CHAPTER XIII

OBSTETRICAL OPERATIONS AND COMPLICATED LABORS

Unhappily, not all labors run the smooth and uncomplicated course which was described in the last chapter. Certain abnormalities sometimes arise to complicate delivery, occasionally necessitating operative interference or relief.

There is little that a nurse can do alone, in the presence of complicated labor, but her preparations and assistance will be more effective if she understands the purpose of the operations, and she will better appreciate the gravity of certain symptoms, which she is required to watch for and report, if she realizes the extreme seriousness of their import.

The principal conditions which give rise to, or follow complications, prevent spontaneous delivery or necessitate operations at the time of labor are perineal lacerations; contracted or malformed pelves; marked disproportion between the diameters of the child’s head and mother’s pelvis; ruptured uterus; exhaustion of the mother; poor muscle tone or certain chronic and acute diseases of the mother; death of the fetus; prolapsed cord; certain presentations of the fetus in which spontaneous delivery is doubtful or impossible.

The preparations for operations in hospitals are all so carefully planned and systematized that in the presence of such emergencies the nurse will merely have to carry out the customary routine, but in a patient’s home she may have to exercise a good deal of originality in attempting to meet the needs of the occasion and imitate hospital provisions.

A satisfactory operating table may be fashioned in any one of a number of ways. If the bed is high enough, it may sometimes be made fairly satisfactory by slipping a board, such as a table leaf, under the mattress to make it firm. The use of a kitchen table is time-honored, but it is an unsafe practice unless the available table is very secure and firm, which is usually not the case with present-day kitchen tables. A flat-topped chest of drawers, with the casters removed, makes an excellent operating table, for it is firm, a good height and about the right size. Or an ordinary bureau may be pressed into service after taking out the casters and removing the mirror by unscrewing its supports. The front and sides of a bureau, or chest of drawers so used should be protected from the damaging effects of fluids and solutions by being covered with a bed-rubber or newspapers. A pad for the top of the improvised operating table may be arranged by folding a blanket or quilt to the proper size and folding over that the rubber draw-sheet and a clean muslin sheet.

If the operation requires that the patient be held in the lithotomy position (on her back with thighs and knees flexed and knees well separated), and the doctor’s equipment does not include a strap to hold the legs, one may be improvised from a sheet. It should be folded diagonally, over and over, into a strip possibly a foot wide, passed over one shoulder and the tapering ends used to tie around the legs, above the knees, to hold them in the desired position. Bandages or tapes are not always satisfactory, for the support is subject to a good deal of strain, and narrow strips sometimes cut painfully into the legs and shoulders. Certainly if tapes or bandages are used, cotton pads or folded towels should be interposed between them and the patient’s skin.

In general, the nurse will prepare as for a normal delivery, in each instance adding such details of equipment, or preparation as the contemplated operation requires. Rigid asepsis must be observed throughout the preparations and the operations. When large instruments or appliances are to be used, a wash boiler is probably the safest thing in which to boil them, for it is scarcely possible entirely to cover them with water in a smaller receptacle; and they must be well covered while boiling, or they will not be sterile.

=Perineal Lacerations.= A large proportion of women during the birth of the first baby sustain some degree of perineal laceration, which may amount to nothing more than a nick in the mucous membrane, or it may extend entirely across the perineal body and tear through the rectal sphincter. The causes of these tears are generally conceded to be rigidity of the perineal muscles; disproportion between the size of the child’s head and the vulval opening; a sudden expulsion of the child’s head, before the perineum is fully distended, and certain abnormalities in the mechanism of labor. Lacerations may, therefore, be prevented, or limited, in many cases by holding back the baby’s head and allowing it to dilate the perineum slowly. But in spite of the most skillful and careful efforts, tears of some degree occur in most primiparæ, and probably in half of all multiparæ. These injuries are usually described as being of the first, second or third degree, according to their extent.

=A first degree tear= is one that extends only through the mucous membrane, usually at the margin of the perineum, without involving any of the muscles.

