CHAPTER II.
THE NATURAL LABOR.
A NATURAL LABOR has been described as one “in which the head presents, and descends regularly into the pelvis; where the progress is uncomplicated, and concluded by the natural powers within twenty-four hours, (each stage being of due proportion), with safety to the mother and child, and in which the placenta is expelled in due time.”
A skillful, careful examination in the commencement of labor will enable you perhaps to decide whether the labor will be natural or otherwise. But it may be your duty first to know if your patient is in ordinary health, or if she have any fever or organic disease, and you should enquire about the bodily functions generally, the condition of the pulse, skin, &c. Before making a digital examination you should notice the character of the pains, their frequency, force and regularity, the amount of voluntary effort, the character of the outcry, &c. From these enquiries you probably will be able to decide whether she is suffering from real labor, or false pains.
She will, however, probably not object to a digital examination and your opinion will be founded principally upon that. The modern practice is to wash the hands in antiseptic soap or some solution before making an examination.
We are directed by most writers to have the patient lie upon her left side near the edge of the bed when we examine her. The fore finger of the right hand (sometimes the left) after being well oiled or soaped should be passed along the perineum into the vaginal orifice, and is to be pressed upward and backward towards the promontory of the sacrum until the os uteri or the presenting part is found. Sometimes this is not reached without an effort. When reached endeavor to find the fœtal head or to determine what is the presenting part—feel sufficiently to distinguish the lips of the os uteri from the presenting portion of the fœtus. Do not be hasty in making the examination; wait till you examine sufficiently to know if the child is forced down; observe both during the time of a pain and during an interval, and observe if the pains dilate the os. Sometimes during a natural labor there may be a severe pain, and when the pain is hardest, the os contracts. By waiting to take a number of pains you will learn if there is real progress. When examining, note the calibre, heat and moisture of the vagina; the general condition of the cervix; the dilatability of the os uteri and the actual dilatation by the bag of waters or the fœtal head during a pain. If the head presents you can best learn the particular position when the pain is off; and after the membranes are ruptured you can decide better than previously. Ordinarily the sagittal suture can be felt, and perhaps both fontanelles, but you must not be discouraged at all if you cannot determine the exact position. Doctors ordinarily do not deem it necessary.
If you can decide that it is a head presentation and that the woman is undoubtedly in labor, you may probably decide that the labor will be natural, and you may properly tell the friends so, adding perhaps, that it will depend upon the character of the ensuing pains whether the labor will be protracted or short.
Various circumstances of which you are possibly not yet cognizant may make your case of labor a tedious or difficult one. You have decided, perhaps, that there is no obstruction to the passage of the child, no deformity of the pelvis, scirrhus or other tumors in the vagina, no cystocele, no prolapsed ovary, and that there is not a rigid perineum or imperforate vagina. If there is, you need to have a medical man present, but should none be obtained you will need to repeat your examination from time to time. Observe if each pain presses down the bag of waters and dilates the mouth of the womb, and if the soft parts are in a relaxed state, and if there is a show. Even if the appearances are thus promising, the labor may be slow and tedious from various causes.
1. Possibly hardened feces maybe in the rectum; if they are you may be assured of the fact when you make a digital examination, as they seem like tumors posterior to the vagina. The remedies are physic, enemas, rest—possibly opium.
2. Inefficient pains may be due to a bladder distended with urine. When this is suspected we should observe whether there is abdominal swelling (not tympanitic) low down; pain on pressure which gives rise to a desire to urinate; a constant desire to pass water though the patient has just performed the act, or a dribbling of water from the parts. If the bladder cannot otherwise be relieved a catheter should be used, and as a precaution to avoid wetting the bedclothes it is well to have a catheter made long enough by affixing a piece of India rubber tubing to the end of it to reach a vessel at the side of the bed. Never use force in passing a catheter in. It is very seldom that it is necessary to use it at all during labor.
