109

ild not

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it does

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ig. 51 and it is to be

etter grasp

be in good condition and the outlook for saving the child not too poor, resort to symphysiotomy.

The indications for version almost always presuppose immediate delivery.

Much has been written on the subject, "Which foot should be drawn down?" If there is no immediate reason for haste and the operator has time to make his selection, it would seem that it is best to draw down that foot which is nearest the anterior surface of uterus. In actual work, however, it does not make much difference which foot is brought down. That

Fig. 51. Introduction of the Left Hand to Bring down the Posterior (Left) Leg.

one is usually best which can be soonest recognized and most firmly grasped (Plate VI).

It is better, in primiparæ certainly, and often in multiparæ, that one foot only be brought down, for the cervix which has permitted a half-breech to escape will be less likely to grasp the after-coming head than if it has been dilated by the pelvis alone. If, however, traction on one leg does not prove successful, it will be necessary to draw down the other (Fig. 51 and Plate VII). As the foot emerges from the vulva it is to be wrapped in a warm towel, which not only offers a better grasp

on the part, but also tends to prevent the cool air of the room from causing enough reflex irritation to establish respiratory efforts on the part of the child. Soon the leg can be grasped in the same way, and at this time traction is to be made in the axis of the brim downward (Fig. 52).

It is very necessary that during the entire process of extraction the assistant should make well-directed pressure on the child's head. This tends to prevent extension of the head and

Fig. 52. Showing Direction of Traction.

also furnishes the vis a tergo which the patient, by reason of the deep anesthesia, cannot give.

As the buttocks emerge from the vulva, one finger of the hand corresponding to the flexed thigh should be hooked into the groin; this will enable the operator to lessen the traction on the extended leg, and at the same time permit him to exert greater tractile force. By raising the buttocks and making traction upward the flexed thigh can be made to clear the vulva. The pelvis should now be grasped with both hands and drawn downward again in the axis of the brim.

As the cord comes down it is to be drawn upon from the placental side, and if it is over one of the legs it must be released (Fig. 53) and placed in the most favorable position as regards pressure. In rare instances it will be impossible to draw the cord down without making undue traction. If such should prove to be the case, it should be secured by means of two artery-clamps and cut. Of course, if this is done, it will be necessary to hasten the delivery as much as possible.

When the scapula appear the arms must be liberated before extraction is continued. Under favorable circumstances, -that is, if the assistant has kept up intelligent pressure on the fundus, or if the cervix was fully dilated previous to the

Fig. 53.-Method of Releasing the Cord.

version, or if the operator has not made traction in too rapid a manner, the arms will be folded on the chest and their extraction will be easy.

Even in the hands of the best operators and with the best assistants the arms sometimes become unavoidably extended. Although their extraction must be accomplished in as rapid a manner as possible, there is no need of breaking the arm if care is taken.

The arm which is to the rear is usually more easily liberated. To do this the operator seizes the legs with one hand and carries the child's body well upward. This will cause the posterior shoulder to be more readily reached, and will permit more room for the manipulations necessary. Two fingers of