This procedure was known to the Japanese. Numerous instruments have been devised for pushing up the foetal part, such as those of May grier, Burton, Aitken, Otto, etc. All these instruments we believe are inferior to the hand, and if the hand fail, we do not think that any in strument will succeed.
Madame Lachapelle has noted in cephalic presentation a cause of diffi culty when traction is made on but one foot. It depends on the fact that the nates may prevent the ascent of the head. If this cannot be pushed up, traction should be made on both feet. In certain instances version is not possible, and then our recourse must be to embryotomy.
We have said that traction should be made downward and forward; but this anterior movement must not be exaggerated, else it may happen that, when evolution is complete, the foot which was not grasped lies across the symphysis, and thus prevents further progress. Then it will be necessary to make traction directly backward, or else to rotate tite dorsum of the foetus backward, or at least laterally, in order that the thigh caught on the symphysis may disengage itself. It is always, be it understood, the an terior hip which thus gives rise to trouble.
The breech once at the superior strait, and at the level of the cervix, version may be considered at an end, and often the case may be left to Nature. We are dealing simply with a breech presentation. But if the pains are slight, if there exist disproportion between the foetus and the genital canal, if version has been indicated by complications threatening the life of mother and child, then extraction should follow at once on version.
3. Extraction of the Fcetus.—The extraction, according to Naegek and Grenser, may be divided into three stages: 1. The body of the foetus as far as the shoulders. 2. Extraction of the arms. 3. Extraction of the head. Only, however, in difficult cases, are these stages marked; in case of favorable conditions and of strong contractions, extraction is so easy that the three stages are merged in one.
While efforts at version are to be made in the interval of, extraction is made during, the pains, and it succeeds the better the stronger and more regular the pains. If the two feet have been grasped and brought to the vulva, they'are wrapped in a towel, and they are seized with the thumbs above the heels, and the remaining fingers on the ventral surface of the leg. (Fig. 12.) The same rule holds where but one foot has been brought down, the hands being moved upwards as the legs and the nates descend, keeping as near as possible to the joints. The hands thus are applied successively to the feet, the legs, the knees, the nates, as close as possible to the maternal parts. (Fig. 13.)
If traction is made on a single foot, as soon as the breech is extracted the second foot appears of its own accord. Only when the second leg has extended on the abdomen of the fcetus, need we artificially disengage it. The finger must then be inserted in the groin, in order to pull down the thigh, and then must seek the second foot and endeavor to extract it, but direct traction must never be made, else fracture will result. The best practice, in such cases, is to continue extraction irrespective of the second foot, when, sooner or later, this will spontaneously appear. If, when the nates appear, the fetus is found astriie of the cord, we must try to loosen this by passing it over the natis belonging to the undelivered foot. If the cord cannot be loosened, then it may be ligated in two places and cut between. Of course, itl such event, very rapid extraction is indicated.
The breech delivered, the thumbs are applied over the sacrum, the other fingers over the anterior of the pelvis, (Fig. 13,) and traction is made downwards and slightly backwards, until the thorax appears. If the cord is tense at the navel, it is pulled gently downward, in order to avoid traction on it. If it cannot be disengaged, it must be cut and the festal end compressed by an assistant till extraction is completed. Usu ally, as the body descends the fcetus rotates, so that the dorsum looks for ward. If this rotation does not occur spontaneously, it must be made artificially. In order to effect this, while downward traction is being made, the fcetus is turned in the desired direction, and this is ordinarily an easy matter. But if the body resists, rather than use force we had best desist.
Where version is easy and contractions good, the arms remain flexed on the chest; but if the uterus retracts more, the arms extend along the head, and must be disengaged. The posterior arm should be first ex tracted, and then the anterior, and there remains only the head.
The head may be flexed or extended, the occiput anterior or posterior. If the uterine contractions are not sufficient, we must extract it rapidly, lest the infant endeavor to breathe, and asphyxiate. Since the extraction of the arms and head offers difficulties, we will describe this later on.
The child born, the cord is to be cut as usual, and the same care is given to infant and mother as is customary after normal labor.
- Version, as we have described it, is simple version. It is not always so easy, and, as we will see, the operation may become one of the most deli cate and difficult the accoucheur is called upon to perform. We will pass the difficulties successively iu review.