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Version, its indications and contraindications
NEW
ORLEANS
GYNECOLOGICAL
AND
OBSTETRICAL
SOCIETY STATED
MEETING,
MAIiCZ
13,
1925
DR. HILLI~D
E. MII~LER read a paper entitled Version, Its Indications and Contraindications. (For original article see page 241.) DISCUSSION
DR. PHILLIPS J. CARTER.-1 believe there is a definite indication for version in certain selected cases, particularly in primiparae with the masculine type of pelvis, funnel-shaped, where the spines and crests show a difference of Ya to 1 cm. and the true conjugate is about 8 cm. I recall one case particularly in which I did a cephalic version at eight months. It was a breech presentation and I am certain that I should have lost the chi1.d had I allowed it to continue as such. As it was, the results were excellent; I applied mid forceps after the head had been arrested for an hour and secured a living child. In another instance I did a cephalic version at the onset of labor. DR. JOHN F. DICK&-I agree fully in all but one point-when I am considcring version 1 pay a good deal of attention to the length of time which the membranes have been ruptured. I think that we cannot emphasize too strongly the importance of what are too often regarded as unimportant matters, such as careful emptying of the bladder, complete surgical anesthesia, an assistant who understands the mechanism of labor, and a slow delivery of the after-coming head. In version and extraction in primiparae particularly, episiotomy is a distinct aid to delivery; in fact, I do not believe it should be attempted in any case before a fairly deep episiotomy has been done. I know I have saved many children by this procedure. Dr. Miller stressed especially, gentleness and deliberation in the delivery of the after-coming head. I am heartily in favor of Potter’s technic at this stage. If it is carefully carried out the baby frequently cries before the hchad is ,delivered and it is obvious that after the mouth has been brought to the vulva ha&e is not essential. Ordinarily I am in accord with Miller’s position about cephalic version not only because of the improbability of the head engaging immediately and satisfactorily in the new position but mainly because ‘I consider the averago breech delivery perfectly safe as a breech. Certainly this is in line Moreover, I have seen more than one instance with modern obstetric judgment. in which the new position was faulty and delivery by vertex presentation was accomplished with more difficulty than the original breech presentation could possihly have caused. DR. J. W. NEWMAN.-1 thoroughly agree with Dr. Miller in his attitude against being done very frequently today by promiscuous version. It is unfortunately both the skilled and the unskilled man, the general practitioner and the specialist in obstetrics. One cannot be too emphatic in the denunciation of such a procedure when it is done either on no indications at all or when the indications are manufactured. I am in hearty accord with what has been said about high forceps. I can think of no condition in which such a procedure is justified and it is never permitted on my service. I do not agree with Dr. Miller that we should decide which hand to use in bringing downi the foot by the position of the 285
child’s feet in relation to the mothc~r ‘s body. The mau who ordiuarily uses his right hand ought not to US(’ his 11% unless he is ambidextrous. Marc than once I have seen an attempt to follow this rule end in failure because the obstetrician was trying to use his left hand wh~u !in was accust,omed to do everything with his right. The choice of t!m foot is unimportant. Ji an arm should prolapse wyc never attempt to push it back; the risk of infection is too great after it has bceu exposed in the vagina and the result is usually too unsatisfactory. we put. a lool) of sterile tape around the arm and keep it down by traction us we make tralation on the feet. &Swinging the rhilds body upward over the mother’s abdomen to aid in the delivery of the arms is an excellent point theoretically but it, must be remembered that if it is not done very carefully serious damage may result to the child. When 1 first went into the Lying-In Hospital in Berlin this was the common practice but so many fractures of the clavicl’e and humerus resulted that it was ultimately abandoned. It is a mistake to insert the whole hand and try to jerk tho arm down. Insert two fingers aud sw-ccp it clown. This is one instance in which the arm used must correspond to the arm we are attempting to deliver. Another point which should be emphasized is that in the delivery of the aftercoming head all traction must 1~ upon the shoulder and never made hy the finger in the mouth. That is introduced solely for purposes of tlexion. I have seen more than one baby whose mouth was practically torn to pieces because this simple point had not been ohaerrcd and who eventually died of inanition hecause it coul(l not nurse.
in
DR. T. B. SELLERS-I all abnormal obstetric
believe procedures
that the necessity of cannot be emphasized
a tlcep ether too strongly.
