4. The uterus must not only allow the introduction of the hand, but it must also be yielding enough to permit festal evolution, and to allow retractility without danger of rupture. Sometimes the uterus is irrita ble, and then, if we wait a little, it will be possible to do version with ease. All depends on the necessity of rapid delivery, which, if it does not exist, may render embryotomy out of the question.
There are, above all, two causes of exaggerated uterine contractions: Total escape, and for long, of the liquor =nil; premature administration of ergot.
1. The most favorable, if not indispensable condition for version, is the integrity of the membranes. This condition, however, is rarely fulfilled, for the presentation being above the brim, premature rupture often oc curs, and the waters flow off readily, the uterus contracting on the foetus the less the amount of liquor amnii present. Enough water, then, must at least remain in the uterus to prevent such contraction, and to allow foetal evolution. Unfortunately, it must be said, premature escape of the waters is often the result of error on the part of the physician, oftener still of the midwife. The membranes are ruptured before the assurance has been gained, by palpation, of the presentation, in the hope that the fatal part will engage. The rule should be to wait for complete dilata tion before rupturing the membranes. Once the time of election at hand, rupture, and at once insert the hand into the uterus, thus effectively tamponing the cervix and preventing entire escape of the waters. In case the head presents, if in the interests of the mother and the infant it is necessary to end labor, push this up, search for a foot, turn and deliver, or else have recourse to the forceps.
2. We have already stated that we are absolutely opposed to the ad ministration of ergot as long as there is anything in the uterus. Particu larly does this apply to cases of abnormal presentation. Unfortunately the error is often committed of administering ergot in these cases, and it is then that we see supervene those tetanic contractions, which are bnt too often followed by spontaneous rupture of the uterus, a rupture all the more certain if we attempt version. Here version is contra-indicated,
and embryotomy must be resorted to, and this is also indicated by the fact that the foetus is usually dead.
Preliminary Precaution.—Before practising version, there are a num ber of precautions to be taken, certain of which are indispensable to suc cess. We must.above all be sure of our diagnosis. If the head presents, make out whether it be vertex or face, to what point of the pelvis the oc ciput or the chin points—in other words, not only diagnosticate the pres entation, but the position, in order to know whore the feet are. If the body presents, recognize by which shoulder; sometimes such exact diag nosis is not possible, until the hand is in the uterus. Further, any in struments which might be required, such as the filet, laryngeal tube, scissors, etc., should be at hand. The bed should have considerable ele vation, and be resisting, for, since it is necessary for the hand to pass to the fundus, the operator will have to depress the arm greatly. It is often necessary to place a board under the mattress in order that the woman's nates may not sink too much. Usually, the woman is placed in the dor sal position, the nates at the very edge of the bed, the feet resting on a couple of chairs, and the limbs separated. An assistant should hold each leg, flexing the thigh on the trunk. If necessary a pillow or cushion may be placed under the nates, to elevate them.
In certain instances, where the feet are in front, or difficult to reach, the woman may be placed, for the time being, in the lateral position. The knee-chest position, advocated by certain gentlemen, appears to us objectionable, because it is our habit to anesthetize during version.
If version is practised at the time of election, and in a woman with large pelvis, chloroform may be dispensed with. Otherwise it is abso lutely indicated. The anesthesia should be complete, surgical, adminis tered by a competent assistant, and should continue during the entire period of the operation. Thus is obtained absolute passivity on the part of the woman, and the operator may act more quickly, aside from the fact that the woman is spared pain.