3. If there is a hernial protrusion of the bowel, or a calculus of the bladder falling down in the passage you will probably have a medical man to officiate. But I may say that if there is need of your doing anything to replace them, or if it is necessary to return a prolapsed bladder, you can best do it when your patient is in the knee-chest position.
4. The lack of expulsive power is sometimes due to the want of sleep. If the first stage, that of dilatation, is prolonged the subsequent uterine contractions seem to want efficiency. In such cases if the patient can have a dose of opium or morphine administered to induce sleep it acts favorably. Where there is nervous excitement particularly, the efficiency of the pains are increased if we give opium and first procure a period of rest.
5. The uterus may be greatly distended and its expulsory power thereby weakened. In such cases there may be a suspension of the action of the uterus for several hours although the labor before that had made considerable progress. If pains of labor are feeble or slow or suspended, no harm can come to the mother or child (in such cases) except that the mother is compelled to bear them for a longer time. The only remedy that I would suggest is that the distention be relieved by the rupture of the membranes and discharge of water. If more efficient pains did not come on, then I would give a dose of morphine, which would either increase the pains, or give a period of rest.
6. Sometimes there are vehement and cramp-like pains in the abdomen producing no effect that is good and adequate, caused by partial irregular or spasmodic contractions of the uterus—usually what are called hour-glass contractions. If the bowels have been evacuated and there is no improvement, I would give one-fourth grain of morphine which will enable the woman to go through her labor more easily, and perhaps quite as quickly.
7. It is generally believed that a cord being very short and being around the neck of the child may protract a labor. I do not deny that this may possibly occur, and when the child’s head is born, and I find that there is a coil of the funis on its neck I loosen it.
8. Weakness of the constitution when the general health of the woman is below the natural proper standard may be a cause why the uterine contractions are not severe. But in such cases the parts are not rigid, and nothing more than a dose of four or five grains of quinine is needed to make the pains effectual.
9. A want of irritability in the constitution frequently observed in fat and inactive women, or in those who are exceedingly timid, will sometimes be a cause of slow and lingering labor. Fear often lessens the energy of all the powers of the constitution, and diminishes or wholly suppresses for a time the action of all the parts concerned in parturition. Attendants should endeavor to inspire such patients with activity and resolution, and remove all fear from their minds. These cases are not dangerous but I have often found it necessary in this kind of cases to apply forceps. The skilled nurse might perhaps give eight or ten grains of quinine, if no physician has charge of the case.
10. Every woman is expected to suffer greater pain and to have a more tedious labor with her first child, and if a woman be advanced in age at the time of having her first child the difficulty attending her labor may be somewhat greater. A longer time may be required for the completion of the labor than in ordinary cases, but I do not advise giving any medicine unless it is perhaps a dose of quinine. There may be a little more need of assistance by instruments, &c.
11. An oblique position of the os uteri, it being projected on one side or the other of the center of the superior strait, or so far backwards that it cannot be felt for several hours after labor has begun, is a cause of delay. The presenting part may be found pressing against the walls of the pelvis at one point, instead of keeping its course in the center of the pelvic cavity. You should endeavor to place the patient so as to remedy this condition. When the presenting part is found to one side, it will be found that the fundus of the womb is lying to the opposite side; this should be remedied by a proper support of the abdominal tumor or by holding it up by the hands. For example, if the os uteri be projected to the left side, she ought to rest on the right side and have a pillow placed under her body; some physicians would prefer that she lay on the left side, but without the pillow under her.
12. Extreme rigidity of the os uteri is a cause of tedious and very painful labors. It sometimes happens that the os is dilatable, but the pains are not sufficiently expulsive. Perhaps at the same time the os is found far back towards the promontory of the sacrum, and the head appears not to be driven directly into the os so as to aid in its dilatation, but rather presses against the anterior wall of the cervix. In such a case the end of the finger can be hooked into the anterior lip of the os uteri so as to aid in the dilatation, and also to help correct the displacement of the os. In other cases we may help dilate the os by a firm and gentle sweep of the finger around the advancing part of the child’s head within the os. But we cannot always do this, because we may be afraid of rupturing the membranes prematurely. If the membranes have been already ruptured, we may act more boldly, but we must never make any great efforts to dilate it artificially lest we excite inflammation. In many cases it is best to give ¼ gr. of morphine, and inform the suffering woman that she cannot possibly get through her labor in a short time, but if you can give her an hours’ rest, the os, which is rigid, will be more relaxed and pains more effectual.