anesthesia
DR. E. L. KING.-1 wish to emphasize the use of version in cases of placenta previa, particularly after preliminary dilatation with the bag. It gives the best results so far as the mother is concerned, and while cesarean section, which is often advocated, undoubtedly at times gi\-es better results for the baby, the argumeuts in its favor as a rule arc fallacious because such babim arc so frequently premature or exsanguinated that the mother’s interest should always bc paramount. It is almost a routinf: procedure in our cases of placenta prcvia at Charit,y (service of Dr. C. Jeff Miller) and our results have been excellent. 1 agree that cpisiotomy should~bc done in all primiparae, particularly if the version is to bc followed by immediate extraction. I feel that I have saved many babies by making traction on the head with forceps rather than exerting excessive force on the neck. Of course the head must he fairly well down, as the high application ‘c take issue with is never permissible and particularly in such instances as this. Dr. Miller and Dr. Newman on the question of inserting tlic whole hand into the vagina. I hart: had cases in whic~li I could not get the posterior arm down with two fingers but the introtluction of the whole hand brought it down at on~c. In connection with version I might mention that we hare had at Charity Hospital on our scrvicc in the last two months two casc;I of spontaneous version One was a multipara who has already from breech to vertex before labor began. delivered, the other is a primipara with a slightly contracted pelvis who is still awaiting delivery. Both cases were diagnosed as breech on admission, troth by The occurrence of examination and by x-ray, and both turned spontaneously. t,ho version in the primipara has bren checked up by examination and x-ray, and the mnltipara, as I stated, has alrrady delivered. h!. LEVY.--In connection with Dr. Newman’s DR. W. danger of using the fingers in the mouth for traction in Veit maneuver, I would say that for my own satisfaction
warning against the the Maurieeau-SmellieI have recently taken
SEW ORLUXS
GSN?COLOGICAL
two stillborn feti (neither of them were effects of traction made by the fingers in little effort I tore through the cartilaginous oven moro careful than I was before when
AEiD OBSTETRICBL
SOCIETY
287
delivered by version) and tested the the mouth. In both eases with very lower jaw and since then I have been this maneuver is employed.
DR. MILLER (closing) .-Commenting on Dr. Newman’s statement about the danger of swinging the feet up over the mother’s abdomen, I would say that deliberation is csscntial. Swinging is perhaps not. the right word. The- feet should bo lifted up after the scapulae arc showing at the vaginal outlet, which permits easy ,delivery of the arms. I do not mean t.o be d.ogmatic about which hand should be introduced to grasp the foot. Tlie assistant is the most important persun in the delivery of the after-coming head. Fortunately, I might say, after you have done a version your hand and arm are pretty well paralyzed and you cannot use much force, therefore, your assistant deserves most of the credit for the delivery of the head.
DR. W. E. LEVY reported a case of Preeclamptic by Pyelitis and Pulmonary Disease.
Toxemia
C‘omplic&ed
Mrs. H. L. L., primipara, twenty years of age, was admitted to Touro Infirmary (l-1-25), with a diagnosis of preeclamptic toxemia. She had been having headaches and blurred vision and at the time of admission was markedly edematous generally; her blood pressure was 178-122 and she ha.d 10 per cent of moist albumin. The estimated date of confinement was February 7. Routine tests showed a normal phthalein output, 5S, a high diastatie activity, 32, and practically negative eyegrounds. I might say that this is strictly in’ line with a recent article in the Jour. Am. Med. Assn. by Cheney of Boston, in which he makes the point that in true eclampsias the changes in the eyegrounds are negligible whereas in true cases of nephritis they are marked. The patient was put on expectant treatment, nonprotein diet, free purgation, frorced fluids, etc, and although she had no acetone or diacetic acid we gave her glucose and insulin. When she failed to improve, medical induction of labor (quinine, castor oil and pituitrin) was attempted but was unsuccessful. Her general condition seemed fairly good but the blood pressure remained persistently high, ranging from 158 to 166, and the albumin also showed a progressive increase. When the albumin suddenly reached 65 per cent, it was decided that expectant treatment was no l’onger justified and under light gas anesthesia catheters were inserted. Twenty-four hours later, in spite of repeated small doses of pituitrin, labor had not set in, therefore, the catheters were removed and a Voorhees bag inserted without difficulty, but it broke as it was being distended. There was nothing left to ado but rupture the membranes and precipitate labor. Pains began a few hours later and dilatation progressed rather slowly but quite satisfactirily. Twentyfour hours after the membranes had been ruptured labor was ended by low forceps. The child was alive and in good condition in spite of its prematurity and the overwhelming toxemia of the mother. On the day of delivery the patient had* a sudden elevation of temperature *to 301.5.” This did not persist, her blood pressuro dropped to 133-90 and the albumin to 5 per cent, and apparently she was making an excellent recovery when on the sixth day after delivery he; temperature rose sucldenly and sharply to 106” and she had a severe chill. In view of her previous toxemia, the intrauterine manipulations to which she. had been subjected and the accident as the bag was being inserted, there seemed no doubt that infection was present. The blood count, however, showed only 9,400 leucocytes and 85 per cent polyps. A blood culture was
