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.