13. In first labors there is sometimes unusual rigidity of the soft parts, which are external. Where the perineum is rigid it may require several hours continuance of the pains before it is sufficiently stretched to allow the head of the child to pass. But the difficulty can hardly be relieved by our interposition. We should generally wait the due time, as we must also if the os coccygis is anchylosed with the sacrum.
14. The head of the child may be comparatively large when the pelvis is of the ordinary form and size. This may be a cause of delay though it may perhaps cause nothing more than prolonged, tedious labor. In such cases you have time to send for a doctor, even if he lives at a distance. After the woman has been a long time in labor he will think it best to apply the forceps.
You will be importuned in cases of slow and tedious labor to administer ergot, but any one who knows the action of the drug would never give it in any of the following cases: 1. Where the os is not well dilated. 2. When any mechanical obstacle exists to the passage of the child, or when there is a tendency to convulsions, and _you_ should never give ergot except for hemorrhage; and when you have much reason to fear it, you may in such cases give one or two twenty drop doses of the fluid extract very near the termination of labor. Quinine may be given as an oxytocic with safety. Morphine is liable to render the pains weak for a time, but it often increases their efficiency.
I will now enumerate your duties when you act as accoucheur.
1. Ascertain if the lady is really in labor. Make a digital examination. If the os is high up so as to be reached with difficulty, slightly patulous and rigid, and the pains are felt in front, there is reason to believe that the labor has not yet commenced—that she only has false labor pains. At this time attend to the bowels; give perhaps paregoric or morphine to relieve her of what is to her useless and exhausting agony, and enjoin rest. You may at this time properly give her an enema containing ¼ of a grain of morphine or fifteen grains of chloral dissolved in gruel or starch or mucilage.
2. When you make an examination and find that the pains are efficient in producing a dilatation of the os uteri, that the parts are soft and relaxed, if there is a secretion called the show, if there is a favorable presentation, and the labor is making some progress, the patient should be told of all that is favorable in the case.
3. Be careful in making early examinations to, first, if possible, reach the os with the finger. When your finger presses against the cervix it will hurt her considerably more than it will when it presses against the presenting part of the child. 2. Avoid rupturing the membranes. 3. Notice if there is anything observable to hinder the progress of the labor. 4. Note any progress of the labor.
4. If everything is favorable, assure the patient of the fact; if you have doubts and fears upon some point, you need not express all your fear, but do not delay to send for a physician.
5. You may in the early stage of labor, permit the patient to move about as she wishes, and she may rest on the sofa when tired. She may have her usual diet, but not any stimulants.
6. From time to time make an examination. If the os is dilatable you need not fear that the membranes may then be ruptured. Learn as fully as possible the presentation and position, and if you press your finger against the child’s head you may thereby reinforce weak pains.
7. Do not annoy the patient by pressing upon the back or anywhere during a pain if she requests you not to, but when she does not object you can make such pressure as will reinforce the action of the abdominal muscles. When she is lying on her back with her shoulders elevated so that she is in an almost vertical position, you can stand beside her with your back towards her head, and make the necessary palpation by pressing with your hands on her abdomen, one of them on each side. Do this only when there is no tenderness, when the os is dilated, when there is a normal pelvic canal and a low position of the presenting part. Seek in thus pressing to move the uterus to the axis of the pelvic brim, then with the palms of your hands to the sides or fundus of the uterus press gradually downward, increasing the pressure for six or eight seconds, and then gradually diminishing. You may repeat this as often as she has a pain, and with an increasing force, and if the patient assents, you may make such pressure unremitting.
