Obstetrics for Nurses

by Charles B. Reed

CHRONIC INFECTIONS

Tuberculosis does not affect fertility or the course of the pregnancy, but the progress of the disease is hastened, and the maternal death accelerated.

The question of artificial abortion in the early months must be seriously considered, and if the case goes on to term, the child must not be nursed or cared for by the mother.

Syphilis is the most frequent systemic cause of the interruption of pregnancy. It is a blood disease, due to an organism, called spirochæta pallida, and it appears in three distinct stages. The first is the primary stage, wherein a hard, nodular ulcer appears on some part of the body, as the vulva, lips, gums, tonsils, or hand. It is not always venereal in origin. The second stage begins six or eight weeks after the sore, and is marked by a general eruption of red spots, chronic sore throat, falling hair, and rheumatic pains in the joints. The third stage is the name given to the later conditions of the disease which affect the bones, blood vessels, and nervous system.

Infection of the ovum may usually be traced to the father, who may transmit syphilis at any stage of the disease. In the third stage, the child alone will be infected; the mother escapes.

The mother may or may not transmit the disease, depending on the period of pregnancy wherein her infection occurs. If she gets the disease at, before, or just about, the time of conception, she will abort three times out of four, and the ovum will show definite lesions. If infected later, abortion occurs less frequently; and if the disease is contracted late in pregnancy, the child may be born apparently free from infection.

Symptoms.—A child with congenital syphilis will show the eruption of coppery spots, blisters on palms and soles, deep cracks on the feet, snuffles, cracks and ulcers around the mouth and rectum, and the weakly, marasmic condition of the body.

The diagnosis in suspected cases can be rendered more certain by the Wassermann reaction. This is a laboratory test of the blood which should always be made before a wet nurse is allowed to nurse a child, or before a suspected child is nursed by a clean woman. In all cases of transfusion of blood, it is imperative.

Treatment.—Antisyphilitic treatment of an infected mother or child by salvarsan, mercury, and potassium iodide must be carried out vigorously in all cases.

The syphilitic patient must be prevented from spreading the infection by having dishes and utensils of her own, which are kept sterile. Discharges are collected and burned, and the nurse in charge of these cases must carefully cover her hands with rubber gloves, and see that all cracks and fissures are properly protected from contact with sources of infection.

Gonorrhœa is an acute or chronic disease of the mucous membranes due to a germ called the gonococcus.

Beginning with a sharp inflammatory disturbance of the urethra or vagina, it may pass slowly up through the genital passage and produce chronic and permanent disabilities, such as sterility, pus tubes, and pelvic peritonitis.

The symptoms are painful urination, painful inflammation of the vagina, with a purulent discharge. During pregnancy all these symptoms are intensified, and warty growths (condylomata) may appear on the vulva.

If infection occurs after pregnancy has begun, the course of the gestation is rarely affected, as the uterus is closed to germ invasion. During delivery, however, there is a serious danger of infection of mouth or eyes of the child if they come in contact with the discharge.

Prophylaxis.—The eyes at birth must be immediately instilled with a drop or two of 1 per cent solution of silver nitrate in water. This is not neutralized by normal saline. Great care must be used that the discharge does not come in contact with the eyes of the mother or attendants, lest infection follow.

Treatment.—Scrupulous cleanliness must be observed. Douches of potassium permanganate, 1:5000, or painting the vagina with iodine or solution of silver nitrate, or suppositories of argyrol or protargol furnish the best means of treatment before labor.

Neither syphilis nor gonorrhea is necessarily caused by venereal infection. They may be spread by barbers, dentists, physicians, and nurses,—by anyone who is unclean; and may be acquired innocently everywhere.

These diseases should not be discussed by the nurse or physician except with the patient. Certainly nothing from the sick room should be repeated elsewhere.

