The bladder and rectum should be emptied, in particular the former by the catheter.
As for the choice of hand to operate with, authorities are not in accord. The general rule is to take that hand which, placed between pronation and supination, corresponds by its palmar surface to the ventral surface of the foetus. In vertex presentations, for instance, in the left occipital the left hand, in the right occipital the right hand—that is to say, left hand if the feet are to the right, and vice versd.
This is the custom in Germany. In England, where version is performed with the woman lying on the left side, the left hand is always used. For our part, we consider the choice of hand a matter of secondary im portance. For if version is easy, one hand will answer as well as the other, and if it is difficult, there is one circumstance which forces us to deviate from theoretical rules. When the liquor amnii has escaped for some time, the inserted hand awakens contraction of the uterus, and the hand is squeezed so that it is deprived of sensation, and we must, of ne cessity, insert the other hand instead. I have often been obliged to make this substitution a number of times. The best we can do to save the hand is to straighten it out during the contraction, and wait for relaxa tion before continuing the operation.
It goes without saying that the coat should be removed and the shirt sleeves rolled up. The nails should be cut short, on a level with the pulp of the fingers, and the arm should be well greased, never, however, greasing the hand which is to seize the foot.
Having made the above preparations, we proceed to the op, alive method.
This, according to most authorities, is composed of three stages: 1. Introduction of the hand and search for the .foot.
2. Evolution of the foetus.
3. Extraction of the foetus. This latter stage does not in reality belong to version, because, once the foetus turned, version is completed, and we may often leave the rest to Nature. Thus, most German writers describe version under breech presentations. But since immediate extraction after version is the rule, we will follow the example of French writers, and de scribe extraction in this place.
1. introduction of the Band and search for the Ret.—The hand should ever be introduced during the interval in the pains. The fingers should be brought together in the shape of a cone, the thumb against them, and penetrate slowly, rotate as it were, into the vagina, the dorsal surface be ing turned towards the sacrum when the bottom of the vagina has been reached. At the same time, it is absolutely requisite to control the uterus
with the other hand, or by the hands of an assistant, in order that as the fingers enter the uterus the vaginal attachments may not be dragged upon or torn, and again in order that the uterus may be depressed as much as possible nearer the internal hand. Another important point is that the hand be made to traverse the vagina in the axis of its curvature, and in order to do this, as the hand penetrates it is necessary to depress the elbow. The hand once at the cervix, which we suppose to be widely dilated, the membranes are either ruptured or intact.
If ruptured, we must immediately enter the uterus as deeply as possi ble, even to the fundus, if necessary. The feet, indeed, are usually higher up than is supposed, and many inexperienced operators fail in version because they do not dare pass the hand deep enough. When the hand has reached the fundus, only the thickness of the walls separates it from the external hand. We must, hence, manipulate carefully, and with ex treme gentleness.
If the membranes are intact, they must be ruptured. Here opinions vary. Peu, Smellie, Efeleurye, Boer, and latterly, Hiller and Naegele and Grenser, advise introducing the hand between the uterine walls and the membranes, until the feet are reached, and only then to rupture. Hater has even been able to perform version without rupturing the mem branes. For our part we are opposed to this, and we believe the mem branes should always be ruptured over the cervix, always, however, at once introducing the hand, and thus tamponing with the wrist, to pre vent escape of the liquor atnnii. Our reasons for this opinion are: 1. While the hand is passing between the uterine walls and the membranes, these often rupture over the cervix, and version is rendered difficult from the fact that the ruptured membranes are applied closely against the fcetus. 2. If we seize the foot through the membranes, we may pull on the mem branes as well as on the foot, and thus cause partial detachment of the placenta. 3. In passing between the uterus and the membranes we may detach the placenta, in case of lateral insertion. 4. Searching for the feet through the membranes necessitates more exact knowledge of their position than we are often able to obtain. 5. As for the possibility of turning without rupturing the membranes, this necessitates very tough membranes, and a very acquiescent uterus; and further, as Schroeder points out, the foot slips in the membranes and is difficult to seize.