MIDWIFERY. 



249 



Of P.riuri- few in proportion to the number of presentations of the 

 Uon. shoulder ; anil in a large city, containing above 100,000 

 * y ' inhabitants, the author has only learned of one instance 

 where this ha* taken place. 



Order Fourth. 



The hips, back, belly, breast or sides, may, though 

 very rarely, present, the child lying more or less 

 transversely. The hip is sometimes taken for the 

 head, but is to be distinguished by the shape and rela- 

 tions of the ilium. In all the other cases, the presen- 

 tation remains long high ; but when the finger can 

 reach it, the precise part may be ascertained, by one 

 who is accustomed to feel the body of a child. In these 

 presentations the hand should be introduced, to find the 

 feet, by which the child is to be delivered. This rule 

 is absolute with regard to all those presentations except 

 that of the hip, which only renders labour tedious, and 

 in this the practice must be determined by concomi- 

 tant circumstances. 



Order Fifth. 



The child may present the head, and yet it may be 

 improperly situated, and give rise to painful and tedi- 

 ous labour. 



\tt. The forehead, instead of the vertex, may be turn- 

 ed towards the acetabulum. In this case, the presenta- 

 tion is felt in the first stage high up, smooth and flatter 

 than usual. In a little longer, we discover the anterior 

 fontanelle, and the situation of the suture*. By degree*, 

 the head enters the cavity of the pelvi*, the vertex 

 being turned into the hollow of the sacrum, and by a 

 continuance of the pains, the forehead either turns up 

 within the pubis, and the vertex panes out over the 

 perineum, or the face gradually descends, and the chin 

 dears the arch of the pubis, the vertex turning up with- 

 in the perineum towards the sacrum, till the face is 

 born. The first is the usual process in this presenta- 

 tion ; all the step* of the labour are tedious, and often, 

 for considerable period, the pain* teem to produce no 

 effect whatever. In the last stage, the perineum is 

 considerably distended, and it requires care and pati- 

 ence to prevent laceration. If it be discovered early, 

 it is certainly proper to rupture the membranes, and 

 turn the vertex round ; a proceeding which is easily 

 nplisbed, and which prevent* much pain and fret- 

 If this opportunity be lost, we may (till give 

 The late Or. Clarke say*, that in thirteen 

 out of fourteen esses, he succeeded in turning round the 

 vertex, by introducing either one or two finger* between 

 the side of the bead near the coronal suture and the 

 aymphytis of the pubis, and pressing steadily, during a 

 pain, against the parietal bone. The writer of this ar- 

 ticle fully concur* in the opinion given by that excel- 

 lent practitioner. The fontanelle, or crown of the head, 

 may also present, although the face be turned to the 

 aero iliac junction. In this case it is felt early, and, 

 by tracing the coronal suture, we may ascertain whe- 

 ther the frontal bone* lie before or behind. It is a 

 much more uncommon presentation than that noticed 

 above. The labour is, at first, a little slower than in a 

 natural presentation , but, by degrees, the head becomes 

 oblique, the vertex descending ; and this may be 

 by supporting the forehead with the finger 

 during a pain. 



'iti, The side of the head may present. In this case 

 the presentation i* long of Iwing felt, but it is recog- 

 nied by the ear. If, however, it ha* been long pres- 

 sed in the pelvis, it is extremely difficult to determine 



VOL. xtr. PART i. 



the case. It is very rare, and Las even been deemed to Of 1'artm i- 

 be impossible. In some instances the child has been t * on - 

 turned, but it is most common to rectify the position of y """Y*~ 

 the head, by introducing the hand. 



3d, The occiput may present, the triangular part of 

 the bone being felt at the os uteri. It is known by its 

 shape, by the lamboidal suture, and its vicinity to the 

 neck. 'I'lie forehead rests on some part of one of the 

 psotr-muscles.and from this oblique position of the head, 

 the labour is tedious-. It has been proposed, in this 

 case, to turn ; but it is better, if we do any thing, to 

 rectify the position of the head with the hand. Na- 

 ture is, however, adequate to the delivery, even if not 

 assisted. 



4th, The face may present, with the chin to one of the 

 acetabula, or to the sacro-iliac junction, or to the pubis 

 or sacrum. The first two are the best, the third is 

 more troublesome, and the last is worst of all. 



If the presentation be discovered early, there can be 

 little doubt as, to the propriety of rectifying the posi- 

 tion, but, if the labour be advanced, this is difficult ; and 

 then it only remains that we should endeavour, if the 

 labour be severe and tedious, to make the face descend 

 obliquely, by cautiously, but firmly supporting with 

 a finger, during the pains, the chin or end which is 

 highest, in order to favour the descent of the lower end. 

 When the chin has advanced so far a* to come near the 

 arch of the pubis, we may follow a different method, 

 and gently depress it, which assist* the delivery, for 

 generally the chin i* first evolved. 



Order Sixth. 



Sometime* the cord descend* before, or along with 

 the presenting part of the child. This has no influence 

 on the process of delivery, but it may have a fatal ef- 

 fect on the child. As soon as the os uteri will admit 

 the introduction of the hand, the child should be turn- 

 ed, if it can be easily done. But if the presentation be 

 advanced before we are called, and turning be difficult, 

 then we must endeavour to keep the cord slack, or re- 

 move it to that part of the pelvis where it is least liable 

 to be compresied ; or it will be still better to endea- 

 vour, with two fingers, to push the cord slowly past the 

 head, and prevent it, for two or three pains, from com- 

 ing down again. 



Should this not be practicable, and the pulsation suf- 

 fer, or the circulation be endangered, we must accele- 

 rate labour by the forcep*. 



Order Seventh. 



The sign* by which the existence of a plurality of 

 children are laid to be indicated, are so completely fal- 

 lacious, that no reliance can be placed upon them, nor 

 can we generally determine the existence of twins, un- 

 til the first child be born. Then, by placing the hand 

 on the alxiomen, the uterus is felt large, if it contain 

 another child, and by examination per vaginam, the se- 

 cond set of membranes, or some part of the child, is 

 found to present. This mode of inquiry is proper al- 

 ter every delivery. 



If the first child present the head, the second gene- 

 rally present* the breech or feet, and vice versa ; but 

 onetimes the first presents the arm, and, in that case, 

 when we turn, we must be careful that tin- fi-rt of the 

 same child be brought down. Thi> lir-t being delii 

 the hand is to be again introduced, to search for tin; feet 

 of the second child, which are to be brought into the 

 vagina, but the delivery is not to be hurried. 



It sometimes happens that, after the first child i* 

 f I 



