The bowels should be carefully regulated. The clothing should be supported from the shoulders, not from the waist, and heavy lifting should be avoided as much as possible.
After a woman has worn a pessary for three or four months, and it is found that the uterus remains in the normal position, the instrument should be removed and the result carefully watched.
If the uterus continues in its normal position of anteversion, a cure has been accomplished and the pessary may be discarded. If the retroversion returns, as it very often does, the pessary should be introduced again, and an unfavorable prognosis of cure by this means should be made. The patient must then choose between the use of the pessary for an indefinite period, under medical supervision, and cure by means of an operation.
The Smith pessary is better adapted to the shape of the vagina, which normally narrows from above downward, than is the Hodge instrument. The Thomas pessary, in which the upper bar is made very broad, is applicable to cases of sharp retroflexion with retroversion, in which the upper bar may become fixed in the angle of flexion in case the retroversion returns. The upper bar is made so broad that the angle of flexion would be spanned by it in case of such an accident.
The action of the pessary depends upon the integrity of the vagina and the pelvic floor. The retroversion pessary, therefore, cannot be used when there is a laceration of the perineum. In such a case the perineum must always be closed as a preliminary step.
The pessary should not be used when there is a laceration of the cervix uteri, for traction upon the posterior lip of the cervix increases the eversion.
The pessary is contraindicated in all cases in which there are pelvic adhesions restraining the uterus, in those cases in which there is inflammatory disease of the Fallopian tubes, and in cases where there is prolapse of the ovary, which may be pressed upon by the upper bar of the pessary.
Before making any attempt to replace a displaced uterus the physician should always make a careful bimanual examination to determine the existence of any acute or chronic inflammation of the Fallopian tubes or the ovaries. Such inflammation is a contraindication to the use of the pessary and to any of the manipulations for replacement of the uterus that have already been described.