Finally, Champetier de Ribes from a careful study of all these methods. and from his own experience, draws the following conclusions: " The best method of making the head pass through the pelvis after delivery of the trunk is: 1. Make the inferior maxilla the fulcrum in order to deter mine the flexion of the head. 2. At the same time make backward trac tion. 3. Associate with these manoeuvres abdominal expression made by the hand of an assistant, not over the entire head, but more particularly over the frontal region of the foetus, in the direction of the superior strait." If Champetier de Ribes has thus been able to cause a head to pass through a pelvis contracted to 2.9 inches, this method ought to succeed where the pelvis is normal.
3. Extraction in these cases is nearly as simple as when the occiput is in front and the head flexed. The body of the foetus should be carried forward towards the abdomen of the mother. Delivery is thus accom plished belly to belly; only, since the occiput is posterior, we must watch the perineum all the more carefully.
4. In this case, the chin being more or less fixed behind the pubes, to pull on the body before having extracted the chin will only complicate matters. As long as the head occupies the antero-posterior diameter of the pelvis, the chin cannot be depressed. We must then, before attempt ing flexion, cause the head to rotate. For our part, the only way to ob tain a living infant, is to apply the forceps, artificially rotate the head, and deliver at once. It has been advocated, nevertheless, in these cases, to
rotate the head with the hand. Such is the advice given by Madame Lachapelle, and Naegele and Grenser; but, while Madame Lachapelle im mediately extracts the head with the hand, the latter apply the forceps after rotation. The following is the method of Madame Lachapelle: The hand is introduced into the concavity of the sacrum, and surrounds the head until it reaches the mouth, and the index and the middle fingers are introduced into the mouth, and while the other hand or an assistant pulls on the trunk, the head is made to rotate. At the same time, the attempt is ma e to depress the chin, and to make the head descend. As soon as the chin points backward, flexion is completed and the head delivered as usual. Naegel6 and Grenser rarely seize the child by the mouth, but passing the hand around the head to the opposite cheek, and seizing the face in the open palm, they try to bring the head down and at the same time to rotate it backward. This manoeuvre can only succeed where the head is large and the pelvis small.
Finally, in addition to the above complications, version may be ren dered difficult by disproportion between the foetus and the pelvic diameters.
The reader is referred to the subject of contracted pelvis for informa tion on this point.