=A second degree tear= is one that extends down into the perineal body and may involve the levator ani, or even extend down to, but not through the rectal sphincter. Such a tear usually extends upward on one or both sides of the vagina making a triangular injury.

=A third degree tear= extends entirely across the perineal body and through the rectal sphincter and sometimes up the anterior wall of the rectum. This variety is often called a =complete tear=, in contradistinction to those of first and second degree, which are incomplete.

It is a fairly general custom to repair these lacerations at the time of labor, no matter what their extent, the sutures being introduced but not tied, during the third stage. The patient is usually sufficiently anesthetized to permit of this, without further anesthesia, in all but complete tears, and as there is usually but very slight bleeding before the expulsion of the placenta, the field is comparatively clear and the stitches are easily put into place. They are not tied, as a rule, until after delivery of the placenta because of the strain which its expulsion would put upon the fresh stitches. In all but very slight tears, the doctor will usually want the patient turned across the bed, with her hips brought to the edge, and her legs supported in the lithotomy position. As the few instruments necessary for perineal repairs should be boiled and placed in readiness before labor, there is usually no further preparation for the nurse to make, and the perineal dressing, after the stitches have been taken, is ordinarily the same as that following a normal delivery. (See Fig. 80 for necessary instruments.)

Some physicians prefer not to repair perineal tears until some days after labor, contending that the congestion of the soft parts immediately after delivery is not favorable to a satisfactory union. When the repair is made subsequently, therefore, the nurse prepares as she would for any perineal operation, performed independently of labor. Repairs are not often postponed for more than a few days, since long delayed or neglected attention frequently gives rise to gynecological disorders, such as descensus or prolapse of the uterus.

=Episiotomy.= Some obstetricians prefer to anticipate a perineal tear by making an oblique incision, usually on one or both sides, extending downward and outward from the margin of the vaginal outlet down into the perineum. This operation is termed episiotomy, and the incision is sutured after labor just as a tear would be. It is the belief of those who perform this operation that the clean-cut incision heals more satisfactorily than an irregular tear, and that by directing the incision to the side, away from the median line, the integrity of the rectal sphincter is preserved, even though the perineum tears beyond the end of the incision, when distended during the birth of the head.

=Breech Extraction.= In some cases of breech presentation, particularly among primiparæ, it is necessary to assist nature in the delivery of the child in order to save its life. Complete anesthesia is usually necessary at such times and the patient is preferably on a table or at the edge of the bed in a lithotomy position.

In the majority of cases, no effort is made toward assistance until the body is born as far as the umbilicus, partly because of the difficulty of taking hold of the child securely before that time, and partly because the perineum is not likely to be fully distended, in which case a serious tear would probably result. But after the body has been extruded as far as the umbilicus, it is usually considered imperative to complete the delivery within eight minutes to save the child from asphyxiation, due either to pressure on the cord between the head and pelvic brim, or to premature separation of the placenta. The baby’s feet or legs are grasped by a towel to prevent slipping, and downward traction is made on the body until the tips of the scapulæ appear at the outlet. During this procedure the nurse may be called upon to make pressure on the uterus with the idea of keeping the baby’s head flexed forward; preventing the arms from becoming extended upward above the head and also to help in expelling the child.

After the scapulæ appear, the arm lying posteriorly is brought down over the chest and delivered. The body is then rotated until the other arm lies posteriorly and that is delivered. After delivery of the arms and shoulders the head is usually delivered by what is known as Mauriceau’s maneuver as follows: The accoucheur slips the index finger of one hand into the vaginal outlet and into the child’s mouth, and supports the body of the child upon his hand and forearm; two fingers of the other hand are slipped around the back of the neck and curved forward like hooks over the shoulders and strong downward traction is made by these fingers; not by the one in the baby’s mouth. The occiput emerges from beneath the symphysis, after which the body is lifted upward and the chin, nose, forehead and entire head are born.

