Obstetric Version

OBSTETRIC VERSION, an operation by means of which one can change a given position of the fetus, for some reason unfavorable for the course of labor, to another, more favorable one, and of course, always only to a longitudinal position. (History of O. v.-see Obstetric Operations). The most unfavorable position is undoubtedly transverse, resp. oblique. To correct it and make it into a proper longitudinal position, one can turn the child to the head or to the breech. But sometimes longitudinal positions are also unfavorable and require correction. In such cases, it is necessary to convert a longitudinal cephalic presentation to breech, and conversely, a longitudinal breech presentation to cephalic. Thus, four types of version are obtained: 1) version from transverse position to head, 2) version from transverse position to breech, 3) version from head (longitudinal cephalic presentation) to breech, 4) version from breech end to head. Of these four varieties, versions to the breech are of the greatest importance for the practical physician. They occur equally often in practice: version from transverse position to breech occurs in approximately 1.4% of all births, and version from head to breech- * about 1%. The other two types of version (to the head) are almost never used at present.-General indications for version. In transverse, resp. oblique, position of the fetus, the indication for version is the transverse position itself; labor in such a position cannot end spontaneously, by natural forces. Rare cases of spontaneous version and spontaneous rotation should not be counted. In the final result, for a woman in labor with transverse position, in the absence of proper assistance, rupture of the uterus threatens; hence it is clear that with transverse or oblique position there is also an indication for version. For version from longitudinal cephalic presentation to breech, the general indication is the need for rapid termination of labor in the interests of the mother, the child, or both together (eclampsia, placenta previa, premature separation of the placenta, prolapse of the umbilical cord, beginning asphyxia of the fetus, etc.). Some incorrect presentations of the head (posterior face, brow) or its incorrect insertion [e.g., Litzmann's] under appropriate conditions also require correction by means of version.-A special place among the indications for version is occupied by a narrow pelvis ('preventive version in a narrow pelvis'). Even Simpson at one time proved that in a narrow pelvis the occiput passes through the narrowed place better than the presenting part. This was explained by the peculiarities of the shape of the head. On a frontal section, the head represents a double wedge, with one part of this wedge, directed downward, pressing with its point into the foramen magnum, and the other, directed upward-into the sagittal suture. According to the laws of mechanics, the action of any wedge will be the stronger, the sharper the wedging angle. With the occiput, this angle will indeed be sharp-and with the presenting part-blunt. Such, in fact, is the theoretical justification for the so-called preventive version. Practice, however, has shown that the indicated theoretical calculations are not justified by reality. The experience of the vast majority of clinics with indisputable convincingly proves that in a narrow pelvis the leading head, with its amazing, exceptional ability to configuration, the limits of which can never be foreseen in advance, passes through the narrowed place of the pelvis much better and with greater benefits for the child than the occiput. By forcibly intervening in the mechanism of labor in a narrow pelvis during version, we thereby disrupt those appropriate adaptations that are obtained during the period of head configuration and thanks to which the latter can pass through the narrowed place-and there is nothing surprising in the fact that, undertaking a preventive version in the interests of the mother and child, the obstetrician, in the overwhelming majority of cases, suffers complete failure: after a difficult version, an unsuccessful extraction of the fetus by the breech usually follows, and at its conclusion-almost inevitable perforation. At present, preventive version is not used in most clinics. In percentage terms, the indications for version fluctuate within the following limits (100%-all cases of preventive version): Transverse oblique position . .5 3.0% Placenta previa. . . 17.0 „ Beginning asphyxia of the fetus . 11.0 „ Prolapse of the umbilical cord.......10.5, Eclampsia............4.0. Other complications.......4.5 „ Conditions necessary for version: 1) absence of absolute narrowing of the pelvis and significant degrees of relative narrowing: the true conjugate during version (actually, for subsequent extraction) should be at least 8-8.5 cm; 2) the fetus must have sufficient mobility; 3) a certain degree of opening of the uterine cervix is required, at least 2-3 fingers, to perform a combined version. From this follow the contraindications for version. Version, therefore, cannot be done if the dimensions of the pelvis and head do not allow the possibility of its passage through the birth canal. Version is contraindicated when the fetus, in transverse position, has long lost all mobility (the so-called neglected transverse position) and when the version operation is equivalent to the risk of getting a rupture of the uterus with all its fatal consequences. Version also cannot be done with a threatening rupture of the uterus, as well as with a ruptured uterus, in the first case-due to the fear of causing a rupture, and in the second-due to the fear of increasing the size of the already occurred rupture. The correct operative procedure in both cases will be one of the destructive operations for the fetus.-The conditions under which the version operation can be performed are not particularly complicated; a bed with transverse position, thorough disinfection, according to general rules, of the external genital parts of the parturient, and, necessarily, of the lower part of the abdomen are required. One should also not forget about the mandatory emptying before the version operation of the bladder and rectum. In severe cases, anesthesia is necessary. Technique of version. Technically, preventive version can be performed by applying one of the following four methods: ^by changing the position of the parturient, 2) external methods [external version according to Wigand], 3) internal methods (internal or classic version)-and 4) external-internal method [combined version according to Braxton-Hicks].