SHOULDER POSITIONS. 453 



1020. However this may be, provided the waters have not been 

 long discharged, if the membranes are not ruptured, and lastly, if 

 the child is to a certain extent movable in the womb, the best prac- 

 tice is to reduce it to a dorso-sacral or left dorso-iliac position: this 

 may be effected in two different ways. 



Unless the head happens to be nearer to the sacro-iliac symphysis 

 than to the right acetabulum, we might, by turning the hand into a 

 very forced state of supination, get hold of the shoulder, as in the 

 cases heretofore treated of, that is, so that the thumb may tend to 

 reach the sternum whilst the fingers remain behind the thorax, the 

 little finger being towards the head; then we act by raising it up- 

 wards a little, the vertex in front; the hand afterwards assumes dur- 

 ing the operation an attitude of pronation, which is more and more 

 complete in proportion as the occiput moves more towards the left 

 iliac fossa. 



1021. Should it be too difficult thus to move the cephalic extre- 

 mity of the child, from right to left, over the major part of the an- 

 terior semicircle of the pelvis, we might, after raising the shoulder 

 and head above the pubis, go immediately in search of the feet or 

 knees, proceeding along the left side. Having got hold of the legs, 

 the act of turning would compel the head, which, besides, is already 

 repelled by the forearm within the uterus, to rise upwards and take 

 a situation in tlie fundus of the womb. But in this case special care 

 should be taken not to permit the child's back to turn to the poste- 

 rior surface of the womb. 



Should the shoulder be so disposed of that the head were to be 

 found above the right sacro-iliac symphysis, that is to say, in the 

 third position of Maygrier, or still nearer to the sacro-vertebral an- 

 gle, the left hand, introduced in a forced state of pronation, might 

 attempt to raise the shoulder, and move the head from the right sacro- 

 iliac symphysis to a situation above the left sacro-iliac symphysis; 

 but although this manosuvre may sometimes be found rather easier 

 than the former one, it should be stated that it is perhaps a more 

 dangerous one; for provided the two or three last fingers should not 

 act with force upon the occiput while the thumb and index are push- 

 ing against the upper part of the chest, there is a risk of doing no- 

 thing more than effecting a retroversion of the head on to the back 

 while endeavoring to displace it. 



Should the membranes have been long ruptured, the womb strongly 

 contracted, and the child not to be moved but with very great diffi- 

 culty, there is a third manoeuvre that ought then to be preferred, and 

 which perhaps it would be well to employ in other cases; it con- 

 sists in pushing the shoulder up with the right hand, from behind 