=Version.= By version is meant the turning of the child within the uterus so that the part which was presenting at the superior strait is replaced by another part, in order to hasten or facilitate delivery. It is usually performed as the patient lies flat on her back, completely anesthetized, and with great gentleness, for fear of rupturing the uterus.

Common indications for a version are a transverse presentation; a prolapsed cord, when the head has just begun to enter the superior strait; and in some cases of placenta prævia. When the fetus is so turned that the head becomes the presenting part, the procedure is termed a _cephalic version_; if so turned that the breech presents, it is termed a _podalic version_. The methods of accomplishing these ends are described as _external version_, if the turning is done entirely with the hands working through the abdominal wall; _internal version_ if one entire hand is introduced into the uterine cavity, and _combined version_ when one hand is outside on the abdomen and two fingers of the other are introduced through the cervix into the uterus.

External cephalic version is often performed late in pregnancy, or early in labor, in transverse and also in breech presentations, to secure a vertex presentation because of the high fetal death rate in breech extractions. Podalic version, or making the breech the presenting part, is often performed in transverse presentations, in placenta prævia and when the cord or extremities are prolapsed. Having converted the presentation into a breech, the usual breech extraction is performed.

=Forceps= are instruments which are used to extract the child when presenting by the head in certain conditions which endanger the life of mother or child. The value of forceps in obstetrics can scarcely be overestimated, as before their invention the only operative method of delivering a live baby was by means of version and extraction, and in these the fetal death rate was high. The obstetrical instruments in use up to that time, therefore, were all for the destruction of the child in utero.

Forceps were devised, and first used, in great secrecy, early in the 17th century, by a Dr. Chamberlen, in England, who jealously guarded all information relating to his invention from every one but members of his own family.

There were several doctors in the Chamberlen family who practiced obstetrics and who used these forceps, but knowledge concerning the nature of the instruments and methods of using them was not shared with members of the medical profession outside of that family, until the beginning of the 18th century. Since that time the use of forceps has been widely extended and the original Chamberlen instruments have been so modified and altered and improved by different obstetricians, that there is now a bewildering number and variety in existence and in use. Probably the most widely used are those which were devised by Dr. Tarnier of France and Dr. Simpson of England, respectively. (Fig. 107.) The Tarnier instrument is known as an axis traction forceps, and can be used in all kinds of forceps operations, while Dr. Simpson’s are suitable for use only in low forceps cases.

There are two groups of indications for the use of forceps; those relating to the condition of the child and those relating to the mother.

Indications for their use in the interests of the child are symptoms of asphyxia, and these are the passage of meconium, in head presentations, and a change in the rate or rhythm of the fetal heartbeat. As pressure on the abdomen of the fetus during labor, in breech presentations, is very likely to express meconium, this is not of special significance in these cases. But in head presentations, the escape of meconium suggests paralysis of the rectal sphincter muscles, due to imperfect oxygenation, which, in turn, is caused by interference with the placental circulation by pressure on the cord or premature separation of the placenta.

Conditions which menace the life of the mother, and indicate the use of forceps, are inadequate contractions of the uterine and abdominal muscles; exhaustion, as indicated by an increase in the maternal pulse rate or elevation of temperature, and in certain chronic and infectious diseases, when the patient may be unable to stand the strain of the second stage.

Forceps are usually employed when the head fails to make satisfactory advancement after two hours of good, second-stage pains, or when it remains in one place on the perineum for an hour, in spite of good, second-stage pains.

Otherwise, there is danger of necrosis or sloughing of the soft parts as a result of pressure, with a subsequent recto-vaginal or vesico-vaginal fistula.

Among the acute conditions in which forceps are indicated are typhoid fever; pneumonia; acute edema of the lungs, hemorrhage from premature separation of the placenta; intra-partum infection and eclampsia, while they are sometimes used in such chronic conditions as pulmonary tuberculosis; various heart lesions, particularly when there is broken compensation.