The valves of the heart are not uncommonly found to be diseased in pregnancy, the mitral being the most often affected, either as an insufficiency or as a stenosis (a narrowing of the mitral opening). Mitral stenosis is the most serious of all heart complications of pregnancy, and where this is present, a woman should be advised to avoid conception.

In other mitral lesions, many pregnancies may be successfully passed, if compensation is maintained; but every one brings further damage to the already weakened heart, and reduces its reserve of force. If the heart breaks down early in pregnancy, and does not respond to medication, abortion should be induced. In the second half of pregnancy, the mother should be given the prior chance, but the child should be saved, if possible.

Renal diseases, such as nephritis, may not only induce abortion by destroying the fœtus, but the kidney lesion may be greatly aggravated by the pregnancy. The most careful observation of the patient’s condition, the regular examination of the urine, and the scientific management of the diet is necessary to relieve the work on the kidneys and keep the patient in a moderate degree of health.

It is the duty of the nurse to protect her patient against fatigue and chill, and to see that the proper diet is followed; but other symptoms, such as headache and disturbance of vision and developing edema, must be noted and reported to the physician at once.

Diseases of Liver.—Acute yellow atrophy is a rare condition, which, for reasons unknown, is promoted by pregnancy.

The symptoms are intense headache and pain in the abdomen, possibly accompanied by vomiting and purging, which are soon followed by coma. There is generally a certain amount of jaundice. The urine is diminished in amount and contains albumin, casts, and sometimes blood. There is no known treatment, and the end is death.

Diabetes is seldom found associated with pregnancy. Its presence is unfavorable to conception and to gestation. Mother and child are both less secure. Abortion or premature labor is the rule.

The hæmorrhages of pregnancy in the first half generally mean abortion, and in the last half, either placenta prævia or premature detachment of the normally implanted placenta (see p. [228]).

Abortion is the expulsion of the ovum before the fœtus is viable, that is, before it is capable of maintaining life after birth. This means the twenty-eighth week, or the seventh month. Subsequent to the seventh month, the interruption is called premature labor. Abortion is a miniature labor, consisting of a stage of dilatation, a stage of expulsion, and a stage of involution.

The interruption of the pregnancy may occur spontaneously or be induced. In spontaneous cases the causes may be sought in diseases of the ovum, or in the mother, in injuries to the uterus or its contents, and such systemic affections as syphilis, Bright’s disease, alcoholism, lead poisoning, etc.

Abortions happen about once in every five or six pregnancies, and more frequently at the third month than at any other time.

The symptoms are hæmorrhage and pain. The dangers are hæmorrhage and infection.

Infection is most common and most serious in abortions that are brought about mechanically.

Hæmorrhage, in some degree, is an invariable symptom, which has its origin in the separation of the ovum from the uterine wall. Hæmorrhage from the uterus is serious at whatever stage of pregnancy it appears.

The duty of the nurse is to put the patient in a cool, dark room, on her back, elevate the foot of the bed, put ice bags on the lower abdomen, and summon the attending physician, with the hope that an abortion can be averted. Bromides and opium are the drugs most to be relied upon. Opium may be given in suppository, 1 grain night and morning.

If the hæmorrhage is alarmingly profuse and the nurse is skillful and clean, under exceptional circumstances she may pack the vagina with sterile cotton while waiting for the doctor. Then the room should be set for operation.

Dead Ovum.—The ovum may be discharged in pieces or in a single complete mass.

The egg may die at any period of the pregnancy, and be discharged in a few hours, or it may not be expelled for weeks, if at all. Fœtal death in the uterus may have its cause on the paternal side in a father too old or too young, or affected with such diseases as diabetes, nephritis, tuberculosis, syphilis, or chronic lead poisoning; on the maternal side, the same diseases, plus cancer, anæmia, insufficient food, and inflammation of the uterus; on the part of the embryo, syphilis or any transmitted or primary disease of the ovum.

