cervix and do injury of serious import to the woman. When version is attempted prematurely, there are two accidents likely to occur: Extension of the arms, and contraction of the cervix around the neck. If this first com plication is readily overcome, it is not so with the second. The extended head is imprisoned, the foetus dies of asphyxia, or if we make violent traction this may result in detaching the head from the body, and leav ing it in the uterus.
There is a time of election for version, and this when the cervix is dilated or dilatable, and the membranes are intact. If now the mem branes are ruptured, and the hand passed at once to the fundus, so as to lose as little of the liquor amnii as possible, the feet may be seized with great ease, and version, except in case of pelvic deformity, may be per formed with ease and rapidity.
2. Version consists in evolution of the foetus. If, now, the fretns is deeply engaged, or immobilized, the passage of the hand, in the first place, is difficult, if not impossible, and, again, it will be necessary to push up the foetal part, and this may be impossible, and effort result in rupture of the uterus. We run the risk then both of killing the mother and the infant.
3. We must never forget that although the flat hand may pass through a contracted pelvis, this hand must come out holding the festal foot, and, therefore, no longer flat but closed—that is to say, it must make its exit increased in volume by the foetal part, as well as by the fact that it is doubled on itself. We must never then attempt version in a pelvis con tracted below 2.7 inches.