Before applying forceps the operator will usually wish to satisfy himself that the following conditions exist: Complete dilatation of the cervix, otherwise severe lacerations with hemorrhage may result; the head must have entered the pelvis, otherwise an imperfect application of the forceps may result in death of the fetus and serious injury to the mother; the position of the child’s head must be known in order that the forceps may be properly applied over the ears; the membranes must have ruptured or the forceps may slip.

Forceps operations are usually designated as being high, mid or low, depending upon the level to which the head has descended into the pelvis. If the head is at the superior strait, a high forceps operation is necessary; mid forceps if the head is half way down and on a level with the ischial spines and low forceps when the head is on or just above the perineum.

The application of low forceps is a simple operation and attended by little danger to mother or child; mid forceps is more serious and high forceps is very serious for the child and sometimes for the mother.

When forceps are applied, the patient must be at the edge of the bed or preferably on a table, in the lithotomy position (Fig. 108), and completely anesthetized. She should be shaved and scrubbed as for a normal delivery, after which a sterile towel soaked in bichlorid 1–1,000 or lysol 2 per cent., is placed over the vulva and allowed to remain until the operation is performed. She should be draped with sterile leggings and towels, one of which is folded over the centre of a wide strip of adhesive about twenty inches long, and hung curtain-like over the rectum by strapping the free ends to the buttocks on each side, while over all is placed a sheet with three openings; two slits for the legs to pass through and one rectangle which exposes the field of operation. (Figs. 109, 110.)

=Pubiotomy=, or hebotomy, consists in sawing through the pubic bone on one side of the symphysis with a string or Gigli saw. This operation is performed in some cases of moderately contracted and funnel pelves, through which the normal expulsive forces of labor are unable to force the child. The separation of the bone allows it to gape, because of the hingelike movement of the sacro-iliac joint, and thus the superior strait is appreciably widened and the child may be delivered by high forceps or version. As the bone heals by fibrous union, there is sometimes permanent enlargement of the pelvis and there are seldom any unsatisfactory after-effects, such as impairment of locomotion. Pubiotomy is sometimes the operation decided upon when a patient is seen for the first time after labor is well advanced, and a conservative Cæsarean section is thought inadvisable because of the risk of infection. But the operation is becoming more and more rare, for the general practice of measuring the pelvis and supervising patients during pregnancy discloses serious disproportions early enough to make a Cæsarean section the elective operation.

=Symphysiotomy.= This operation is a cutting through the cartilage of the symphysis pubis, instead of through the pubic bone, as in pubiotomy. It was formerly performed for much the same reasons that pubiotomy is now used, but has been practically abandoned since the development of the latter operation. The reasons for giving it up were that the close proximity of the bladder to the symphysis resulted in frequent injuries to that organ, and as the cartilage of the symphysis does not heal as well as the pubic bone, the patients frequently experienced difficulty in walking and showed a tendency to tire more easily after the operation than before it was performed.

=Vaginal Hysterotomy=, or vaginal Cæsarean section, as it is sometimes called, consists of incising the cervix anteriorly and posteriorly, delivering the child and placenta and suturing the wounds. It is sometimes performed in cases which for some reason require immediate delivery, as in severe cases of eclampsia. It is only possible when the relation between the pelvis and the child’s head is such as to permit the child to pass through the inlet. It is rarely done in primiparæ, because rigidity of the outlet prevents proper exposure; or in multiparæ at term as the incisions have to be extended so high to deliver a term baby, that there is danger of tearing the lower uterine segment.

=Cæsarean Section= is the operation by means of which the child is delivered through an incision in the abdominal and uterine walls. It is believed by some that the operation was named for Julius Cæsar, who was presumably delivered by this method, but this seems scarcely probable. The operation was frequently fatal in those days and, moreover, as the uterine wall was not sutured after the child was extracted, a woman was not likely to have other children afterward even if she did live, and Cæsar’s mother had several children after he was born. Another explanation for the name is that during Cæsar’s reign a law was passed which required that the abdomen be opened and the child extracted in every case in which a woman died late in pregnancy, as one means of increasing the population.

