452 DYSTOCIA. 



1017. The left hand is to be introduced; the thumb is to be press- 

 ed on the anterior face of the shoulder or the sternum; the other 

 fingers slip behind the scapula or chest, and the little finger remains 

 turned towards the child's occiput. 



To conform to this rule, the hand ought to be introduced half 

 supine, or in a more or less complete state of supination or pronation, 

 accordingly as the vertex happens to be near the symphysis pubis, 

 the sacro-vertebral angle, or the iliac fossa; after having raised up the 

 shoulder, taking care at the same time to push it backwards, so 

 that the anterior surface of the fcEtus may look somewhat down- 

 wards, we should endeavor to push the head towards the middle of 

 the iliac fossa, provided it were at too great a distance from it be- 

 fore, which often requires a skilful combination of the efforts of the 

 hand that presses upon the hypogastrium with those of the one which 

 is operating in the womb. The thumb then abandons the sternum, 

 is placed alongside of the index, and for the remainder of the pro- 

 cedure we act as was directed in speaking of the left occipito-iliac 

 position. 



1018. When the head is found completely in front (left dorso- 

 iliac position), or even somewhat near the right acetabulum, we may 

 proceed as above; only that in order to get hold of the right shoul- 

 der, the hand is in a forced state of supination, and that after having 

 lifted it up, the head is to be carried from right to left, as far as pos- 

 sible, towards the iliac fossa, by acting chiefly with the thumb exact- 

 ly applied to the sternum. 



In cases where it is situated very near the posterior median line 

 (right dorso-iliac position), it is very difficnlt to bring it back to the 

 left extremity of the great diameter of the pelvis, because the thorax 

 only moves, whereas the head retains its primitive position. To 

 overcome this difficulty, we are to support the upper part of the 

 chest with the thumb and fore finger, while the others are extended 

 as far as the occiput, and thus serve to push from behind forwards, 

 and from right to left, as if we wished to tilt it over from the occiput 

 towards the chin. 



1019. Borso-pubal position (4th of Baudelocque). The maceu- 

 vre is generally much more difficult in this than in the preceding po- 

 sition, for it can scarcely be terminated without first being converted 

 into a left cephalo-iliac position, or into a position of the right side. 

 But, in either of these cases, the change we are obliged to make in 

 the situation of the foetus is so great, that if it be somewhat com- 

 pressed by the uterus, its life is often found to be exposed to the 

 greatest dangers. This is certainly a case where it would be proper 

 to bring the head to the orifice, and afterwards apply the forceps, in- 

 stead of turning and delivering by the feet. 



