THE CARE OF THE WOMAN DURING LABOR When summoned to attend upon a case of labor, it is better to go provided with a male and a female catheter, a pair of forceps, and a blunt-hook. Emergencies, may arise requiring in haste the use of one or more of these instruments, and no time should be lost in sending for what might so easily be taken in the first instance. Our little pocket-case of medicines we take with us, of course; for we should never go to church even without this potent weapon against evil.
Before entering the room our arrival should always be announced; that we may not shock our patient by our unexpected entrance. We should take especial care to be ourselves in a happy frame of mind that we may appear in an easy, unaffected manner. And we should have no other thought in our mind than to attend strictly to our business in as agreeable a manner as possible.
First we should inquire into the nature of the pains, with a view to prescribe for any abnormality that may appear in the sufferings of our patient (see Dystocia). After observing attentively, without seeming to look at the woman, the nature of her pains, we may, when we think it necessary, propose an examination per vaginam, in order to observe the condition of the internal organs, the presentation, &c.
It may not seem out of place to observe that the first object of search will be to see if the woman be pregnant; for it has some times happened that every preparation has been made for parturition when no pregnancy exists. The writer has met with such cases where the real facts were not revealed until examination was made per vaginam, as if to ascertain the presentation.
Having then determined the existence of pregnancy, the next thing is to learn if the patient is in labor, or whether she have not, instead, certain abdominal or lumbar pains, called “false pains. If she is really in labor, we shall find, on retaining the finger in the os uteri during a few pains, a rigidity and tenseness of the os accompanying every contraction, and followed, after the pain, by a corresponding looseness and state of relaxation. Or if the membranes are entire and become tight and firm under the contraction, relaxing as it passes off, the woman is certainly in labor.
The next step is to inquire, if she is at full term. This inquiry will of course be settled in our own minds affirmatively, if we find the neck of the uterus absolutely blended or spread out into the globe of the uterus. The internal os will not be felt, the orifice leading to the membranes now being simply that of the os tincae. If the internal os still remain closed or partially so, the cervix uteri will also be capable of being distinguished, as the full term has not arrived; and we must hasten, as in threatened abortion or premature labor, to arrest all further progress by means of quietness and the exhibition of the proper Homoeopathic remedy.
The next question to determine is, are the membranes ruptured? And this is not always an easy task, since they are some times so closely drawn over the scalp as to deceive a new practitioner. But during a pain, unless the head has already descended low down in the excavation, so much water will be forced down between the membranes and the scalp, as to make it quite apparent that the former are still intact. And besides, there is a certain greasy smoothness perceptible in the touch of the unruptured membranes, which differs from the sensation experienced in feeling the hairy scalp of the child. Bearing these things in mind, we never need to mistaken, if we press firmly down upon the scalp; for the rough, hairy condition of the uncovered scalp is never simulated by the unbroken membranes.
Next we wish to determine how far the labor has advanced, and what part of the child presents. In primiparae particularly, it is not always easy to find the os uteri; for sometimes it is not discoverable till we carry the finger far upwards and backwards, upon the anterior face of the sacrum, nearly up to its promontory. In such cases it may be necessary for the female to lie on her back till the anterior obliquity disappears; and this can be aided by the accoucheur elevating the fundus with one hand applied externally, and with a finger of the other hand in the os to draw it down.