Thus it will be seen that the operation itself is very ancient, but as performed to-day it embodies the most modern and scientific knowledge and methods. The usual indications for it are cases of contracted or deformed pelves; cases of tumors which block the birth canal or when very speedy delivery is imperative as in some cases of eclampsia.

The anatomical indications for Cæsarean section are dependent upon the degree and character of the pelvic contractions and upon the size and mouldability of the child’s head in relation to the pelvis. This explains why in two women with pelves of the same size and shape, one will have a spontaneous delivery and one will require a section. The former has a relatively small child which can pass through her pelvis; while the second woman’s baby is too large, or the head not sufficiently mouldable, to pass through hers.

This is one exemplification of the great importance of pelvimetry and of constant watching during pregnancy, for the best results from Cæsarean section are obtained when it is recognized that spontaneous delivery is unlikely or impossible; the operation accordingly is performed at a time which is deliberately selected by the obstetrician. The elected time is often about two weeks before the expected date of confinement in order that the baby may have the longest possible intra-uterine life and that the operation may be performed before the patient goes into labor. In these cases in which it is known that a section is to be performed vaginal examinations are omitted after the pelvic measurements are taken, in order to minimize the possibilities of infection, this being one of the great risks of the operation.

Until recent years the operation was usually delayed until after the patient had been vaginally examined, had been in labor long enough to be exhausted and the only other courses open were high forceps or a destructive operation upon the child. The results of the operation undertaken under such circumstances were not good, and the maternal deaths from infection were so frequent that the operation on the whole was very hazardous. But improved surgical technique and extended knowledge of the pelvis have so revolutionized Cæsarean section that it is now successful in the majority of cases.

There are three main types of Cæsarean section: conservative, radical and extraperitoneal.

The =conservative= operation consists of opening the abdomen in the mid-line; incising the uterus; extracting the child and placenta, and suturing both uterine and abdominal walls. This is the usual operation when there is a choice, but because of the danger of infection, it is ordinarily performed only before the onset of labor or in the early part of the first stage, and many obstetricians are loath to undertake it then if the patient has been examined vaginally, particularly if the technique of the examination was open to question.

In the =radical= operation the abdomen and uterus are incised; the child and placenta extracted and the uterus is amputated just above the cervix. This operation is usually performed when labor is well advanced and there is fear of infection.

In the =extraperitoneal= operation the incision in the abdomen is made low down on one side, the peritoneum is not incised but is peeled back from the bladder and lower part of the uterus. The uterus may thus be opened and the child and placenta extracted, without entering the peritoneal cavity, thereby greatly reducing the risk of infection, and also without necessitating the removal of the uterus as a safeguard against infection. This operation, also, is performed late in labor when infection is feared, but is considered very difficult and therefore is not common.

The nurse’s duties in connection with a Cæsarean section are the same as those in any abdominal operation plus preparations for receiving and reviving the baby.

=A Ruptured Uterus= is a splitting of the uterine wall at some point, usually in the lower uterine segment, that has become thinned or weakened and unable to stand the strain of further stretching incident to uterine contractions, and is accompanied by an extrusion of all or a part of the uterine contents into the abdominal cavity. The rupture of a uterus during labor is a very rare accident, occurring but once in from 500 to 1,000 cases and usually only in prolonged labors, obstructed labors or certain faulty presentations. It is also a very grave accident, since the baby nearly always dies and sometimes the mother as well.

The cause of a ruptured uterus may be found in scar tissue, following a Cæsarean section or an injury; inherent defects in the tissues comprising the uterine wall; contracted pelves; neglected transverse presentations and the accident may occur during a version. It is usually preceded by extreme tenderness in the lower uterine segment, the part that is being abnormally stretched. The common symptoms, after the rupture has occurred, are sudden and acute abdominal pain during a contraction, which the patient describes as being unlike anything she has ever felt and as though “something had given way” inside of her. There is immediate and complete cessation of labor pains because the torn uterus no longer contracts. Sooner or later the patient has symptoms of shock because of the hemorrhage, which is usually internal, though there may be vaginal bleeding as well. Her face becomes pale and drawn and covered with perspiration; her pulse is weak and rapid; she appears exhausted and collapsed and may complain of chilly sensations and air hunger.