The results of retention of the dead ovum vary with the case. Infection of the ovum is rare, except where the membranes have ruptured and an open channel exists. No harm follows the death of the fœtus, except in the presence of infections, all other changes are benign. The embryo in the first and second months may be absorbed, but at later periods, it becomes macerated petrified, or otherwise altered.

Among the signs of fœtal death are prolonged cessation of fœtal movements after being definitely observed, chilliness, languor and malaise of the mother, sense of weight in abdomen, and possibly a bad taste in the mouth. Furthermore, the uterus does not correspond to the period of pregnancy, and may have become smaller. Retrogressive changes take place in the breasts.

The diagnosis is only certain when the heart tones are persistently absent, or the macerated head of the fœtus is felt through the partly dilated os as a flabby bag of bones.

Treatment in noninfective cases is expectant. Spontaneous expulsion will occur sooner or later and there is no necessitous indication for interference. Local signs of putrefaction, however, make the immediate emptying of the uterus necessary.

CHAPTER VII
PREPARATIONS FOR LABOR AND THE NORMAL COURSE OF LABOR

The Nurse.—Scientific obstetric nursing is a specialty that enlists the interest of exceptional women only.

It demands a high sense of duty, a strong physique, broad training, unusual judgment, and rare tact. The nurse must be professionally aseptic and personally clean. She should keep herself free from odors, and bathe at least three times a week. The presence of pus anywhere on her body disqualifies her at once, and she should report off duty.

The compensation should always be somewhat higher than for other work, because there are two patients to be cared for.

An obstetric nurse should specialize in her work, and not take infectious cases. Unhappily the haphazard character of the onset of labor presents a difficulty. The patient frequently can not afford to have the nurse for a long time in advance of labor, and the nurse whose income is limited by the number of her cases can not afford to be idle. Hence, it is better for two nurses to work in alternation with one another, so that one is always available in an emergency.

Both doctor and nurse should visit the lying-in room before labor begins, and plan its rearrangement. At least a week before the expected confinement, the chamber selected should be thoroughly cleaned and the woodwork wiped off. Curtains, draperies and bric-a-brac and all useless furniture should be removed. Carpets must be taken up, or at time of confinement, well protected. Rugs can be easily managed. A chair, a bed, and the various tables for instruments and solutions are all that are required.

The nurse usually is called to the case first, and upon her falls the responsibility of the diagnosis and the burden of the preparation. As soon as she arrives and satisfies herself that the patient is really in labor, she puts the final touches to the room. In her own mind she goes over all possible emergencies and prepares to meet them.

The following supplies should be in the house for the labor:

3 hand basins, 10 inches in diameter.

3 hand brushes.

1 two-quart douche bag.

15 yards nonsterile gauze.

2 lb. each of cotton batting and absorbent cotton for making bed pads.

2 pieces of rubber sheeting 1 by 2 yards.

5–yd. jar of borated gauze.

4 oz. lysol (or ziratol).

100 c.c. of Squibb’s chloroform.

2 oz. green soap.

2 oz. solid albolene.

8 oz. alcohol.

½ oz. ergotol.

½ oz. bismuth subnitrate and ½ oz. boric acid powder mixed.

1 nail file.

Nurse’s outfit consists of the following: Nail file, surgical scissors, catheter (silver is best), hypodermic syringe with tablets of morphine, strychnine, and digitalis; two fever thermometers, one for mouth and one for rectum; a pair of tissue forceps and a razor.

Some time before the labor, the nurse should call on the patient and establish a working acquaintance. It adds greatly to her authority and to the patient’s confidence in her. Her advice will be sought on a multitude of subjects, partly real and partly to try her out.

Fig. 31.—Abdominal binder with crosspiece to hold vulvar pads.

Fig. 32.—T-binder, used in all cases after the fifth day post partum.

Sterilizing may be done in a hospital, or, if this is not feasible, the nurse should go to the house two or three weeks before the expected labor and sterilize in an Arnold or Rochester sterilizer the following articles:

½ doz. sheets.