If it now appear that we have a timely labor to treat, it will be necessary to provide for it accordingly. Where we can have our choice, the woman should be placed in a large, airy chamber, exposed to the sunny side of the house; and as much retired as possible, the above more important points being secured. The temperature of the room should be about sixty-five degrees during labor; about seventy degrees afterwards; the covering should be sufficient for the comfort of the patient. A strict adherence to these rules may prevent fatal, or at least dangerous accidents, such as hemorrhages, chills, metastases, &c. If her bowels have not been freely evacuated within twelve hours, she had better take a large injection at once, that no accumulation of feces remain in the rectum. She should now be suitably dressed for the occasion. Let her be arrayed in the dress she intends to wear in bed, but so adjusted that it cannot slip down below the waist. Next to this let an old sheet, or something of the kind be pinned around her, so as to cover all the lower part of the body, hips and legs. Next the bed must be suitably prepared for its own protection and for the comfort of the patient. An india-rubber sheet, about one yard wide, should be placed across the middle of the bed upon the mattress. A clean sheet should now be spread over the whole bed. Across the foot of the bed an oil-cloth, or another piece, of india-rubber, a yard wide, should be placed; and this covered with a thick doubling of blanket. The patient should lie upon this, with her feet placed against the foot of the bed as a purchase during the expulsive efforts of labor. She should lie with the breech near the edge of the bed, with her thighs flexed at right angles with her abdomen, and the legs at the same angle with the thighs. During the expulsive pains, an assistant may hold her hands, or a towel may be so attached that she can assist herself by drawing with her hands in the direction of the support of her feet.
The last rule to observe in relation to attendants, is to have only the husband, the nurse and the doctor. The husband at all events, and not more than two female friends; the doctor to be in and out, from time to time, as his judgment may dictate. It is better to be absent as much as possible and keep due surveillance over the case, till towards the close of the labor. In the first stage the female may make herself as comfortable as she best can, by walking about, sitting in her chair, or changing form one to the other. Unless the labor be very protracted, cold water is the only refreshment required.
When the head has commenced descending into the cavity of the pelvis, and the os uteri is fully dilated, the accoucheur should not absent himself from the patient long at a time. It will be better for him to take his seat at the patient’s bed, in a position to watch the appearance of her face, place the finger on the presenting part, mark well its progress, and be ready for any emergency that may arise. Some women are troubled with a terrible shivering during the early part of labor, or at its commencement, and sometimes it follows immediately afterwards; but it is of no account. When it occurs as a first symptom, the labor is apt to be correspondingly quick.
Patients are apt to be frightened at the noise of the rupture of the bag of waters; so that it is best to forewarn them in time to prevent any alarm. When the labor seems delayed by the tardy discharge of the waters, and the os is fully dilated, and yet the head is evidently kept back by something, it is better to plunge the finger forcibly into the sack, during a pain, and let the waters escape, then the labor will advance much faster. When the membranes are tightly drawn over the head, they can be scratched through by means of the finger nail, and then they may be torn up each way, by forcing the finger between them and the scalp.
Sometimes the child is very movable at the superior strait; and several portions presenting in alternation; in such cases when the head presents, the membranes may be ruptured, and the head thus caused to engage in the superior strait. Where there is evidently an over-distention of the uterus by excessive amount of liquor amnii, weakening the contractions, the membranes may be punctured at any time we are certain of such a complication.
During the first stage of labor the woman should never bear down; since her strength must be exhausted in making such useless efforts. It is only in the second stage, when the expulsive pains occasion a sort of involuntary forcing, that advantage can be taken of this effort, for then only is it useful. Too much voluntary exertion should not be used at the very last, for fear of rupturing the perineum. Nor should women be allowed to rise to the chamber, near the close of the second stage, for fear of accidents; however much she may desire to evacuate the bowels; for it is far easier to remove such discharges from the bed, than to extricate a new-born child from the chamber, as has sometimes been necessary in such cases.
As the head is about to escape from the vulva, the accoucheur should bear his right hand upon the perineum, in such a manner as to encircle the labia as much as possible, with his thumb and fingers; and while he is drawing down with these upon the labia, he must press gently forward upon the perineum with the palm of the same hand.
THE CARE OF THE CHILD DURING LABOR
Immediately after the expulsion of the head, we should feel with one finger about the child’s neck to ascertain if the cord is around it; if this is the case, a slight elevation of the cord upon the finger will cause the placental extremity to yield, thus the loop will become large enough to slip over the head. Should the cord prove too short for this purpose, when the next pain occurs it may still be loosened sufficiently to enable the child to pass through it in safety without becoming strangulated.