-Version by changing the position of the parturient is performed as follows: the parturient is placed on the side where the large part of the fetus is located, on which one wants to turn the child. If, for example, there is an oblique position and the head is on the right and closer to the entrance to the pelvis, the parturient should be placed on the right side, in which case the buttocks, as the more voluminous part, together with the trunk will fall to the same side, and the head, deviating to the left, will approach the midline, i.e., to the entrance to the pelvis. The described method of version has to be used rarely. First of all, it can only be used with oblique positions; with transverse positions, and even more so with longitudinal positions, it is obviously not applicable. In addition, for this version, an extraordinarily large mobility of the fetus (intact membranes, large amount of amniotic fluid) is required, which is often not present in practice. Ultimately, the method of version under consideration can only be tried in the last months of pregnancy, if the pregnant woman has an oblique position. By making her lie on the corresponding side, we can thereby achieve correction of the incorrect position.-External version (according to Wigand) is performed only by external methods, without any effect from the side of the vagina: one hand of the obstetrician is placed on the head, the other-on the breech end, and with appropriate pushing movements, the presenting part is made to descend downward, and the other large part-to move in the opposite direction, upward. Everything said about the first method of version can be fully attributed to the external version as well. The advantage of this version over the first is that it can be done not only with oblique, but also with true transverse position. With longitudinal positions, version according to Wigand is not applicable. If with the help of external version it is possible to correct the incorrect position of the child, subsequently care should be taken to fix the achieved result, making the parturient lie on the side where the presenting part was previously located (usually the head). To counteract the backward movement of the head, it is recommended to place a pillow (roller), fixing it with bandages. The same can be achieved by rupturing the membranes, of course, if there is sufficient dilatation of the uterine cervix.-Internal version (classic) is performed with the help of the entire hand, which is inserted into the vagina and uterus, and in this case it is helped by the external hand. The main role in the classic version belongs to the internal hand. This method is dangerous in terms of introducing infection into the uterine cavity.-Combined version (according to Braxton-Hicks) is performed as follows: the entire hand is inserted into the vagina, and into the uterus-only two or three fingers, depending on the dilatation of the cervix.

As with internal version, the external hand here assists the internal one, in which case it assumes the primary importance. The version according to Braxton-Hicks can, accordingly, be performed with earlier dilation of the uterine cervix, which is utilized under certain pathological conditions. - The most frequently encountered in practice are: version from transverse position to breech and from vertex to breech (in their various modifications). Version from transverse position to breech occurs frequently (in 53% of all cases of version). It can be performed by all four methods. At the end of pregnancy, one can attempt, especially if there is an oblique position, to correct the latter by changing the position of the pregnant woman. During labor, correction of transverse position should begin, if suitable conditions exist, with external version. More often, however, due to the absence of favorable conditions, one must refrain from external version and perform an internal one. Combined version is performed for special indications (see below). A. Internal (classic) version from transverse position to breech. In the version, three moments should be technically distinguished: 1) introduction of the hand, 2) finding and grasping the leg, and 3) turning the fetus (the actual version).- 1. Rules for introducing the hand. It is recommended to introduce a specific hand, and with transverse position, it is more correct to introduce the hand corresponding to the fetal breech, considering the side of the accoucheur. Thus, with first transverse position (head to the left), the left hand is introduced, since the breech is on the left side of the accoucheur. With the second position, the relationships will be reversed. The hand should be introduced during a pause, outside of a contraction; it is introduced in a fist-like manner: the thumb is bent toward the palm, and the other fingers are tightly closed at the tips. The hand should be moistened with lysol, otherwise it is difficult to introduce into the vagina. The hand is introduced in the anteroposterior diameter of the pelvis; after passing through the vaginal introitus and being inserted to the wrist, it is turned into the transverse diameter of the pelvis, in such a way that its dorsal surface faces toward the sacral hollow. Only after this is the hand introduced into the uterus. This concludes the first moment of the operation.