DELIVERY OF THE PLACENTA. 543 



made use of, the cord almost always separates them, and therefore 

 it would be quite as well to place them crosswise, in the upper part 

 of the vulva, as is the practice with some persons. 



The way to derive the greatest possible advantage from them is 

 to pass them up as far as the foetal surface of the placenta, even 

 should that be above the os uteri, and then make them act like a lever 

 of the first kind. The back of them rests against the top of the 

 pubic arch, and while the other hand is drawing the cord along the 

 axis of the inferior strait, they are pressed against the root of the 

 cord; then by a sort of see-saw motion, communicated by the gra- 

 dual rising of the wrist, they force the placenta along from above 

 downwards and from before backwards, towards the point of the sa- 

 crum, and in the axis of the superior strait. 



This stage of the operation is the most delicate, the most impor- 

 tant, and most difficult to perform well. The womb is sometimes 

 so bent forwards that if the fingers do not push the cord almost 

 directly backwards, the placenta remains immovable; at other times 

 they must be directed a little to the left or right, because the os 

 uteri is deviated more or less to one side or the other; the axis of 

 the womb, besides, presents a thousand shades which it would be 

 necessary to apprehend, and which practice alone can enable one to 

 recognise. This is the reason why a delivery deemed by one ac- 

 coucheur to be impossible, will often be quite a simple case to an- 

 other person; and why this operation, in appearance so easy and un- 

 important, deserves, notwithstanding, the most minute attention from 

 those who desire to perform it Avell. Should the pulley (composed 

 of the ends of the fingers) be not well placed; should the lever re- 

 presented by the fingers not be well situated, or not act properly, the 

 after-birth, from being arrested by the upper edge of the pubes or the 

 posterior surface of the symphysis, would not come down; the whole 

 of the power would be directed upon the root of the cord, which 

 would certainly break, or upon some part of the uterine orifice, 

 whence that dragging and pain which give rise to the idea of preter- 

 natural adhesions. 



Be this as it may, when the placenta has come down into the 

 vagina, the fingers of the left hand should be continued in the same 

 situation they occupied before, but merely so as to favor the escape 

 of the membranes which 'might not have cleared the os uteri, and 

 to form a sort of inclined plane, along the inferior surface of which 

 the whole after-birlh might glide while pulled by the right hand 

 along the axis of the inferior strait. In this way the hand that holds 

 the cord may be raised upwards without fear of being embarrassed by 

 the pubic arch, and we avoid being stopped by the inferior surface 



47* 



