Besides the above-mentioned advantages in supporting the perineum, we may mention another which is not generally noticed, and which is sometimes of considerable service. In cases where the head has completely descended upon the perineum, and begins to protrude somewhat through the os externum, the pains occasionally fail at this moment, the labour becomes very lingering, while the advance of the head and state of the parts show that two or three active pains would bring the child into the world; firm pressure applied at the lower end of the sacrum, in a direction forwards, materially adds to the effect of each pain in bringing the head through the os externum, and seems also to excite the patient to make a more powerful effort with the abdominal muscles. On several occasions we have thus assisted the expulsion of the head, when otherwise the labour would have been very protracted, or would have even required the forceps to disengage it. Madame La Chappelle is the only authority in midwifery, as far as we know, that has noticed this fact. _Cord round the child's neck._ As soon as the head is born, we must examine whether the cord be twisted round the child's neck; and here the advantage of supporting the perineum with the left hand becomes evident: it is ready to support the shoulders when they begin to pass, while the right hand is at liberty to perform any manipulations which may be necessary. If it be important to support the head during its passage over the perineum, still more so will it be to support the shoulders; for if a small laceration has already been produced, it is invariably converted into a wide rent at this moment, if great care be not taken: indeed, we are justified in saying that most of the cases of severe perineal rupture are produced by the shoulders, not by the head. _Passage of the shoulders._ If the pains cease for a time, or the child be large, the shoulders do not pass immediately: in this position the face swells and grows purple from the pressure upon the neck, although it does not necessarily result from the cord being round it; if, however, we find that this is the case, we can in most instances loosen it somewhat by the finger, and as the shoulders advance, slip it first over one and then the other: we must recollect that the shoulder, which is forwards, passes out first, and that, therefore, we must slip the cord over it first.