PARTURITION. 
686 
lure be made on the head when it prefents at the brim 
of the pelvis in this unfavourable pofition, the pains 
will readily force it into the paflage in the proper direc- 
ti6n. When the locked head has aftually taken place, 
the pradlice mull be varied according to the circurn- 
llances of the individual cafe; hence the long forceps, 
and fometimes even the crotchet, are required. 
The long diameter of the head may alfo be applied to 
the Ihort diameter at the brim, in a different manner, 
viz. with the face towards the pubis, and the occiput 
to the bafe of the facrum. The obltacles to the progrefs 
of the head are not in this cafe fo great as in the former; 
for, as the occiput is round, and its furface inconfide- 
rable, while at the fame time the promontory of the fa¬ 
crum is round, the labour-throes, after fome time, force 
the occiput either a little to one fide, or at leaft pall the 
promontory. The cafe, however, is'tedious, painful, 
and even dangerous to the patient; for, as the face pre¬ 
fents a larger furface to the pubis than the occiput, it 
mull require longer time to pafs ; and, as there are many 
inequalities on the face, the patient mult fuffer much 
pain from their prelfure, and from the fame circumllance 
mull incur the hazard of having the urinary bladder or 
the urethra irreparably injured. Although in this cafe 
the natural efforts moll ordinarily complete the procefs, 
yet in many inftances the injury which threatens the 
urinary bladder renders the application of the forceps 
expedient. 
Although the head may have entered the pelvis in 
the molt natural pofition, yet it may not make thofe 
changes in fituation which are required to accommodate 
it to the outlet; for the face may turn under the fym- 
phyfis pubis inllead of into the hollow of the facrum. 
When this happens, the phenomena already defcribed in 
the preceding paragraph take place. 
It fometimes happens, that inllead of the finooth part 
of the cranium being forced firll into the pelvis, th eface 
prefents. In this cafe it may be fituated in three pofi- 
tions, viz. with the chin to the facrum, or to the pubis, 
or to the fide. 
The firll cafe is efteemed the moll dangerous both for 
the mother and child. For the mother, becaufe the 
child in this pofition requires more room than the pelvis 
affords, confequently the foft parts in contatt with the 
chin and fmooth part of the cranium are much compref- 
fed; and hence, if the delivery be not fpeedily accom- 
plilhed, much injury to thofe parts will enfue. As the 
chin too mull pafs along a curve line formed by the fa¬ 
crum and coccyx, the obllacles to delivery are very 
great; and, even after the face has been forced fo low as 
to prefs on the perinasum, that part is in much hazard 
of being torn by the violent dillenfion which it under¬ 
goes. The delivery in fuch cafes is very rarely accom- 
plilhed naturally; and Dr. Conquell recommends the 
employment of the lever, which is to be fixed over the 
occiput, and during each paroxyfm of pain by drawing 
down the back part of the head, and at the fame time 
elevating the forehead, fo as to caufe a clofer approxi¬ 
mation of the chin to the chell, the termination of the 
cafe may be materially accelerated. 
The fecond cafe, viz. where the chin is placed towards 
the pubis and the finciput to the facrum, is neither fo 
dangerous for the mother nor child. For, if by the force 
of the pains the face be puffed fo far forward that the 
chin becomes engaged within the arch of the pubis, then 
the inferior edge of the fymphyfis pubis forms a fulcrum 
on which the inferior jaw moves, by which the finciput 
and occiput pafs readily and eafily along the hollow of 
the facrum, their furface being well adapted to that of 
the facrum, and the feveral parts of the face pafs in fuc- 
ceflion through the vulva. But, lliould the uterine 
energy not be adequate to the completion of the labour, 
a Affiance is to be given ; either firll, if the refillance be 
trifling, by difengaging the forehead and chin, fo as to 
convert it into a vertex-cafe, by lleadily preffmg the 
face upwards and Tideways, with a femi-rotatory motion 
during pain, fo that the occipito-vertex lhall be placed 
againll the facro-iiiac fymphyfis; or, fecondly, if the 
cafe be difcovered early, the lever may be moll advan- 
tageoully ufed as a hook fixed on the occiput, which it is 
to deprefs, whillt the face is gently raifed by the fingers. 