8. When the os uteri is fully dilated or soft and dilatable, the membranes may be broken by pressing with the end of your finger against it, or if this does not suffice, the finger nail previously nicked may open it.
9. When free hemorrhage occurs prior to delivery, it may depend upon placenta previa; that is, upon the placenta being attached very near or over the mouth of the womb; in such a case obtain a physician to take charge of the case if possible. You may yourself give half a teaspoonful of extract of ergot in the emergency.
10. During the progress of the labor you must always remember that the unassisted, natural powers are in most instances fully sufficient to bring the labor to a safe termination, and whatever you do should be of the kind that is not harmful. The important thing for the attendants to possess is gentleness and patience, and it is a good thing for the patient if she can be kept tranquil and cheerful.
11. A little light food may be offered the patient at any time during labor.
12. During the first stage of labor the patient must not strain or bear down to the pains, but it is my practice when I examine my patient and find that the head has not yet entered the pelvis, at the same time that the touch stimulates the uterus to contract, I direct the patient to bear down during each pain. After the head is fully engaged in the bones, no stimulus to pain is needed; however, as the bearing down pains come on, she should be advised to strain or press down.
13. Towards the last, when she is in great pain, if she be inclined to cry out, let her do so; never reprove her.
14. I approve of giving chloroform in some cases, but I do not advise the skilled nurse to give it except when a physician is present to direct its use.
15. During the latter part of the labor the only assistance you can render the woman is to support the back, and to give her something to pull upon if she is so inclined. A sheet tied to the foot of the bed may be useful for this purpose. At the very last, bearing down efforts should be discouraged.
16. When the head is about to be expelled we always fear there may be slight or severe lacerations of the perineum. Do not in any way hasten the expulsion, even if there should be a number of pains in which a part of the head presents externally during the pain, and then recedes when the pain goes off. I have not always been able to prevent laceration, but the following directions are the best that I can give: Endeavor to have the patient extend her legs, and do not have her knees drawn up close to the body at the last. When the perineum is put on the stretch, place the thumb and forefinger of the right hand on either side of the perineum, and press so as to aid the stretching or distention. When the perineum is distended and protruding you may cover the hand with a soft napkin and apply it across the perineum, also by the sides of the vulva, and make firm, moderate pressure during the pain. Endeavor to have the pressure equable around the head of the child.
17. When the head is expelled an attendant should make steady gentle pressure upon the uterus and follow it down, keeping her hand firmly upon it for several minutes, perhaps for half an hour, or if you have given a little attention to the child, you yourself may put your hand on the contracted uterus and firmly knead it for ten minutes.
18. It is not necessary to extract the body immediately after the expulsion of the head. It is better to wait three or four minutes for the return of a pain before making any traction.
19. Although a little traction can be made on the head, it is a better way while an attendant presses on the uterus, and while you hold on to the child’s head with one hand, insert a finger of the other hand into the axilla, (under the child’s arm) and gently extract the body.
20. The child may be born apparently asphyxiated—its face swollen—and of a dark livid color, and at first make only feeble and gasping efforts at respiration; if there is the least beating of the heart can be perceived, there is fair hopes of its recovery. The cord should at once be tied and the child removed from the mother. If one or two slaps on its body does not make it cry, try immediately artificial respiration by the Sylvester method perhaps, not omitting at first and afterwards to throw a little cold water on its body. If these efforts fail I would try to induce respiration by placing my hand over its nostrils and blowing into its mouth, and immediately afterwards compressing its lungs.
21. As soon as the child cries, as it most generally will as soon as it is born, proceed to tie and separate the cord. Tie the cord tight, so that it is thoroughly compressed and the vessels obliterated, applying the ligature about one and a half inches from the child, and then cut the cord one inch further from the child. The child can be rolled in flannel and removed, and you can attend to the mother and to the removal of the afterbirth.