When the head is delivered it should be carefully supported and protected from the clots and other discharges from the uterus, patiently waiting for the subsequent contractions of the uterus to complete the delivery. The more we trust to nature in this respect, the better it will be for the mother, and the less will she suffer from subsequent hemorrhage and after-pains. No interference should be attempted at this stage unless demanded for the safety of the child. When the occiput remains posteriorly we should not interfere any more than when it rotates to the front, all the instructions of former accoucheurs to the contrary notwithstanding.
After the expulsion of the child, it is better to turn its back of the mother, and let her covering fall between the child and herself, thus at the same time bringing the child to our full view, and completely protecting the mother from cold or exposure. A soft napkin should now be used to wipe the child’s face, eyes and mouth. By this time, if not before, it will cry lustily; and the cord may be tied first about an inch and a half from the abdomen, and again a little further along, then cut between the two ligatures. The child is now ready to be enclosed in a flannel wrapper and handed to the nurse to be washed and dressed.
When the breech presents, great care should be observed not to interfere further than to watch the condition of the cord, after the lower part of the body is born. We should take hold of the cord with the thumb and finger and draw it down a little, to prevent it from being dragged upon at the navel. Then it should be examined to ascertain if pulsation still continues; if not, try to disengage it from compression, by slipping it sideways, or by drawing it a little lower down. For as long as the cord pulsates there is no danger to the child. But there is danger, in this breech presentation, of making so much traction upon the child as to pull the body away from the flexion of the head, and thus cause the chin to hang upon the superior strait, or to become fixed in the cavity of the pelvis. Great care should be observed till the head has descended into the pelvic cavity; and then, if there is need to hasten delivery, the finger can be introduced into the child’s mouth, by which means extension may be prevented and the child delivered instanter.
The death of the child in breech presentations is nearly always due to the compression of the cord; therefore when its pulsations are seriously interfered with, it will be better to make traction upon the lower extremities during a pain, but with great care; and as soon as the finger can be introduced into the child’s mouth, a good deal of pressure can be applied to keep the chin down upon the chest, and then almost any amount of force can be exerted upon the shoulders with safety. As already stated, it is better so far as possible to avoid manual interference either with mother or child, during labor. The more perfectly nature can be helped by the use of Homoeopathic remedies, where assistance is required, the better will it be for both parties, much less suffering will be entailed, and much better health will be enjoyed in after-life.
Diet and Regimen of the Woman in Labor
Cold water or lemonade is all the refreshment usually required in labor. The use of fermented liquors of any kind should be dispensed with. If the patient is in the habit of taking tea, a small quantity, either cold or warm, will sometimes be found very refreshing. A little broth, or some other light food, may be allowed in case the labor proves tedious, but no spices.
It is necessary that the enema should not be forgotten, where it may be needed, in order that the rectum may be as free from obstruction as possible, and for other obvious reasons. The patient should be encouraged to evacuate the bladder occasionally during labor; and if there be reason to apprehend an accumulation of urine which she cannot void, the male catheter should be at once employed. Much danger and inconveniences are avoided by such precautions; the over-distended bladder often becoming so paralyzed that the urine cannot be voluntarily passed for days. Therefore always beware of an over-distended bladder during parturition. After the discharge of the liquor amnii, a distended bladder can be detected by the fluctuation between the pubis and the umbilicus. In order to introduce the catheter, the patient should lie flat on her back, and the presenting portion of the child be pressed backwards and upwards as much as may be necessary.