Abdominal palpation shows that the lower uterine segment is even more sensitive than formerly and that the presenting part has slipped away from the superior strait while at the side of the fetus the contracted uterus, partly or entirely empty, may be felt as a hard mass. The symptoms of shock may be delayed for some time when they will be accompanied, as a rule, by abdominal distension, due to hemorrhage, and a slight elevation of temperature.

The prevention of this disaster lies in performing version and prompt extraction in transverse presentations, as soon as the cervix is dilated, and in interference if the presenting part does not engage after an hour of strong, second-stage pains.

The treatment of a ruptured uterus is influenced by many factors. Possibly the most frequent course followed is to open the abdominal cavity and repair or remove the uterus, after extracting the fetus and placenta, according to existing conditions and the judgment of the operator. Sometimes the fetus is removed through the vagina and the uterus repaired through that channel.

=Destructive Operations= have as their purpose the crushing or dismembering of the child in utero so that it may pass through the pelvis. In the early days such operations were resorted to fairly often in the presence of conditions that threatened the mother’s life and which apparently could not be met in any other way. They are performed less and less frequently to-day because of the success attending the performance of Cæsarean section, version, pubiotomy and forceps operations. They are never sanctioned by the Catholic Church in cases where the child is alive.

=Induced Abortions and Premature Labors.= As was explained in the chapter on complications and accidents of pregnancy, it is sometimes deemed advisable, or necessary to terminate pregnancy by artificial means, in the interests of the mother or child or both.

The procedures are termed _induced abortion_, _induced premature labor_ and _accouchement forcé_. The effects of these operations, _per se_, when skillfully performed, for therapeutic purposes, are not usually considered more serious for the mother than a normal delivery, since they can be performed with deliberate care and cleanliness and can be followed by adequate aftercare. When the reverse conditions prevail, as in criminal abortions, the patient’s subsequent suffering or ill health are more likely to be due to the poor obstetrics and unclean work which is characteristic of practitioners who are willing to do illegal operations, than to the termination of pregnancy itself. It is important that the nurse fully appreciate this and be as scrupulously careful in her preparations for, and assistance with these operations as for a major operation or a normal delivery.

=Induced abortion= applies to the termination of pregnancy before the child is viable, or before the end of the twenty-eighth week, and is performed solely in the interests of the mother, as the fetus is always lost. It is resorted to in those cases where the mother is suffering from some condition, which may or may not be inherent to pregnancy, which threatens her life or health but which it is believed may be cured or arrested if uncomplicated by pregnancy. Such conditions may be toxemic vomiting; nephritis, particularly with evidences of increasing renal insufficiency; bleeding, due to an incomplete abortion; a dead fetus; infection following an attempt at criminal abortion. Contracted pelves and pulmonary tuberculosis are sometimes taken as indications for inducing abortions, but with the development and improvement of obstetrical operations, more and more women are able to go nearly, or quite, to term and be delivered of live babies; while increasing medical knowledge concerning the care of patients with tuberculosis, and also with some heart lesions, is applied so successfully during the prenatal period that some pregnancies which formerly would have been terminated, are now allowed to continue, and with happy results.

The methods of induction depend upon the stage to which pregnancy has advanced and also upon the importance of haste. In the very early stages, one method is for the operator to dilate the cervix with a dilator; insert one finger into the cervix and up into the uterus and separate the placenta from its uterine attachment, while making pressure on the uterus from above with the other hand on the abdomen. Another method is to introduce a gauze pack into the cervix, packing it and the vagina firmly and leaving the packing for twenty-four hours. When it is removed the ovum frequently follows. Sometimes the membranes are ruptured, after which the amniotic fluid drains off and the ovum is expelled; or vaginal hysterotomy is sometimes performed when the patient’s condition is such that haste is imperative. The termination of pregnancy before viability is never sanctioned by the Catholic Church, because of the almost certain loss of the child.