ORLEANS
GYNECOLOGICAL
AND
OBSTETRICAL
SOCIETY STATED
MEETING,
MAIiCZ
13,
1925
DR. HILLI~D
E. MII~LER read a paper entitled Version, Its Indications and Contraindications. (For original article see page 241.) DISCUSSION
DR. PHILLIPS J. CARTER.-1 believe there is a definite indication for version in certain selected cases, particularly in primiparae with the masculine type of pelvis, funnel-shaped, where the spines and crests show a difference of Ya to 1 cm. and the true conjugate is about 8 cm. I recall one case particularly in which I did a cephalic version at eight months. It was a breech presentation and I am certain that I should have lost the chi1.d had I allowed it to continue as such. As it was, the results were excellent; I applied mid forceps after the head had been arrested for an hour and secured a living child. In another instance I did a cephalic version at the onset of labor. DR. JOHN F. DICK&-I agree fully in all but one point-when I am considcring version 1 pay a good deal of attention to the length of time which the membranes have been ruptured. I think that we cannot emphasize too strongly the importance of what are too often regarded as unimportant matters, such as careful emptying of the bladder, complete surgical anesthesia, an assistant who understands the mechanism of labor, and a slow delivery of the after-coming head. In version and extraction in primiparae particularly, episiotomy is a distinct aid to delivery; in fact, I do not believe it should be attempted in any case before a fairly deep episiotomy has been done. I know I have saved many children by this procedure. Dr. Miller stressed especially, gentleness and deliberation in the delivery of the after-coming head. I am heartily in favor of Potter’s technic at this stage. If it is carefully carried out the baby frequently cries before the hchad is ,delivered and it is obvious that after the mouth has been brought to the vulva ha&e is not essential. Ordinarily I am in accord with Miller’s position about cephalic version not only because of the improbability of the head engaging immediately and satisfactorily in the new position but mainly because ‘I consider the averago breech delivery perfectly safe as a breech. Certainly this is in line Moreover, I have seen more than one instance with modern obstetric judgment. in which the new position was faulty and delivery by vertex presentation was accomplished with more difficulty than the original breech presentation could possihly have caused. DR. J. W. NEWMAN.-1 thoroughly agree with Dr. Miller in his attitude against being done very frequently today by promiscuous version. It is unfortunately both the skilled and the unskilled man, the general practitioner and the specialist in obstetrics. One cannot be too emphatic in the denunciation of such a procedure when it is done either on no indications at all or when the indications are manufactured. I am in hearty accord with what has been said about high forceps. I can think of no condition in which such a procedure is justified and it is never permitted on my service. I do not agree with Dr. Miller that we should decide which hand to use in bringing downi the foot by the position of the 285
child’s feet in relation to the mothc~r ‘s body. The mau who ordiuarily uses his right hand ought not to US(’ his 11% unless he is ambidextrous. Marc than once I have seen an attempt to follow this rule end in failure because the obstetrician was trying to use his left hand wh~u !in was accust,omed to do everything with his right. The choice of t!m foot is unimportant. Ji an arm should prolapse wyc never attempt to push it back; the risk of infection is too great after it has bceu exposed in the vagina and the result is usually too unsatisfactory. we put. a lool) of sterile tape around the arm and keep it down by traction us we make tralation on the feet. &Swinging the rhilds body upward over the mother’s abdomen to aid in the delivery of the arms is an excellent point theoretically but it, must be remembered that if it is not done very carefully serious damage may result to the child. When 1 first went into the Lying-In Hospital in Berlin this was the common practice but so many fractures of the clavicl’e and humerus resulted that it was ultimately abandoned. It is a mistake to insert the whole hand and try to jerk tho arm down. Insert two fingers aud sw-ccp it clown. This is one instance in which the arm used must correspond to the arm we are attempting to deliver. Another point which should be emphasized is that in the delivery of the aftercoming head all traction must 1~ upon the shoulder and never made hy the finger in the mouth. That is introduced solely for purposes of tlexion. I have seen more than one baby whose mouth was practically torn to pieces because this simple point had not been ohaerrcd and who eventually died of inanition hecause it coul(l not nurse.
in
DR. T. B. SELLERS-I all abnormal obstetric
believe procedures
that the necessity of cannot be emphasized
a tlcep ether too strongly.
