Chapter 63

Placenta Praevia.--The after-birth is placed in the lower part of the womb; (after-birth before the child). This is a dangerous condition and terrible bleeding may occur. It occurs about one time out of every one thousand. The main symptom is bleeding and this may occur at any period of pregnancy. It usually appears from the seventh to the ninth month. The outset is without any appreciable reason and without pain. The amount of blood lost at the first attack may be so slight as to escape notice or copious enough to endanger the life of the mother. This flow may occur at any time during these months, and it may be small or great. If during the course of pregnancy the bleeding occurs at intervals in the increasing amount, the greater will be the loss of blood during the labor.

Treatment.--There is little danger of dangerous bleeding before the seventh month, and a waiting treatment may be adopted, but the woman should be closely watched and told what the trouble is, so she will be willing to remain quiet. Rest in bed, the avoidance of all muscular exercise and quieting medicines may enable the mother to carry the child until it can live, when pregnancy must be quickly terminated. If the child is dead the womb must be emptied at once. After the seventh month an expectant treatment is no longer allowable, and authorities declare the pregnancy should be terminated without delay. The mother is in great danger from sudden free flow. This treatment must be given by an experienced hand and only a physician can do it. If the pregnancy is allowed to continue to full term the danger to the woman is very great, as the mortality runs from thirty to sixty-five per cent; but under modern treatment it has been brought down to five to ten per cent. The death rate of the child is between fifty and seventy-five per cent.

[528 MOTHERS' REMEDIES]

Labor.--Labor may be defined as the physiological termination of pregnancy whereby the mature foetus (child) and its appendages (after-birth, etc.), are separated from the maternal organism.

Premonitory Signs of Labor.--Premonitory signs of labor, usually observed from one to two weeks before the onset of the labor pains, is a sinking down of the womb in the abdomen, whereby some of the unpleasant features of pregnancy are relieved, and the so-called "lightening" takes place. The waist line becomes small, the breathing is easier and the general well-being of the woman is better, so that her friends are attracted by her feeling of relief. But as a result of the womb descent and the consequent pressure, irritation of the bladder and rectum may occur, and she may have frequent calls to empty these organs. The vagina secretes more actively, the veins enlarge, some dropsy may appear in the extremities, and the womb contractions of pregnancy, which have been painless, begin to cause more and more discomfort.

These false pains recur at regular intervals of hours or even days, and generally at night, last for a varying period and usually disappear in the morning. They often deceive the woman and lead her to the belief that the labor has already begun; but examination of the cervix will reveal that this is not so. It is well to bear in mind that the true labor pains usually begin in the back, extend down to the thighs and often around to the front and they recur at regular intervals, and with increasing intensity.

The beginning of labor is characterized by recurring pains at regular intervals and of increasing severity. There is also a discharge from the vagina of mucus, and this is sometimes tinged with blood, "the show." If an examination is now made, it will be found that the cervix (neck of the womb) is shortened, and that the mouth of the womb is beginning to dilate. At the beginning, the pains are usually in the back and spread to the abdomen and down the thighs; but they may be felt first in the abdomen. They return every half hour or twenty minutes, but as labor goes on the interval is shortened, so that toward the end of the second stage when the child is being born, they appear to be continuous, and the patient feels as if she is encircled by a belt of pain; however, with all this, she will bear the suffering easier and better for she knows that progress is being made, and that she will soon be over the pains and the child born. A pain rarely lasts more than one minute.

[OBSTETRICS OR MIDWIFERY 529]

STAGES OF LABOR.--First stage extends from the beginning of labor until the mouth of the womb is dilated. Second stage, from the complete dilation until the complete birth of the child. Third stage, from the birth of the child until the expulsions of the after-birth--Placenta.

The First Stage.--The first stage varies greatly in different women. The average duration of this stage is from ten to fourteen hours in the woman with the first child, and six to eight hours in the woman who has borne children. During this stage the woman prefers to remain on her feet, sit, stand or walk about. The amount of pain experienced varies greatly, according to the temperament of the patient; in nervous women it may be excessive. The pains now have nothing of that bearing down character which they afterward acquire; they are described as "grinding," are usually felt in the front. The genitals become bathed with secretions, which are sometimes tinged with blood. This is an especially trying period to a young wife, for she cannot see that the pains are doing any good, only making her restless, tired and nervous. Little can be done by the physician in this stage except to encourage and explain what is really being accomplished by these seemingly futile pains and by tact and proper encouragement, a physician tides this stage over and gives great comfort to the needy patient. This stage ends with the opening and dilation of the mouth of the womb and the second or expulsive stage sets in, with pains altered in character.