=Induction of premature labor.= This procedure is the termination of pregnancy after the twenty-eighth week, or after the child is viable, and may be performed to save either the mother or the child or both, from conditions which would evidently work destruction if allowed to persist. The indications for inducing labor prematurely may be a seriously overtaxed heart or kidneys; pulmonary tuberculosis; preëclamptic toxemia or nephritic toxemia; chorea, neuritis; pyelitis; placenta prævia; a fetus that has been dead for two weeks, with no signs of labor; in some cases of nephritis when the fetus during previous pregnancies has died, and it is believed that the child may be saved by inducing labor before the stage in pregnancy at which the others perished.

Labor is sometimes induced when the mother’s pelvis is normal, but the child has grown as large as is safe in anticipation of a spontaneous labor, and particularly if the expected date of confinement has passed.

A common method of inducing labor when haste is not important, is to introduce one or more bougies (Fig. 111) through the cervix into the uterine cavity between the membranes and the uterine wall. The presence of the bougies will often stimulate the uterine contractions and bring on labor, with expulsion of the fetus, in from six to twenty-four hours.

More speedy results are obtained by the use of rubber bags, which may be collapsed before introduction and expanded afterward by filling them with sterile salt solution. There is a great variety of bags for this purpose, two of which that are frequently used are the Champetier de Ribes (Fig. 112) and the Voorhees bags. (Fig. 113.) They come in graduated sizes, the largest holding about 500 cubic centimetres.

The operation is performed with the patient in the dorsal position. The cervix is drawn down into sight, with forceps, and if intact, is slightly dilated. The bag is rolled tightly, held in suitable forceps (Fig. 114), and after being well lubricated is introduced through the slightly dilated cervix into the lower uterine segment, and pumped full of sterile salt solution. The solution is first measured in order to be sure that the bag is filled to its desired capacity, and is then introduced by means of a syringe, (Fig. 115), through the rubber tubing which is attached to the lower end of the bag, and which is then closed off by the stop cock, to prevent escape of the fluid. It is very important that the solution be sterile in view of the possibility of any rubber bag rupturing, particularly when pressed upon by the contracting uterus. (See Fig. 47 for position of bag after introduction into uterus.)

The presence of this bag stimulates uterine contractions, the cervix dilates, the bag is expelled and in some instances the child is delivered spontaneously and in others by means of forceps. The effect of this bag in producing labor may be hastened by tying a weight to the end of the tubing and allowing it to hang over the side of the bed. This traction and pressure help to dilate the cervix and seem to increase the irritation of the uterine muscles, thus increasing the force of their contractions.

=Accouchement forcé= is a speedy, forced delivery requiring the forcible widening of an intact, or partly dilated cervix, manually, or instrumentally. It is sometimes performed when existing conditions require extreme haste, as in certain heart lesions; eclampsia; concealed or accidental hemorrhage or in any condition which suddenly arises to threaten the life of the patient or her expected baby. But as the shock of this operation is great and the condition which threatens the patient can usually be better relieved by means of some one of the operations already described, it is less and less frequently performed.

THE MIRACLE[7]

by

Elizabeth Newport Hepburn

The wind blows down the street, A shutter bangs somewhere, While twilight falls as softly as A woman’s flowing hair.

Within a quiet room, Adventurers at rest, A mother holds her newborn son, Safe, now, upon her breast!

For out of Night and Pain, The womb of mystery, Is sprung this miracle of Life That she can touch and see.

No seer’s prophetic dream, No star in all the skies Burns with a lustre half so bright As happy mother eyes.

No quester for the Grail, No searcher for the Truth, Counts more than those who bear and rear And love and nurture Youth!

Within her curving arm, All safe and warm he lies, The heir of all that Man has won Down countless centuries!