2. Often we know more certainly, beforehand, the position of the knee.
3. In podalic version the force which changes the presentation acts with greater advantage on the knee, and further we may use more force on it, without endangering the fetus, in case of difficult version." Barnes adds that the knee is nearer than the foot, and while the latter must be seized by the full hand, the finger bent on itself is enough to pull down the for mer.
When the inferior extremities are too far from the superior strait, Deutsch advises the following procedure: 1. Make the foetus undergo a movement of rotation around its longitudinal axis. 2. Disengage the feet. " As for the choice of hand, this is according to rule. If we are dealing with a shoulder presentation, for example, the dorsal surface of the foetus being posterior, the palmar surface of the hand is applied to the thorax or the shoulder of the fcetus, and by pressure from in front back, and 'from below above, the foetus is turned on its longitudinal axis so that its anterior surface looks downward, and the thorax is elevated. Often many attempts are necessary for the success of this marlituvre. The fo3tus is held in this position by the thumb, and the four other fin gers are turned downwards, and passed along the back to the nates, the legs are pushed towards the sacroiliac synchondrosis, and the feet full of themselves into the hand of the operator." (Naegelt and Grenser.) According to Deutsch, by this method the uterus is less irritated, version is easier, and the danger of fracturing the limbs is slight. The method does not seem to us practicable, except in the presence of much liquor amnii, a small foetus, and a non-irritable uterus, and here the usual method will succeed as well.
Finally Gueniot advises, in difficult cases, a method already used by Cazeaux, and which he calls the ano-pelvic.
"1. The weight of the body is to be used to penetrate to the fundus.
2. To take as the fulcrum of the tractions on the foetus, the pubic arch, or the sacro-coccygeal joint, by means of the curved finger in the rectum.
3. Thence to proceed as in ordinary version." The advantages of this method are: 1. The foetal pelvis is usually easier to find than the feet. 2. The fulcrum chosen is most solid, and does not yield. 3. Traction
being direct, no force is wasted. 4. Whatever the direction of the trac tion, the evolution of the kettle may be affected. 5. When podalic ver sion has failed, the ano-pelvic method may still be resorted to with suc cess.
2. Evolution of the consists in making the foetus turn on itself, so as to convert the existing presentation into the pelvic. In order that the fcetus may turn, it must not be fixed in the uterus. We must hence act between the uterine contractions.
Wigand has described two methods of action: " The foot seized, trac tion is made during the pains, taking the precaution to bend the child along its anterior surface, flexion thus being easier and more complete. Formerly this was called the great turn. Usually, however, we make traction by flexing the foetus, first anteriorly, and then laterally, without fear of compression of the spine. This has been called the little turn." These divisions are rather theoretical than practical, for if evolution be easy, it is accomplished as well by the great as by the little turn, and if it be difficult, that method which is the most rapid is the best, and the accoucheur must act according to circumstances.
Having firmly grasped the foot, traction is made, and we feel the foetus move. In a general way these tractions should be made downward and forward, in order to bend the foetus anteriorly. At the same time the other hand, on the abdomen over the head, endeavors to push this up towards the fundus. The tractions should ever be slow and continuous. If the version be easy evolution is rapid, but it may happen that either the head or the shoulder do not move, and evolution does not occur. We then, according to Naegele and Grenser, try to push up this shoulder or head towards the side of the pelvis with the thumb or the palm of the operating hand, at the same time that the feet are pulled down. If this does not succeed, we may resort to what has been called double manipu lation. (Fig. 11.) This consists in applying a loop over the foot, and of pulling on it, while the hand in the uterus tries to push the presenting part upward. The uterus must be well steadied by an assistant.