3 doz. towels.

2 pillow slips.

3 abdominal binders of unbleached cotton, 16 in. wide and 36 in. long, folded and hemmed.

4 T bandages.

3 breast binders.

2 jacket parts of pajama suits.

3 pairs of long white stockings.

3 packages of vulvar dressings (see Preparation of Supplies, p. [326]).

2 obstetric pads 1 by 36 by 36 inches.

1 pillow slip full of cotton pledgets for sponges.

1 jar applicators (cotton twisted about toothpicks).

1 jar of gauze pledgets for perineorrhaphy and cord dressings.

Everything must be neatly wrapped and labeled.

Fig. 33.—Breast binder.

Fig. 34.—Baby’s dress with winged sleeves.

Infant’s Outfit.—

12 plain slips 27 inches long of dimity or nainsook (with winged sleeves).

3 long sleeve shirts, silk and wool (size No. 2).

6 pinning blankets, made of outing flannel, if it is a winter baby.

3 bands, 6 by 18 inches, clip or notch edges, do not hem.

3 petticoats, flannel bottoms and muslin waists, without sleeves and with small button on shoulders.

3 outing flannel wrappers.

6 plain, soft muslin dresses.

3 (Arnold) knitted night gowns, light weight.

4 doz. light weight cotton diapers, 20 x 40 inches. Bird’s-eye linen is the best. Wash and dry these in the air before using.

4 soft towels (linen preferred).

2 quilted pads.

4 soft wash cloths.

4 wool wrapping blankets.

1 pair scales that weigh ounces and fractions thereof.

4 oz. of olive oil or benzoated lard.

4 oz. of alcohol (95 per cent).

¼ lb. boric acid crystals.

½ lb. absorbent cotton.

1 cake of castile soap.

2 oz. solid albolene.

½ oz. subnitrate of bismuth powder and ½ oz. of powdered boric acid mixed.

1 bed pan.

2 basins, holding 2 quarts each.

1 papier mache, rubber, or enamel ware bathtub.

Anæsthetics.—Excessive pain is destructive and disintegrating to the vital forces. Many a woman who has passed through a particularly severe labor remembers her experience with a horror that forever precludes its repetition.

This is the day of relative painlessness in labor, and all the world is striving to make childbirth easier and less lethal. No woman, unless she herself requests it, should be permitted to go through the agony of labor without an anæsthetic, judiciously selected and carefully administered.

Pain-deadening agents are numerous and inexpensive, and it is only a matter of experience and judgment to choose a method that will reduce the suffering of childbirth to a minimum. The second and first stages of labor, in the order named, demand the most in the way of relief.

A prolonged first stage with nagging, violent and apparently useless pains may devitalize the patient more than short, but acute pains of the second stage. In the first stage, under proper selection of cases and experienced supervision, “Twilight Sleep” will be successful in seventy to eighty per cent of the cases.

By success, is meant that the patient is relatively free from pain. When the drugs do not relieve pain, the case is a failure (fifteen per cent), although in no case, when properly given, is the mother or child endangered. Morphine solution ⅙ gr. and scopolamine hydrobromid 1/200 gr. to 1/150 gr. is the customary dosage for the first injection. Another injection of 1/200 gr. is given in a half or three-quarters of an hour. The room is darkened, talking is forbidden, and the family exiled. The patient gets red in the face and very thirsty, the pulse is rapid but full. She answers questions very slowly and drowsily, awakes for her contraction but goes right off to sleep again. In this condition she is kept through bi-hourly repetitions of the scopolamine until the delivery. It is this half waking and half sleeping condition that suggested the name of “Twilight Sleep.”

Morphine and scopolamine will relieve the pains of the first stage without greatly protracting the labor. The same drugs may and probably will prolong the duration of the second stage. The first dose should be given as soon as the patient is well started in labor.