Second Stage.--The pains now become more frequent and severe and last longer, and the patient now manifests a strong desire to expel the contents of the womb. The woman now feels better in bed and when the pains come she involuntarily bears down, with each contraction she sets her teeth, takes a deep breath, fixes the diaphragm, contracts the muscles of the abdomen and bears down hard if you allow her to do so. The knowledge that she is working to overcome an obstacle gives her some satisfaction and she feels that she is accomplishing something by the efforts she is making. The physician can aid greatly by suggesting to the patient how to use the pains and how much bearing down to do. He can tell her when not to bear down, and so save her strength for the next real pain when bearing down will do good. Although the pains are really harder in this stage, nervous women suffer no more, for their mind is now concentrated upon the work at hand. Sometimes at the beginning of this stage the patient feels chilly or has a severe chill; a hot drink and more covering counteract this. Another phenomena is the escape of the waters and a lull in the pains for a little time, when they come on more effectively than before as the womb contracts down upon the child and is not hindered by the "bag of water." The pains keep on at intervals until the child is born and the physician can now be of help by guiding, directing and assisting the birth of the head. This stage averages about two hours.

[530 MOTHERS' REMEDIES]

Third Stage.--The birth of the head is very soon followed by the shoulders and the rest of the body, and the woman is now at comparative rest. The cord is now tied and cut and the child laid away, if all right, in a warm place until it can be washed and dressed. Following the birth of the child there is a short resting period, the contractions of the womb cease and it becomes smaller through retraction. After a few minutes the pains begin again, the after-birth separates from its attachment in the womb, and together with the membranes is extruded into the vaginal canal and vulvar opening; whence it can be easily delivered by pressing upon the abdomen over the lump (womb) and by guiding the after-birth with the cord. This should be done slowly so that the membranes will all come away with the after-birth.

This should always be examined to be certain that everything has come away. A greater or less amount of clots of blood come with the after-birth. The contraction of the womb stops the bleeding, one hand should be kept on the abdomen over the womb, to see that it remains hard and retracted. The womb moves under the hand. If it softens, gentle rubbing should be kept up and the womb will soon remain contracted. This stage averages about fifteen minutes.

MANAGEMENT OF LABOR.--Preparation of the Bed.--The bed should be high, springs not soft, with a firm and smooth mattress. It should be placed so that both sides are accessible. The bed should be made up on the right side as a rule, as the woman usually lies on her left side when delivered. Place a rubber, or an oil cloth sheet, over the mattress, and over this an ordinary muslin sheet and secure this with safety pins to the corners of the mattress. This is the permanent bed; on top of this is the second rubber sheet and this is covered with another muslin sheet and both held by safety pins. This is the temporary bed. Plenty of hot and cold boiled water should also be at hand. Frequently only a temporary bed is made with rubber or oil cloth underneath, blanket and sheet above this. They should be fastened so that the movements of the woman will not disorder them. These can be removed after the confinement and new, clean warm clothes put in their place. The objection to this is the woman may be too tired to be moved, while, with the permanent and temporary bed arrangement she need not be moved at all, only lifted, while the temporary bed is being removed and she is then let down easily upon clean bedding.

Preparation of the Patient.--The patient, if she desires, can take a full bath. The bowels should be moved thoroughly with a soap and water injection so that the rectum will be fully emptied. This makes labor not only easier, but pleasanter, as no feces will be discharged during labor. The bladder should also be emptied. The external organs should be scrupulously cleansed and bathed with some antiseptic solution, like glycothymoline, listerine, borolyptol, etc. A fresh suit of underwear may then be put on and over this a loose wrapper.

[OBSTETRICS OR MIDWIFERY 531]

Examination of the Patient.--The physician needs to satisfy himself as to the position of the child, etc. This can be done by an examination of the abdomen and also of the vagina. He must determine whether the child is alive, its position, the condition of the cervix and mouth of the womb. In making such examination a routine plan should be adopted. The coat must be removed, the shirt sleeves turned up and the hands and arms washed with soap and water. The abdomen should be thoroughly palpated (felt) and listened to with the ear or stethoscope to determine the character of the child's heart beat, whether it be very slow, one hundred and twenty or less, or a very rapid one, one hundred and fifty or more. It may indicate danger to the child and necessitate a hurried delivery. After these things have been done, the hands and arms must again be thoroughly washed and sterilized, the fingers anointed with carbolated vaselin and the examination of the vagina made.

