66 OBSTETRICS. 



posed to favour the engagement of the head in the first position. If 

 the membranes have not ruptured at the commencement of this stage, 

 and the head has passed the circle of the os uteri, they may be 

 broken either by pressing the finger upon them during a pain, or by 

 means of a probe passed along the index-finger, provided always, 

 that it is not a first labour, and the attendant is satisfied that their 

 usefulness as a dilating agent is at end. 



When the head has reached the floor of the pelvis, and is begin- 

 ning to distend the perineum, the latter should be supported by the 

 palm of the left hand, (guarded with a soft napkin,) in such a way 

 as to delay the passage of the head slightly, and to bear it towards 

 the pubis, so as to prolong the curve of the sacrum, and make cer- 

 tain of the head being carried forward to the anterior orifice of the 

 vagina, and not allowed to perforate the perineum for want of a just 

 support. 



As the head escapes from the os externum, it should be received 

 in the hand of the practitioner, and allowed to perform the motions 

 of restitution, carrying it forward as the shoulders are expelled ; he 

 should also be careful to observe whether the cord is twisted about 

 the neck, and if it be to disengage it. The perineum should be 

 supported during the exit of the shoulders, and the whole body car- 

 ried forward in the axis of the pelvic outlet, and not by any means 

 pulled out^ in order to relieve the woman from pain, and facilitate 

 the delivery. 



When the child is entirely born, and respiration is established, or 

 the cord ceased to pulsate, it may be separated from the mother. 

 To do this, one strong ligature should be tightly tied around the 

 cord about two inches from the umbilicus, and another about an inch 

 further on, and the cord cut between them. The two ligatures are 

 useful in case of twins, which sometimes have a common placenta, 

 and also for the sake of cleanliness. 



The accoucheur should then place his hand on the abdomen of the 

 mother, for the purpose of ascertaining whether there be a second 

 child or not, and also tC discover, from the state of contraction of the 

 uterus, whether the placenta is discharged or not. 



If the uterus be well contracted, the placenta will probably be 

 found in the vagina ; as soon as it has descended so low that he can 

 feel the insertion of the cord, he may withdraw it by gentle traction 

 in the axis of the vagina. No force should be used in this operation, 

 for fear lest the placenta should be still adherent, and thus the risk 

 of inversion be produced, or the cord torn from its insertion. The 

 pudendum should now be carefully and gently dried, and covered 

 with warm napkins ; after which the binder should be so applied as 

 to extend from the pubes to the ensiform cartilage, and drawn 

 moderately tight, thus afTording an adequate support for the uterus 

 and abdominal viscera. 