“Twilight Sleep” is at present a hospital procedure, and the technic so exacting as to weary the attendants greatly. It can not be employed until the woman has definitely gone into labor and is at least three hours away from delivery. It is not serviceable where the pains are weak and shallow; and it must be used with wise circumspection, if at all, in the presence of complications.

For the second stage, there is a choice of three drugs: gas, chloroform, and ether. Like twilight sleep each is open to some objection, but each may be of the greatest assistance if used under appropriate indications and conditions.

Gas has one advantage, in that it in no way interferes with the pain activities; and Lynch and Davis have shown that with a proper admixture of oxygen, it may be given with comparative safety for the two or three hours which may mark a normal second stage. To administer it a competent machine for mixing the gas is necessary. It should not be given to patients who have bad hearts, high blood pressure, or toxæmia. Neither is it a satisfactory anæsthetic when the head delivers, for the mother being less relaxed and more rigid, the legs and muscle action are harder to control and unnecessary perineal lacerations are liable to occur. The patient is instructed to take several deep breaths just as the uterine contraction comes on and the gas bags supply about 75 per cent nitrous oxide and 25 per cent oxygen. As the pain passes off the oxygen is increased and the nitrous oxide diminished until the mind is again clear.

To save the perineum and better to control the patient, when the head is about to pass the vulva, it is wiser to abandon the gas for chloroform or ether.

Obstetrical operations, such as forceps and version, require ether or chloroform, and not gas. The dangers vary with the anæsthetic chosen, as well as the amount and the method of administration. Ether affects the respiration, chloroform attacks the heart. Ether must not be given near an open flame. Chloroform is not explosive but is decomposed by fire into an irritating gas. Chloroform must be diluted with 90 per cent of air, hence the mask must be open, or the napkin held free from the face, so that plenty of air can enter. Ether and chloroform, when given “a la reine;” i. e., a few drops on the mask at the beginning of each pain and increased up to the acme, is relatively free from danger. They have the additional advantage that the sleep may be instantly deepened if operation is required. Chloroform, it is now believed, predisposes mildly to post partum hæmorrhage. Davis has shown that neither ether, gas, nor chloroform affects the child injuriously if the administration is intermittent and not too greatly prolonged.

To summarize: Morphine and scopolamine combined is a first stage analgesic, which has too much value to be neglected.

Gas, if an apparatus is to be had, may work well for the greater part of the second stage, while for operations, or for the period of expulsion, during which the head passes the perineum, chloroform and ether give bests results. Moreover, chloroform “a la reine” may be given safely and efficiently by a competent nurse and in many instances must be given by the nurse, if at all.

When the perineum bulges, or the head becomes visible at the vulva, the nurse should anoint the lips, cheeks and tip of the nose with cold cream or olive oil, to avoid burning the skin, and lay two or three thicknesses of handkerchief or gauze over the nose (an inhaler is best). An abundance of room must be left underneath and at the sides of the mask for air to enter.

At the beginning of the pain a few drops of chloroform are poured on the cloth and the patient instructed to breathe vigorously. The cloth is removed as soon as the pain ceases and when the next contraction comes on, the process is repeated. As the head passes the perineum, the chloroform should be pushed to complete anæsthesia, both to save suffering and to give the doctor full control of the perineum. When the nurse gives the anæsthetic, she should watch the doctor for his signal to increase the vapor or remove the mask.

Summary.—Cover the eyes with a wet towel and anoint the face with cream or oil before using chloroform. Remove false teeth, if present.

Obstetric degree—a few drops on mask at beginning of each pain.

Surgical degree—complete anæsthesia.

Watch pulse and respiration.

A nurse should never leave a patient who has had an anæsthetic until she is conscious. Vomiting is especially dangerous.

Normal Labor.—Labor is the process by which a fœtus of viable age is expelled from the uterus.

