CHAPTER VI.

CONCLUDING INSTRUCTIONS IN MIDWIFERY.

What I shall say of PLURAL BIRTHS, and MONSTERS, of CHILDREN AFFECTED WITH HYDROCEPHALUS, OR ASCITES, of EXCESSIVE SIZE OF THE FŒTUS, of DEFECTS IN THE FORMATION OF THE FŒTUS, of PROLAPSE OF THE FUNIS, &c., will be compressed in a few words. I am not instructing the nurse to attempt to conduct a case of even natural labor without having a physician if he can be obtained, but she should consider the services of a trained practitioner _imperatively_ necessary in these unusual cases. In either instance there may be a safe delivery by the natural powers alone, and the nurse may act in an emergency, but it would not be consistent with the plan of this work for me to describe in detail the various operations that are sometimes performed in these several cases, or to give instructions in the use of instruments, which I advise the nurse never to use.

In regard to those instances where it seems as if it would be necessary to use instruments, I quote the following rules adopted by accoucheurs: 1. Meddlesome midwifery is always bad. 2. In no case need we interfere when the obstacles to be overcome can be overcome in a reasonable time by nature or without an operation. 3. Cases in which instruments are to be used are exceptions to the general rule, and no instrument should be used in a clandestine manner. 4. We should not have such an aversion to the use of instruments that we too long delay that assistance we have the power of affording with them.

PLACENTAL PRESENTATION.

PLACENTA PREVIA will never be treated by the nurse, but she should know its nature, know that it is this that causes unavoidable hemorrhage, and she should not fail to obtain a skillful physician early, to attend the case. The flooding is the necessary consequence of the dilatation of the os uteri, by which the connection between the placenta and uterus is separated, and the more the labor advances, the greater the disruption, and the more excessive the hemorrhage.

The woman usually passes through the early part of pregnancy without any sign that denotes the peculiar attachment, but the placenta can easily be distinguished from the membranes or coagulated blood as soon as the os uteri is a little opened. When a hemorrhage comes on from this cause the patient is never free from danger till she be delivered. Often the medical man is obliged to free the patient from imminent danger by artificial delivery, but I can conceive of no circumstance in which a _nurse_ would be justified in turning for unavoidable hemorrhage.

Before, during, and after the delivery, the appliances used in other cases of hemorrhage may be used with some advantage, but I would hardly advise the nurse to do any thing before the doctor arrives.

ACCIDENTAL HEMORRHAGE.

That form of FLOODING that arises from a partial and accidental separation of the placenta which occupies its usual position, must here be briefly referred to, as the nurse may be called on to do something in an emergency. The immediate cause of the flow is the separation of some portion of the placenta from the womb, and the laceration of the vessels. The hemorrhage is at first internal, is accompanied with dull pain at the spot where it takes place, it generally becomes external, it may or may not be attended with the discharge of coagula from the os uteri, and when the discharge commences it varies in quantity from a few ounces to an amount that is alarming. It is generally necessary to make a digital examination, to distinguish the accidental from the unavoidable hemorrhage.

Until the doctor arrives the patient should be kept in bed on a hard mattrass and very lightly covered with bed clothes. The temperature of the room should be kept very low, and nothing but cold water allowed.

The danger from hemorrhages that occur at or near the full period of utero gestation, may often be estimated by the absence or degree of pain, as well as from the quantity of the discharge. Hemorrhages are much more dangerous with sudden than with slow discharges of blood, and women are always in greater danger when they are not accompanied with pain. Puerperal convulsions, whether of the hysteric, epileptiform, or apoplectic variety will always demand and almost always receive the prompt attention of the physician.

While the nurse is waiting for the doctor to arrive she might possibly administer a cathartic, thirty grains of bromide of potash, and an enema, but as a general rule she should not give anything. She might insert a wedge or roll of linen between the teeth to prevent injury to the tongue, and she should remove every thing out of the way, by striking against which, the patient might hurt herself.