-2. Rules for grasping the leg. A specific leg is located and grasped. With transverse position, the leg should be grasped depending on the type of transverse position. With the anterior variety (spine forward), in order to support it as the most favorable, the lower leg should be grasped; when grasping the upper leg, the posterior variety can easily occur in such cases, which is certainly unfavorable in all respects. With posterior varieties, conversely, the upper leg should be grasped, as this makes it easier to convert the posterior variety to anterior. When grasping the lower leg, ceteris paribus, we maintain the posterior variety, which, obviously, should not be done at all. When locating the leg, two methods can be used: to go directly to where the legs are (short method, German), or to reach them gradually - first advancing the hand along the fetal spine, descending to the buttocks, then going along the thigh, leg, and thus reaching the corresponding leg (long method, French), which is grasped at the ankle joint. When choosing a leg, the French method must of course be used. One leg is always located and grasped, i.e., in other words, the version is performed on one leg, not both. By bringing one leg down, we convert the transverse position to an incomplete breech presentation, in which the buttocks, going together with the other leg, better contribute to the dilation of the uterine cervix, and thus better prepare the soft birth canal for the subsequent passage of the head. When locating and grasping the leg, it is necessary to pay attention to one essential detail which has exclusively important significance. When locating the leg, the external hand assists the internal one; it lies on the breech and lowers it to the pelvic inlet, toward the internal hand. But as soon as the leg is found and grasped, it is necessary to immediately transfer the external hand from the breech to the head and push the latter away. If this is not done and after grasping the leg the external hand is left in its previous position (pressing on the breech), so-called head entrapment can occur - a complication that threatens complete failure of the version (see below). 3. Turning the fetus, the actual version. Here one must remember the following three rules: a) the fetus must be turned outside of a contraction, b) traction must be performed downward, toward the perineum, because traction toward oneself and especially upward will be hindered by the symphysis, and c) these tractions must be performed until the knee of the fetus emerges from the vulva. Only then can one be certain that the fetus has assumed the correct longitudinal position. When the leg is brought out to the knee, the version is complete. Further, if there are no special indications, labor is left to the forces of nature and conducted as with incomplete breech presentation. If, however, there are indications for rapid termination of labor, so-called extraction of the fetus by the breech is then performed. Prognosis. Maternal mortality after classic version from transverse position to breech is approximately 3%, with it being twice as high in primiparas as in multiparas. Of course, in this case, a significant portion of the mortalities falls on those complications for which the version is undertaken. If one considers the reduced maternal mortality after classic version, it will not exceed 1%. Maternal mortality in version is associated with the possibility of uterine rupture, as well as large ruptures of the cervix with severe subsequent hemorrhage. Infection also occupies not the least place in this regard. Fetal mortality in classic version from transverse position to breech is approximately 30%. And here, of course, the complications of the birth act itself, which can cause the death of the fetus (placenta praevia, eclampsia), are of great importance. Fetal mortality in connection with the version operation itself barely exceeds 5%; in primiparas it is also greater than in multiparas. B. Combined version according to Braxton-Hicks from transverse position to breech. One of the main indications for such a version is placenta praevia. Recently, however, such a version is performed significantly less often even with placenta praevia, having given way to classic cesarean section. The version according to Braxton-Hicks is performed with the uterine cervix dilated to two or three fingers. The operation is performed by the same rules as internal version. The hand corresponding to the fetal breech is introduced into the vagina, considering the side of the accoucheur, and only two or three fingers are introduced into the uterus, which must grasp the leg. In this case, all importance belongs to the external hand, which lies on the breech, lowering it to the pelvic inlet, to give the fingers of the internal hand the opportunity to grasp some leg. With placenta praevia, bullet forceps can be used to grasp and lower the leg. The grasped and lowered leg in placenta praevia acts as a tampon to stop the bleeding. Of course, with insufficient dilation of the uterine cervix, no further extraction of the fetus can be performed, and even less so with placenta praevia. Labor after lowering the leg should be left to the forces of nature. Technically, combined version is extremely difficult. The difficulty of this atypical version lies in the fact that with two fingers introduced, it is almost impossible to penetrate high enough to grasp and lower the leg. Version from vertex (longitudinal cephalic presentation) to breech. The version is performed by two methods, internal and combined. Internal version with longitudinal presentation is performed by the same rules as with transverse position. A specific hand (corresponding to the small parts, again considering the side of the accoucheur) is introduced into the vagina and uterus; the hand is introduced as deeply as possible (to the elbow), the upper (anteriorly lying) leg is located by the French method, and it is lowered according to the rules mentioned above. When introducing the hand into the uterus, it is important to first push the head aside and especially important not to forget to promptly transfer the external hand from the breech to the head after the leg has been grasped. Head entrapment here is particularly unfavorable. When turning from vertex to breech, the leg can be confused with the hand. To avoid this, it is necessary, first, to introduce the hand more deeply (to the elbow), and then, when grasping the leg, to pay attention to the heel tuberosity, which distinguishes the leg from the hand. Combined version from longitudinal position to breech is performed almost exclusively with placenta praevia. Everything that has been said regarding combined version from transverse position to breech fully applies also to the version according to Braxton-Hicks with longitudinal positions.