This cleanliness is necessary, and if this plan were carried out by everyone connected with the patient during the whole confinement, there would be fewer cases of "child-bed" fever, with its resultant diseases. The patient should lie on her back with the knees drawn up. There is no need for any exposure now, for the covering can be held up by an attendant so that it will not touch the physician's hands. The soft parts are now separated by the fingers of one hand while the examining fingers are introduced into the vagina. These fingers should never touch any external part and especially the parts near the anus. If the cervix is found to be long and the canal still undilated, or only slightly so, and especially if it is the first child (primipara), the physician's presence is not needed and he may safely leave for an hour or two. But if the mouth (os) of the womb is dilated to the size of a silver dollar he should on no account leave the house.

Frequent examination of the vagina should not be made. In ordinary cases during the first stage, the woman should be up and encouraged to walk about the room, to sit or assume any comfortable position. During a pain she may stand beside the bed resting her hands upon something or kneel in front of the bed or chair. The standing position assists in the birth. The bladder should be emptied frequently, as a distended bladder retards labor and may even stop the womb contractions. The pains become more frequent and severe as the end of this stage approaches and each contraction is now accompanied by straining or a bearing down effort on the part of the woman, and as a rule the membranes rupture spontaneously about this time. An examination of the vagina should now be made with the woman in bed, and if the membranes have not broken and the womb is completely dilated as shown during the pain, they may be ruptured by pressing against them with a finger-nail during a pain. Sometimes we use every means to retain the membranes intact, but that is when protection for the child is needed for sometime longer. If the suffering is very severe, during this stage, fifteen grains of chloral hydrate, well diluted with water, may be given every fifteen or thirty minutes until sixty grains have been given. (This medicine should never be given to a person with heart trouble). I find one drop doses of the tincture of Gelsemium every fifteen to thirty minutes of benefit, especially if the womb does not dilate well, or the patient is very nervous. The patient may receive and can receive light nourishment during this stage.

[532 MOTHERS' REMEDIES]

Management of the Second Stage.--After the rupture of the membranes the labor proceeds faster and a termination may be expected within a reasonable time. There is a short lull in the pains, usually, after the waters have escaped and during this time the patient should remove her clothing and put on a night dress, and to prevent its being soiled roll it well up under the arms and retain it there. After labor it can be very easily pulled down and made comfortable for the patient. A folded, clean, sterile sheet is now placed about the body and extremities and held in place by a cord around the waist. The opening in the sheet should be in the right side, as this will allow the assistance being given as needed. The powerful force of the abdominal muscles is now brought into action; the force is best utilized with the woman lying on her back.

She should now be encouraged to bear down during the pains and she will be greatly assisted by pulling on a sheet or long towel tied to the foot of the bed, or by holding the hand of the nurse. A support for her feet frequently aids the woman. Pressing low on her back relieves her to some extent. In the intervals between the pains she should rest, do nothing, and be perfectly passive. It is now that an anesthetic may be used to relieve the suffering. She should not be put completely under its influence for that is not only unnecessary, but injurious. Chloroform when used should be given on a handkerchief opened and loosely held over the woman's face, and administered drop by drop on the handkerchief. The handkerchief should be placed over the face at the beginning of the pain and be taken away as soon as the pain is stopped. The woman inhales the chloroform during the pains and their sharpness is blunted. Given in that way it is not considered dangerous. It should only be pushed to unconsciousness during a forceps delivery, and even then it is not always necessary to render the woman unconscious. I have used the forceps without giving an anesthetic. They should be placed without causing any special pain, and assist in delivery without causing any more pain when the head is down low. Of course if the forceps must be used when the head is high up a greater amount of anesthetic is needed.

Dr. Manton, of Detroit, says:--"The dangers of anesthetics are the same when employed for obstetric purposes as in surgery, and then use should be governed by the same rules in each instance." As soon as the head begins to dilate the vulvar opening, the patient should be turned on her left side with her knees drawn up and her body lying diagonally across the bed, with the buttocks close to and parallel with the edge. This position allows the physician to give better assistance and is no harder for the patient.

[OBSTETRICS OR MIDWIFERY 533]

The physician with his hands thoroughly sterilized and with a clean sterilized gown, seats himself on the edge of the bed and watches the progress of the labor, ready to assist the woman at any moment. And at this time he can do much by words of encouragement and proper directions to the laboring woman how to use her pains so as to get the most from them; and also by manipulation of the soft parts and the head. The head advances more and more with each succeeding pain, and the perineum is put on the stretch, each contraction is followed by a resting pause during which the head slips back a little and relieves the perineum. Tear of the perineum is liable to take place when the head is about to escape through the vulvar opening, especially if the contractions are strong, the woman bears down forcibly and the interval between the pains is short, so that the head is forced out before the parts have time to completely dilate and soften. Here is where the physician's work comes in, by holding the head back and fully flexed (bent), chin upon the breast, and keeping the back of the head (occiput) well up towards the bone in front (pubic arch) until thc perineum is completely dilated.