22. In only a very few cases I have had post partem hemorrhage or adherent placenta to trouble me, and I commend to you the method that I have used for the removal of the placenta. I do not tie the cord until circulation has ceased in it. I then sever it, and usually two or three ounces of blood may flow from it. This I suffer to run into some vessel to avoid soiling the bed uselessly, and then wind the cord around my right hand so that I can hold it. If I cannot have an attendant to make proper pressure on the uterus, I immediately endeavor to compress it as much as I possibly can with my left hand, but I make very little traction on the cord. I usually instruct some one else to make strong and firm pressure upon the uterus, and I pass two fingers of one hand into the vagina, and learn thereby when the placenta descends, and if necessary assist in its removal. Although we should never hurry in removing the afterbirth, I believe that it always is easily removed if we make the effort very soon after the child is born, and if it is necessary for you to pass your hand into the uterus you can do so then better than at any other time. Judging from my own experience in cases of retained placenta, if you pass your hand along the cord into the uterus, you will find that an hour-glass contraction retains the afterbirth (whether adherent or not) in the fundus. You will have to press your fingers through the constricted portion and grasp it, and you can remove it steadily and slowly, but not stopping to give it “one or two turns in the vagina.”
23. POST PARTEM HEMORRHAGE is liable to occur; when it does, obtain a physician as soon as you can, but some things must be done immediately. 1. Some one must grasp and compress the womb continually. 2. Remove the pillows and raise the foot of the bed so that the patient’s body lies higher than her head. 3. If you have it, give a small teaspoonful of extract of ergot, or twenty drops spirits turpentine or (F. 96.) 4. Examine to know if possible, the source of the hemorrhage; if it comes from the vagina or perineum where there is laceration, it is not very dangerous. Inject hot water of the temperature of 115° into the uterus, and apply a dry cotton cloth, heated as hot as possible, to the abdomen externally. 5. Before using the injections remove all clots from the vagina. 6. Quinine and stimulants may be exhibited if there is sinking, and ice may be applied to the abdomen and to the internal surface of the uterus, if the bleeding continues. I will here direct another thing which is very effectual, and which might be used at first in preference to anything else. 7. After removing the clots take a handkerchief or piece of muslin, saturated with vinegar, in your hand, pass it entirely into the uterus, and let it remain there 15 or 20 minutes, and your hand also. Your hand will compress the open blood vessels, and keep a clot in the mouth of them, and the vinegar will act as the best astringent that can be used. In one case of violent flooding I simply _held my hand still_ in the uterus for five minutes, and the flow ceased. After the hemorrhage subsides you must be careful not to raise the patient’s head above the level suddenly; her life may be put in jeopardy by suddenly raising her so that she sits up.
AFTER PAINS are very seldom severe in primapara cases, and they are less likely to be severe if the proper manipulations have compelled the womb to close completely, expelling all clots, &c. But sometimes there is a peculiar irritability or neuralgic condition of the womb which gives rise to excruciating pains. Ordinarily you may use Tully’s powder. (F. 123, 93, 95, 107.)
RETENTION OF URINE in some cases necessitates repeated visits of the physician, and he will appreciate a nurse who can introduce the catheter. If the patient cannot at first void the urine, perhaps the application of a hot wet sponge over the pubis may enable her to do so. But it may be necessary to introduce a catheter two or three times a day until she regains her power over her bladder, or until the swelling of the urethra subsides.
It is well for the nurse to know that owing to the distensible state of the abdominal parietes, the patient will lay twelve or fourteen hours, perhaps, after the child is born, without manifesting a desire to void the urine, though her bladder may be very full, and you should remind her of the necessity of passing the water, lest it produce cystitis. In some instances the urethra and neck of the bladder are extremely irritable, causing strangury, and there may be some difficulty in passing the catheter, but the urine must be evacuated, and afterwards it may be necessary to use ergot, laxatives, opiates and fomentations. (F. 125, 126, 162.)