From a technical standpoint, a combined version in longitudinal positions is of course even more difficult than in transverse positions. Maternal mortality in version from longitudinal vertex to foot position is significantly higher (4%) than from transverse position. Version performed with full dilation of the uterine cervix results in lower mortality (1.7%) than with incomplete dilation (6%). Fetal mortality in version from longitudinal to foot position is also higher than in version from transverse position. Mortality in this version among primiparas is particularly high. An inexperienced physician, in the early stages of his practice, will act correctly if he performs version in primiparas only for maternal indications (transverse position, eclampsia), and not for fetal indications. Complications and failures of version. The most important complications and causes of failure of version are as follows: 1. Prolapse of small parts (hands and cord) during version from transverse to foot position. In transverse position, the prolapsed small part cannot be replaced. Replacement in this case is pointless, as the replaced part usually prolapses again. When prolapse occurs, without attempting correction, one should immediately proceed with version if the necessary conditions are present. A loop should be applied to the prolapsed hand so that it cannot subsequently be thrown over the head. It is useful to determine which hand has prolapsed—right or left—as this allows for accurate orientation regarding the type of presentation in transverse position, and the type of presentation is important when choosing the foot. Determining which hand has prolapsed is not difficult: one only needs to greet the prolapsed hand (greeting can only be done with the homonymous hand). 2. Version fails because traction is applied incorrectly. According to rules, traction should be applied downward, whereas the obstetrician sometimes pulls toward himself or upward. 3. Version is performed during a contraction, when it should be performed between contractions. 4. Head entrapment has occurred because the obstetrician forgot to transfer his hand from the pelvic end to the cephalic end after grasping the foot. In such cases, it is first necessary to attempt to push the head away. If this fails, the other foot should be brought down, thereby creating more space in the uterine cavity, and another attempt made to push the head away. If this also fails, the following two approaches are recommended: either perform perforation or first try the so-called manual double maneuver according to Smellie-Siegemundin. This maneuver is performed as follows: a loop is applied to the grasped foot, which together with the hand is withdrawn from the vagina; the other hand, corresponding to the head, is inserted, which pushes the head away, while the outer hand pulls on the loop, i.e., on the pelvic end. Thus, both hands act on both ends. This maneuver is undoubtedly dangerous, for which reason some obstetricians completely abandon it (Fomenov called it "version at all costs"). 5. Crossing of the legs can also be a cause of failure: the leg resting on the symphysis, crossing with the leg being brought down, hinders the turning of the fetus. It is necessary to bring down the other leg to remove the obstruction. In conclusion—brief remarks about versions to vertex. Version from transverse to vertex position, as already indicated, is extremely rare. When performing version to vertex, one must be certain that no obstacles will be encountered in the further course of the labor for its natural progression. One of the main requirements in this case is the absence of any narrowing of the pelvis, even if only to the slightest degree. Version from transverse to vertex position can be performed by all four methods described above. Of these, at present, external version appears to be the natural method, which is nevertheless rarely applied. The other methods have fallen into disuse. In a few words, we will only mention the internal version to vertex. In this case, it is performed in two ways—according to Busch and according to d'Outrepont. Version according to Busch is performed as follows: the hand corresponding to the head (counting from the obstetrician's side) is inserted, which directly grasps the head, while the outer hand pushes all other parts upward (direct version). According to d'Outrepont, the reverse is done: the hand corresponding to the pelvic end is inserted; it pushes everything upward except the head, while the outer hand brings the head down to the pelvic inlet (indirect version). Version from pelvic to vertex position is not applied by anyone today. No one, having a foot in hand, will perform version to vertex when the further course of labor will already be beyond the obstetrician's control. In former times, this type of version was recommended for two indications: a) to avoid large tears in elderly primigravidas, and b) to avoid a dead fetus, especially in cases where previous vertex presentations ended in fetal death.