anesthesia
DR. E. L. KING.-1 wish to emphasize the use of version in cases of placenta previa, particularly after preliminary dilatation with the bag. It gives the best results so far as the mother is concerned, and while cesarean section, which is often advocated, undoubtedly at times gi\-es better results for the baby, the argumeuts in its favor as a rule arc fallacious because such babim arc so frequently premature or exsanguinated that the mother’s interest should always bc paramount. It is almost a routinf: procedure in our cases of placenta prcvia at Charit,y (service of Dr. C. Jeff Miller) and our results have been excellent. 1 agree that cpisiotomy should~bc done in all primiparae, particularly if the version is to bc followed by immediate extraction. I feel that I have saved many babies by making traction on the head with forceps rather than exerting excessive force on the neck. Of course the head must he fairly well down, as the high application ‘c take issue with is never permissible and particularly in such instances as this. Dr. Miller and Dr. Newman on the question of inserting tlic whole hand into the vagina. I hart: had cases in whic~li I could not get the posterior arm down with two fingers but the introtluction of the whole hand brought it down at on~c. In connection with version I might mention that we hare had at Charity Hospital on our scrvicc in the last two months two casc;I of spontaneous version One was a multipara who has already from breech to vertex before labor began. delivered, the other is a primipara with a slightly contracted pelvis who is still awaiting delivery. Both cases were diagnosed as breech on admission, troth by The occurrence of examination and by x-ray, and both turned spontaneously. t,ho version in the primipara has bren checked up by examination and x-ray, and the mnltipara, as I stated, has alrrady delivered. h!. LEVY.--In connection with Dr. Newman’s DR. W. danger of using the fingers in the mouth for traction in Veit maneuver, I would say that for my own satisfaction
warning against the the Maurieeau-SmellieI have recently taken
SEW ORLUXS
GSN?COLOGICAL
two stillborn feti (neither of them were effects of traction made by the fingers in little effort I tore through the cartilaginous oven moro careful than I was before when
AEiD OBSTETRICBL
SOCIETY
287
delivered by version) and tested the the mouth. In both eases with very lower jaw and since then I have been this maneuver is employed.
DR. MILLER (closing) .-Commenting on Dr. Newman’s statement about the danger of swinging the feet up over the mother’s abdomen, I would say that deliberation is csscntial. Swinging is perhaps not. the right word. The- feet should bo lifted up after the scapulae arc showing at the vaginal outlet, which permits easy ,delivery of the arms. I do not mean t.o be d.ogmatic about which hand should be introduced to grasp the foot. Tlie assistant is the most important persun in the delivery of the after-coming head. Fortunately, I might say, after you have done a version your hand and arm are pretty well paralyzed and you cannot use much force, therefore, your assistant deserves most of the credit for the delivery of the head.
DR. W. E. LEVY reported a case of Preeclamptic by Pyelitis and Pulmonary Disease.
Toxemia
C‘omplic&ed
Mrs. H. L. L., primipara, twenty years of age, was admitted to Touro Infirmary (l-1-25), with a diagnosis of preeclamptic toxemia. She had been having headaches and blurred vision and at the time of admission was markedly edematous generally; her blood pressure was 178-122 and she ha.d 10 per cent of moist albumin. The estimated date of confinement was February 7. Routine tests showed a normal phthalein output, 5S, a high diastatie activity, 32, and practically negative eyegrounds. I might say that this is strictly in’ line with a recent article in the Jour. Am. Med. Assn. by Cheney of Boston, in which he makes the point that in true eclampsias the changes in the eyegrounds are negligible whereas in true cases of nephritis they are marked. The patient was put on expectant treatment, nonprotein diet, free purgation, frorced fluids, etc, and although she had no acetone or diacetic acid we gave her glucose and insulin. When she failed to improve, medical induction of labor (quinine, castor oil and pituitrin) was attempted but was unsuccessful. Her general condition seemed fairly good but the blood pressure remained persistently high, ranging from 158 to 166, and the albumin also showed a progressive increase. When the albumin suddenly reached 65 per cent, it was decided that expectant treatment was no l’onger justified and under light gas anesthesia catheters were inserted. Twenty-four hours later, in spite of repeated small doses of pituitrin, labor had not set in, therefore, the catheters were removed and a Voorhees bag inserted without difficulty, but it broke as it was being distended. There was nothing left to ado but rupture the membranes and precipitate labor. Pains began a few hours later and dilatation progressed rather slowly but quite satisfactirily. Twentyfour hours after the membranes had been ruptured labor was ended by low forceps. The child was alive and in good condition in spite of its prematurity and the overwhelming toxemia of the mother. On the day of delivery the patient had* a sudden elevation of temperature *to 301.5.” This did not persist, her blood pressuro dropped to 133-90 and the albumin to 5 per cent, and apparently she was making an excellent recovery when on the sixth day after delivery he; temperature rose sucldenly and sharply to 106” and she had a severe chill. In view of her previous toxemia, the intrauterine manipulations to which she. had been subjected and the accident as the bag was being inserted, there seemed no doubt that infection was present. The blood count, however, showed only 9,400 leucocytes and 85 per cent polyps. A blood culture was