The effect of the pains can be lessened, if necessary, also, by telling the woman to open her mouth and not to bear down during the pain for a few times. In this way the perineum will dilate properly and be torn little, if at all, and perhaps much future trouble for the woman saved. I always tell my patient why I ask her to do certain things in labor and I have never found any woman who, when able, was not willing to do as I asked. A torn perineum is not desirable, because even when sewn up immediately after labor, it may not unite thoroughly, and thus cause displacements of the womb in the future. A little time and care at the time of labor will save the perineum and every woman is willing to do her share when the conditions are plainly explained to her. It takes only a few minutes longer, and only a few more pains to bear. When the head begins to stretch the opening, the left hand of the physician should be carried over the woman's abdomen and between the thighs, her right leg being supported by a pillow placed between her knees, and this left hand presses the back of the head (occiput) forward and against the "pubic arch." The right hand may also press the head upward by being placed against the posterior portion of the dilated perineum. The edge of the perineum should now be closely watched. A small towel wrung out of a bowl of hot water placed handy on a chair, should be held constantly against the perineum to hasten the softening and dilatation of these tissues. Plenty of hot water and small towels should be at hand. The head advances with each pain and again recedes until the parts are properly dilated, and the perineum slips backward over the child's face.

[534 MOTHERS' REMEDIES ]

If torn, it should be sewed before the physician leaves, as it can be done easily and without pain to the mother. As the head of the child emerges, the anesthetic should be pushed, or the woman told to open her mouth and cry out. This lessens the pain and the child's head emerges slower, and the perineum is saved. The child's head should be received in the hand. After the head is born, there is a lull for a few moments. Then the shoulders rotate into the proper position and are easily born. There may then be a flow of watery fluid for a few seconds. Before this time the physician has examined to see whether the cord is around the child's neck, released it if it has been, and also cleaned out the child's mouth. The child usually cries a little about this time and it is soon seen whether it needs quick attention. The perineum should be guarded also while the shoulders are being born as it can be torn by them. The shoulders are generally born without any help. The child's head is held in the physician's hand. As soon as the body is born, the child should be laid upon the bed behind the mother's thighs, and the cord pulled down to prevent it pulling upon the after-birth. After the beating in the cord has ceased, generally from five to ten minutes have elapsed, the cord is then tied, tight enough so it will not bleed afterward, about one or one and one half inches (some say more) from the body and tied a second time an inch or so from the first ligature, and the cord cut between the two ligatures. Care should be taken so as not to cut a finger or toe of the baby. If the cord is very thick it is best to pinch it at the point of tying and the contents stripped away before the first ligature is applied. After the cord is cut it should be wiped off to determine that bleeding from the vessels has been permanently cut off, and if not it should be tied again. The child is now taken up by placing the back of its neck in the hollow between the thumb and forefinger, and the other hand over the backbone. It should then be placed in a warm receiving blanket, and put in a safe place.

Management of the Third Stage,--The contractions of the womb are renewed and with the second or third the after-birth may be expressed. The top (fundus) of the womb is grasped by the hand through the relaxed abdominal walls, and squeezed, and at the same time make a downward pressure. The after-birth is loosened from the womb and slides through the vagina and outlet, and it may be caught in a tray which has been placed between the patient's legs, or by the hand and given a few twists in order to roll the membranes together; while this is being done, gentle rubbing should be applied to the womb, when the membranes will slip out without tearing; no drawing on the cord should be done in delivering the after-birth.

From the time of the birth of the head to the delivery of the after-birth the womb must be controlled by the firm pressure of the hand on the abdomen. It is well for the nurse, when the after-birth is separating from the womb to follow the womb, throughout this whole stage, by keeping her hand upon it and if, while the physician is attending to the child, the womb softens and enlarges she should at once notify him. There may be bleeding within the womb. After the womb is empty, friction should be made over the womb whenever it softens at all in order to stimulate the womb to perfect contraction, and it should be kept up at intervals for one hour after the after-birth and membranes have been delivered.

[OBSTETRICS OR MIDWIFERY 535]

THE CHILD.

The eyes should be washed soon and normal respiration established. If the child does not breathe well, cold water may be sprinkled in the face and chest and if this fails, immersions in hot water at 106 degrees F., and sprinkling with cold water must be resorted to. If necessary, artificial respiration must be given. Slap the child on the back and move the arms up and down by the side a few times, or breathing into the child's mouth.