SOME THOUGHTS ON MALPOSITIONS AND MALPRESENTATIONS.

BY EDWIN H. SIMS, M.D., COLUMBUS, GA.

In casting about for a subject on which I might write something to interest you gentlemen, I have selected this one, not that I consider myself better prepared on this particular branch, but because I consider it a subject in which we are all more or less interested, and one, too, upon which we might spend profitably much time and labor to our own gratification and with great and lasting benefit to our patrons.

I shall not attempt to exhaust the resources of my subject, as it is practically fathomless, but I shall endeavor to call your attention to a few points in obstetrics that have been useful to me, hoping thereby to solicit a discussion that will be of mutual benefit.

I fear that many of us feel too lightly the great responsibilities conferred upon us when we are engaged to pilot the pregnant woman through the greatest ordeal of her life, and to call your attention to our duty to her under these circumstances is the object of this paper.

Beginning in the early stages of gestation when all things appear to be normal, we have to direct out attention to her diet, limiting the quantity of fluids and foods rich in albumen, because the former in too great quantities has a tendency to produce hydrops amnii, and the latter, excessive growth of the fetus. Meats, green vegetables and potatoes should be allowed, while eggs, peas and beans should be avoided. Under this régime there will usually develop a small, but a vigorous and healthy child, and the tendency to the formation of an excessive amount of liquor amnii is reduced to a minimum. I wish especially to call your attention to this point, because in my opinion, in the majority of cases of malpositions, we have this abnormality as a casual factor; at any rate this has been my personal experience.

It is much to be desired that a small and vigorous child be produced, that it may better withstand the ordeal of labor, and more particularly if instrumentation is resorted to in effecting delivery. I need not tell you that a small, yet strong child is to be desired, for you at once realize that a small fetus can be more easily delivered and with less damage to the parturient canal, and hence less peril to the life of the mother, while the stronger the child, the greater the probabilities of its being delivered alive.

Given a case of hydrops amnii with the uterine cavity distended to proportions incompatible with the size of its contained fetus, we can easily see how abnormal positions are assumed; therefore, we should carefully watch our patient and adopt such dietary regulations as will tend to prevent this abnormal condition of things. It has been wisely said that "to be forewarned is to be forearmed."

The physician should as early as possible obtain a perfect mental picture of the intrauterine position of the fetus. External palpation and intravaginal digitation will, in most instances, make for us a correct diagnosis, but diagnostic errors are not infrequent, even to experts, when only those methods above are resorted to; hence auscultation of the fetal heart-sound will frequently be of service in diagnosticating the intrauterine position of the child.

In external palpation we have a diagnostic agent too seldom used and too seldom appreciated, I fear. And those who will accustom themselves to study every obstetrical case in this way will be surprised to see how soon experience will yield happy results. A necessary prerequisite to an intelligent management of a case of labor is a correct diagnosis of the presentation. By presentation, is meant that part of the fetus which enters the pelvic inlet. In the vast majority of instances, the presentation may be determined prior to labor by the diagnostic agencies already named.

The longitudinal axis of the fetus may be coincident with that of the uterus, or it may occupy the transverse diameter, or it may assume an intermediate position. The first of these positions is normal, while the others may be regarded as abnormal.

To properly perform abdominal palpation, the pregnant woman should lie on her back with the legs flexed on the thighs, and they on the abdomen, the entire body covered with a thin sheet. The bladder should, of course, be empty. There need be no exposure of the patient's person, and if the reasons for the examination are explained to her, she will rarely offer any objection to the procedure; on the contrary, she will have a higher regard for her attendant, who impresses her that he is taking every precautionary measure that might be good for her ultimate welfare.

By percussion the outline of the uterus is determined. The flattened hands are now made to traverse the uterine tumor with a view of determining the direction in which the uterus is elongated; marked increase in the transverse diameter suggesting that the fetus occupies this diameter, chiefly, and, in which event, the fetal poles on deep palpation will be found above the iliac crest, one above and the other below a line drawn through the center of the uterine tumor transversely. The patient should be counseled to breathe quietly, and resist any effort to contract the abdominal muscles. The tips of the examining fingers may thus be insinuated more deeply, and a greater sense of resistance will be met with at one or the other side of the uterine tumor. To the touch the sensation may be one of greater hardness and the outline may be rather spherical. In this instance, the inference is that the fetal head is being palpated. If this portion be struck sharply it will ordinarily rebound from the fingers, giving abdominal ballottement. In case the abdominal walls be thin and the gestation advanced to about the seventh month, the palpating hand may trace the outline of the fetus from this hard surface along the dorsum to the breech and may reach the fetal small parts usually the feet. The dorsum of the fetus being harder than the anterior aspect, and being applied closer to the uterine walls, always yields a greater sensation of hardness.

The evidence thus obtained of transverse or of oblique position as regards the uterine axis may now be corroborated by palpating at the pelvic brim. The fingers of one or both hands are applied just above the pubes and pressed down as far as possible. If the fetus occupies the transverse diameter of the uterus, no fetal extremity will be found in the pelvic inlet unless there be multiple pregnancy, in which event corroborative evidence must be sought.

Vaginal examination will clear up any doubt as to whether the pelvic inlet or the space just over it be occupied. When the fetus presents with its longitudinal axis coincident with that of the uterus, digital examination, per vagina, will reveal a fetal pole resting in the lower uterine segment. If this segment be not occupied and external palpation has revealed the transverse axis of the uterus occupied, the inference is clear that we are dealing with a transverse presentation. This presentation may be directly transverse or oblique. In the former event the longitudinal axis of the fetus will be coincident with the transverse axis of the uterus; in the latter, one fetal pole will be found just above one or the other iliac crest.

Auscultation will assist in making a correct estimation of the fetal position. When the position is transverse, the beat of the fetal heart will be heard approximately in the mid-line, variable in its distance from the pubes, depending upon whether the dorsum of the fetus is anterior or posterior. The information of the transverse or oblique position of the fetus thus acquired is especially valuable, since, if detected before rupture of the membranes and in the presence of a sufficient amount of amniotic fluid to allow of the procedure, external manipulation will enable us to convert it into a vertex presentation. Transverse or oblique presentations militate against normal labor, and whenever detected, proper efforts should be made toward converting them into cephalic or breech presentations— preferably the former. Under these conditions the shape of the uterine tumor is more that of a flattened sphere, the transverse diameter not being enlarged out of proportion to the longitudinal.

By palpation occipito-anterior and occipito-posterior positions can usually be diagnosed. There is a distinct sense of resistance when the dorsum of the fetus is applied to the anterior parietes of the uterus. When the dorsum of the fetus is posterior the resistance will not be felt except on deep palpation, but instead, the small parts (usually the feet), may be palpated with greater or less ease, according to the amount of adipose tissue in the abdominal walls, and the quantity of liquor amnii.

In the early part of last year, the author was called to see a primipara at about the seventh month of gestation. He found a small woman with thin abdominal walls, with a fetus presenting an occipito-posterior position. The feet and hands were easily palpated. After several ineffectual