A Text-book of Diseases of Women

by Charles B. Penrose

Fig. 94.—Replacement of retrodisplaced uterus by means of the uterine repositor, with patient in the knee-chest position (Baldy).

Sometimes it is not possible to make the entire correction of the displacement at one time. The uterus may perhaps be reduced from retroversion of the third degree to that of the first degree, and at a subsequent attempt it may be reduced still more, until finally it is brought to its normal position. In some cases the difficulty of producing complete reduction at one time is due to the fact that the woman is unaccustomed to the position and the manipulations, and is constantly straining and involuntarily resisting. Complete relaxation of the abdominal walls is necessary.

If the uterus can be reduced to the normal position, the pessary may be immediately introduced. If the reduction is not complete, it is best to pack the vagina with cotton to maintain the degree of reduction that has been attained, and to repeat the attempt the next day, continuing in this way until the uterus has been brought approximately to its normal position, when the pessary should be introduced. The cotton should be packed into the vagina in the form of balls or pledgets about one and a half inches in diameter, which should be introduced with the forceps ([Fig. 95]) and carefully and tightly packed into the posterior vaginal fornix. Other pieces should then be packed against the anterior aspect of the cervix, and then the rest of the vagina should be rather loosely filled.

Fig. 95.—Uterine forceps.

The pessary should be introduced with the woman in the knee-chest position. A number of pessaries, of various sizes and shapes, should be at hand, in order to have a suitable assortment for choice. The pessary must be of the proper length, breadth, and shape; these requirements differ in various cases. The length of the pessary should be such that when the upper transverse bar lies in the posterior vaginal fornix the lower transverse bar is over the position of the internal urinary meatus. The course of the urethra is marked by small transverse folds of mucous membrane on the middle of the anterior vaginal wall, and the internal urinary meatus is situated approximately where these small transverse folds cease and become merged into the larger oblique folds of the vaginal walls. This distance may be measured upon the uterine repositor or it may be estimated with the eye.

It should be remembered that all the dimensions of the vagina are exaggerated in the knee-chest position, as the vaginal canal is distended by atmospheric pressure. The width of the pessary should be such that there is no lateral tension put upon the vaginal walls.

The curvature of the pessary should be such that the upper transverse bar does not press upon the posterior aspect of the cervix, but is so placed that the posterior vaginal fornix is drawn upward and backward.

The curvature of the pessary may be altered to suit any case by dipping the instrument in oil and gently heating it over the flame of a spirit-lamp. In this way the rubber is softened and may be pressed into any shape. While soft and under pressure it should be plunged into cold water to set it in the altered form.