PARTURITION. 
684 
not fufficlently relaxed, the woman may be miferably 
torn. The violent action of the uterus towards the ter¬ 
mination of labour proceeds from fome power of that or¬ 
gan itfelf, or from the ftimulus communicated by the po- 
fition of the child. This circumftance, however, is fome- 
times beneficial; as for inftance, when the child is in an 
unfavourable pofition. Dr. Denman was the firft who 
difcovered this efteCt of violent uterine aCtion, and pub- 
lilhed it in the fifth volume of the London Medical 
Journal. 
II. The malpofition or malprefentation of the child 
may occur in different ways; but they may be confidered 
under two divifions, i. Prefentations of the lower ex¬ 
tremities ; 2. of the fuperior extremities. As in a natu¬ 
ral labour the head always prefents, it would feem moll 
analogous that we fhould begin with noticing the pre- 
fentation of the upper extremities, as the head (in a 
wrong pofition), arm, fhoulder. See. But, as it will be pre- 
fently feen, that, in the greater part of malprefentations, 
it is thought advifeable to turn the child, and deliver 
by the feet, the propriety of explaining that procefs firft 
in order, is fufficiently obvious. 
i. Presentations of the Lower Extremities. 
Prefentations of the lower extremities comprehend 
cafes where one or both feet, one or both knees, or the 
breech, prefent. 
Cafes where both feet prefent, are more frequent than 
thofe where one only prefents. It has been calculated 
that the feet prefent once in 105 cafes of labour. This 
is moreover the moft fimple, and probably the fafeft to 
the mother, of all the preternatural pofitions : but the 
hazard to the child is confiderable, particularly if it be a 
firft labour. The danger to the child arifes principally 
from the compreffion of the navel-ftring, between its 
own head and the parts of the mother, after the body of 
the child has palled through the pelvis. The great ob- 
jeCt of the accoucheur, then, is to prevent this com¬ 
preffion 5 and this is to be effected, by getting the head 
of the child through the pelvis, with all proper expedi¬ 
tion, as foon as the body is born. In order for this, it is 
not neceffary to haften the delivery of the body of the 
child : on the contrary, it is defirable that the delivery 
of the body fhould be effected (lowly ; for thus the parts 
of the mother will become more dilated and fpacious, 
and of courfe there will be lefs refiftance oppofed to the 
paffage of the head. But, if attempts are too early made 
to reach the feet, and to expedite the delivery by draw¬ 
ing them down, and afterwards to extraft the body ra¬ 
pidly, it will be found, when the head comes to occupy 
the pelvis, that the foft parts of the mother will be too 
rigid and undilatable to let the bulky head pafs through 
them ; and thus fo much delay will take place, and the 
funis will be fo much compraffed, as to deftroy the child. 
Some authors have divided labours of this kind into a 
great variety of fpecies. There is, however, no necefiity 
for fuch divifions, and they tend to mifiead and embar- 
rafs practitioners. All the varieties may be reduced un¬ 
der three heads ; for the toes muft be either towards the 
fide of the pelvis, or towards thefacrum, or towards the 
pubes. 
1. Where the toes are towards the fide of the pelvis, 
the child is generally placed in fuch a manner that the 
abdomen, breaft, and face, pafs in fucceffion along the fa- 
cro-iliac fynchondrofis of that fide. This is the moll fa¬ 
vourable fituation in which the child under fuch circum- 
ftances can be placed j for the largeft parts of its body pafs 
through the largeft aperture of the pelvis. 
In this cafe, then, the aCtion of the uterus forcing for¬ 
ward the child, the feet are by degrees excluded through 
the external parts, the toes being fituated between the 
point of the coccyx and the tuberofity of the ifehium; the 
thighs follow, then the abdomen and thorax ; but the 
farther progrefs of the child is for fome time interrupted 
by the arms palling up along each fide of the head, which 
add confiderably to its bulk; at laft, however, the re¬ 
peated contractions of the uterus force the face into 
the hollow of the facrum, and then, the nape of the 
neck turning on the inferior edge of the lymphyfis pu¬ 
bis as on a pivot, the face is excluded, followed by the 
finciput and occiput. 
2. Authors have generally confidered that to be the 
moft favourable pofition in which the feet can prefent, 
where the toes are towards the facrum. But two difad- 
vantages attend this pofition : firft, the largeft part of 
the child’s body is forced through the fmalleft part of 
the outlet of the pelvis; and 2dly, The longeft diame¬ 
ter of the head is applied to the fhorteft diameter of the 
brim of the pelvis. In fuch cafes, therefore, the patient 
commonly fuffers much pain, and the child’s life is de¬ 
ftroy ed. 
3. When the toes are turned to the pubes, it has been 
univerfally acknowledged, that the feet are in the word 
pofiible pofition. Indeed not only do the difadvantages 
llated as refulting from the laft pofition equally take place 
in this one, but another caufe of difficulty and danger is 
added, viz. that, the face being applied to the pubes, the 
chin may projeCt over, and reft upon the offa pubis, and 
it will be difficult to extricate it from this untoward fitu¬ 
ation. To guard againft this accident, it will be proper, 
as foon as the nates have paffed through the os externum, 
to take hold of the nates and both thighs with a warm 
napkin; and, when the next pain comes on, to give 
fuch an inclination to the body of the child, by guiding 
it with the hands, as will direct the face towards the mo¬ 
ther’s fpine. The napkin is neceffary, in order to give; 
the operator a fufficiently firm hold; without it, his 
fingers would flip, and his objeCt be defeated. There is 
not much difficulty in effecting this turn, if it be done 
prudently and cautioufly. Much force is not required ; 
nor is it neceffary that the fore parts of the child be. 
turned quite round to the mother’s back: an inclina¬ 
tion towards the back is all that is wanted. 
During the pain which, with the affiftance of the ac¬ 
coucheur, produces this turn of the child, it is probable 
that the whole of the body will be expelled, and nothing 
will remain in the pelvis but the child’s head, with the 
arms extended on each fide above it. It has been a quef- 
tion much difeuffed, whether it be beft in fuch cafes to 
finifh the delivery, leaving the arms thus extended on 
each fide of the head, or to draw them down by manual 
affiftance, before any attempt is made to bring the head 
into the world. Some writers have afferted that the arms 
fliould not be drawn down, becaufe, while thus extended, 
they prevent the os uteri from contrasting round the 
neck of the child, and impeding the paffage of the head. 
But, if the early part of the labour has been permitted 
to proceed fufficiently flow to allow the os uteri to be¬ 
come properly dilated, fuch a contraction is little to be 
dreadedj and the arms need not be fuffered to remain 
for this purpofe. 
A far better reafon for not bringing down the arms, is, 
the danger of diflocating or fraCturing them} and, if the 
praftitioner will be fo heedlefs and imprudent as to at¬ 
tempt to extraft them at an improper time, or to employ 
violence and undue force in effecting it, this danger will 
be imminent} but, if the attempt be cautioufly and judi- 
cioufly made, no hazard need attend it. The operation 
confifts in paffing the finger over the fhoulder of the 
child, as far as to the bend of the elbow} which is then 
to be gently depreffed, and the fore-arm commonly paffes 
through the vagina without much difficulty. One arm 
being brought down, the extraction of the fecond be¬ 
comes more eafy. In proportion to the rigidity of the 
foft parts will be the difficulty of the extraction : fhould 
it be found that the operator’s finger cannot reach the 
bend of the elbow', or does not readily diflodge the arm, 
it will be better to defer the attempt, or to give it up 
altogether, rather than to do injury to the infant. With 