On the Attentions to the Woman immediately after Labor. After the child has been handed to the nurse, the accoucheur should not leave his patient till the after-birth is delivered. This will usually take place in from ten to thirty minutes. In most cases there is a momentary suppression of the labor-pains after the expulsion of the child; after this interval of a few minutes the pains return, by which the placenta becomes entirely detached from its uterine adhesions, and it is then finally expelled from the vagina. Should there be any unusual delay, or should hemorrhage occur, the proper remedies should be administered to arrest it, promote the expulsion of the placenta, and the consequent normal contraction of the uterine parietes.
If necessary the delivery may be facilitated by making gentle traction upon the cord, taking care not to draw the cord upward in such a manner as to change its proper line of direction, and endanger its breaking against the inferior margin of the pubic arch. Sometimes the placenta may be merely inclosed and detained in the mouth of the uterus, although entirely detached from adhesion to the uterine walls. In such cases a slight manipulation with the finger may hook it down, and with the co- operation of gentle traction upon the cord itself, the entire mass may be removed with the next pain. A dry napkin will be found useful to apply to the cord, to prevent the hand from slipping. Especial care should always be observed, not to draw too forcibly or too violently upon the cord, and thus tear it away from the placental mass, while this latter still remains adherent. Much more force of traction will be borne, if slowly, gently and steadily applied; and this should be done only during the pain, and in the absence of the pain the cord should be slacked a little as the uterus recedes. When the placenta finally begins to emerge from the vulva, it should be received into the palm of the left hand, and rotated with the right hand, in order to secure the complete twisting up and removal of the last membranous shreds; since even a small fragment left behind will occasion very great annoyance to the patient, even if it does not give rise to more serious complications. Where any shreds are thus left behind, one end will appear at the vulva in two or three days, when it may be seized with a dry napkin.
The woman should then be made dry; a soft dry cloth applied to the vulva. Let her then be straightened out a little in bed, and in all respects made as comfortable as possible. No bandage should be applied. Since this doctrine is so entirely opposite to the usual practice, it will be proper to state the reasons which have led to the adoption of this method. First: It will be evident, from a moment’s consideration of the natural position of the fundus uteri, inclining forward, that the application of a bandage could not but change this position so as to render the uterus itself nearly perpendicular to the plane of the superior strait. This must of course bring the uterus into a line with the axis of the superior strait; this position must evidently be more favorable to prolapsus, and it may even lead to retroversion. Second: The great object intended to be secured by the bandage is to promote the contraction of the parietes of the abdomen, both for the safety of the patient and for the symmetry of her form. Now we believe not only that this is better accomplished by nature in her own way, uninterfered with by mechanical and compulsory appliances; but that such appliances actually weaken the walls of the abdomen, and so in reality tend to defeat the very object sought to be secured. Third: The omission of the bandage, as we have found by much experience, by allowing free circulation in the adjacent parts and avoiding unnatural compression of the peritoneum and uterus, in many cases removes much of the danger from peritoneal inflammation, and greatly facilitates the speedy recovery of the patient.
A dose of Arnica should usually be given, and perfect quiet maintained in order that she may procure a little sleep. After an hour or two, when she may have thus rested, the nurse may safely proceed to place her in bed, by gently moving her up to her place, rolling the soiled clothes up into a lump and removing them. Thus the patient will be at the same time rendered neat and comfortable; her clean clothes being brought down from her waist as the others are removed, and her lower limbs made dry and warm. The nurse will, of course, understand her duty of keeping the patient clean and comfortable, by constant attention to the lochia, and in other respects.
The natural phenomena of the lying-in state may now be briefly stated. The relief experienced immediately after parturition is, in a great majority of cases, truly remarkable, according to her own expression, the patient feels “as though she were in heaven. Afterwards, it is no uncommon occurrence, however, for the patient to be seized with a shivering, or chattering of the teeth. With the addition of a little covering this soon passes off; she begins to feel a glow of heat, her skin becomes moist, and there is no more trouble. After a little sleep, which, as already suggested, she should seek to obtain as soon as possible, she seems to recover from the shock of delivery, and once more appears in a natural, healthy condition.