MALPOSITION AND MALPRESENTA TION.—Under this subdivision we have the most prolific causes of dystocia. The great danger lies solely in the fact that when a malposition more than a malpres entation occurs it is seldom recognized. We refer especially to occipito-posterior positions, than which no more trouble some complication arises. We empha size the fact that a malposition of a nor mal presentation is possible. Similar malpositions would include chin-pos terior cases and brow cases.. The fault in the non-recognition of these cases al ways rests with the physician. Most ex aminations are perfunctory; the attend ant rests satisfied so long as he feels the round bony head, whether engaged or non-engaged.
Characteristic of all vicious positions are early rupture of membranes, slight nagging pains, and slow or absent en gagement of head. Non-engagement of the foetal head always means either a malposition or a relative or absolute pel vic contraction; in short, a pathological condition. The accoucheur might pos sibly err in failing to find a pelvic dis tortion or contraction; he must never fail, however, to clear up a malposition. If this is not possible by the ordinary means, he must insist upon the intro duction of the whole aseptic hand into the uterus to clear up the condition, although this requires anTsthesia. It is evident, reasoning from practical ex perience, that, since contracted pelves in this country are rare, the most fre quent causes of dystocia can be ascribed to malpositions and malpresentations. Early recognition and timely interfer ence as the case demands, operating then and there only when the indications present, is here the secret of absolute success.
Out of 400 cases of occipito-posterior positions collected, spontaneous rotation forward occurred in 353.
In failure of rotation the hand was in troduced to dislodge the occiput from the sacrum, and, when further rotation was required. Tarnier's forceps was found especially useful. Maternal mor tality, 0.5 per cent.; of 660 contrasted cases of occipito-anterior position, 0.46 per cent. Foetal mortality in occipito posterior position, 2 per cent.; in an terior position, 0.76 per cent. It was
found necessary to apply the forceps at the pelvic inlet in 6 per cent. more cases than in anterior positions. Bataillard (Annales de Gynec. et d'Obstet., Aug., '89).
Treatment.
Prophylactic Measures.—We must presuppose that the pregnant woman has been very carefully examined in ad vance from a physical stand-point and every constitutional abnormality noted, and that any disease of an organic na ture discovered has been so treated as to avoid complicating factors. It is sumed that every means has been util ized to place the patient in the best pos sible position to help her to safely pass through the trying hours of pregnancy and labor. To fail in methodically amining the urine and to obtain a care ful estimate of the excretion of urea in twenty-four hours might prove a fatal dereliction. This should be repeated every two weeks. Albumin means very little, more of a danger-signal than any thing else; on the other hand, patients sometimes die of eclampsia without the faintest trace of albumin in the urine. It is the urea or its derivatives and toxins of uncertain nature that kill, not the min. It is when the amount of urea diminishes that the accoucheur should 'look out for storm, even though no albu min be present. Rest in bed, milk, ac tively stimulating all the emunctories, and, in the event of their failing, liberate induction of labor are indicated. In women of flabby build with consider able adiposis, in whom we suspect a fatty degeneration of the uterine muscle, good results are claimed for the continuous use of small doses of strychnine through out pregnancy or small doses of quinine for their salutary effect in stimulating the uterine muscles.
It sometimes happens that a woman will go from one pregnancy to another, always losing the child either artificially by instrumentation or from the results of a prolonged labor, in whom, while the pelvis is normal, the children are all very large. This constitutes a pelvis which is relatively contracted. Much can be clone to reduce the size of the child by appropriate treatment, either medical or dietetic.