This method of managing fuch cafes refers exclufively 
to them when difcovered early, and when the refinance 
is inconfiderable: but lallly, if the face be low down, 
and firmly wedged in the pelvis, then the procefs adopted 
by nature mull be imitated, and with the lever fixed 
over the fide of the face, the chin mull be made firll to 
emerge ; or the forceps may be applied as in a vertex 
cafe, only that the blades, running in a line from the 
face to the occipito-vertex, will have their extremities 
at the occipito-vertex, and the locking part at the face. 
The third cafe, viz. where the chin is to one fide, 
is Hill more favourable than the fecond ; for the face 
paffes readily through the oblique diameter of the pelvis 
till llopt by the tuberofities of the ifchia, when the chin 
turns into the arch of the pubis, and then the fame phe¬ 
nomena which occur in the fecond cafe take place. 
On fome rare occafions the fide of the head prefents, 
fo that one ear is in the centre of the pelvis. In fuch a 
cafe, the llrongelt contraftions of the uterus cannot 
make the head enter the pelvis, and the woman would 
generally die undelivered were it not for the interference 
of art. Cafes of this kind are remarkably rare. The hand 
of the operator mull be carried up in fuch cafes, and 
moderate prelfure mull be made in fuch a diredlion as 
lhall allow the contradlions of the uterus to puff the 
fmooth part of the cranium into the cavity of the pelvis. 
If fuch prefentations be difcovered early, we may fo em¬ 
ploy the lever as very materially to improve the relative 
fituation of parts. This inftrument is to be carried over 
the vertex laterally ; and, whillt tradlion is employed 
during every parturient exertion, the bafe of the cra¬ 
nium is to be raifed by two fingers. 
Sometimes the hand or arm defcends with the head into 
the pelvis.—Independent of the awkwardnefs of pofition 
which the head may affume, from the circumllance of 
the hand or arm defcending with it, there will be fo 
much increafe in the bulk of the part, as to render its 
paflage flow and difficult. Yet, if the cafe be not in¬ 
terrupted by mifmanagement, it will terminate favour¬ 
ably ; for this complication of prefentation feldom hap¬ 
pens but in a wide pelvis. 
There will be fome difference in the difficulty of the la¬ 
bour, accordingto the mannerin which the fuperiorextre¬ 
mity enters the pelvis. If it be only the fingers or hand 
coming down in a flattened lliape by the fide of the head, 
the difficulty will not be very great. If the elbow be the 
part, with the fore-arm bent back upon the humerus, the 
difficulty will be increafed. And it will be Hill more per¬ 
plexing, if the hand and arm have defcended before the 
head; the head rellingupon the arm at the bend ofthe elbow. 
Occafionally it will be prafticable, by means of the ope¬ 
rators fingers, to prevent the hand or arm from defcend¬ 
ing below the brim of the pelvis, till the head has funk fo 
low as to be clear of the impediment; but, in attempting 
this, care mull be taken not to make the cafe more embar- 
raffing by drawing the arm down lower, or forcing the 
head above the brim; for this might convert the cafe 
into a truly preternatural labour, and render the turn¬ 
ing of the child neceffary. The arm of the child is often 
very much bruifed and tumefied in confequence of this 
pofition; and it is fometimes difficult to perfuade the 
attendants that it is not fraflured or diflocated. How¬ 
ever, it feldom fails to recover itfelf in a few days. 
There are no prefentations more dangerous, nor more 
difficult to manage, than thofe of the fuperior extremi¬ 
ties ; for, whether the part prefenting be the hand, the 
elbow, the ffoulder, or both hands, it is clearly impof- 
lible that a full grown foetus lliould pafs through the 
pelvis, unlefs this pofition be altered. 
6 
It 