By normal labor is meant a case where the fœtus presents by the vertex and terminates naturally without artificial aid, or complications. It varies greatly in severity, duration and danger to mother and child. A first labor is more prolonged and difficult than later confinements. A woman in her first delivery is called a primipara, in subsequent cases, a multipara.

The date at which labor comes on is difficult to determine accurately. The average duration of pregnancy is from 275 to 280 days, forty weeks, or ten lunar months, but conception does not occur necessarily at the time of coitus, nor is it possible to know with any certainty when it does occur.

Labor may occur two weeks earlier than calculated, with benefit to the mother, and no harm to the child; but if the woman goes over time, the child becomes much larger and the labor harder and more dangerous to both.

Causes of Labor.—Why labor should occur at all is not known. Many theories have been advanced, none of which is entirely satisfactory. Some of the best known are the growing irritability of the uterus accompanied by an increase in the frequency and strength of the intermittent uterine contractions or increasing distention of the uterus. Thus it is believed that when the uterus is distended up to a certain point, it will try to relieve itself like the bladder, or a baby’s stomach. It may be that any one of the following factors, or all of them acting together, are influential.

Dilatation of the cervix by the presenting part.

Increasing distention of the lower half of the uterus with pressure on neighboring nerve structures.

The circulation of fœtal products of metabolism (toxins) acting on the nerve centers.

The menstrual periodicity.

Heredity and habit.

Physical and emotional causes.

The onset of labor probably is not purely accidental, and yet it is so inconstant in appearance and so indifferently early or late, that it has every appearance of being an affair of chance. The time when labor will come on is highly speculative in general, but the phenomenon is preceded by certain definite symptoms:

The lightening.

False pains.

Show.

Rupture of membranes.

The pains.

Lightening.—About two weeks before labor, especially in a primipara, the uterus and the head sometimes descend into the pelvis. The body of the child falls forward and the abdomen protrudes, the stomach is flatter, the patient breathes easier and feels, as she says, “lighter.” But walking is more difficult, the bladder is stimulated to frequent evacuations and the rectum is compressed.

This occurrence is a premonitory sign of labor, and also favorable inasmuch as it demonstrates that this particular head is not too large to pass this particular pelvis.

False pains may appear, especially in multiparas, from two to four weeks before labor. In some of these cases the pains may be due to gas or indigestion and respond to hot applications and enemas, or there may be definite uterine contractions, as shown by the hardness of that organ during a pain, but the phenomena are irregular and therefore not typical of labor pains.

Usually they pass off in a few hours, but if the patient is nervous, the doctor or nurse may be called needlessly. The patient, therefore, should be instructed to have the pains timed by the watch for half an hour or an hour. If they are regular during this period, the physician should be notified. Upon his arrival, an internal examination will reveal the true character of the disturbance by the condition of the cervix and os.

The show is a discharge of thick, white mucus, slightly stained with blood. This is the mucus plug which occludes the cervix during pregnancy and when the os begins to dilate, the mass is released and passes out. Labor usually comes on vigorously within twelve hours.

The membranes may rupture before labor begins and much fluid escape. The advantage of the dilating bag of water and lubricating qualities of the liquor amnii are thus lost. Such a labor is called a “dry birth” and is frequently slow, exhausting, and extremely painful.

The pains are the subjective manifestations of the powers of labor. The forces concerned are uterine and abdominal muscles, principally assisted by those of the back, legs, and arms. Their constricting action on the nerve fibers in the walls of the uterus is the cause of the pains in the first stage. The onset may be violent and go on to a quick delivery, but generally the inception is more insidious.

The irregular, painless contractions, (of Braxton Hicks) that were mentioned on an earlier page, gradually at term change their character and become regular and painful.

At first they may be slight and vague, lasting only half a minute and separated by intervals of ten or fifteen minutes and scarcely attract the patient’s attention. They are felt chiefly in the abdomen.

More or less rapidly they increase in frequency, severity and duration. They last from a minute to a minute and a half and come every three minutes. The whole uterus hardens and its outline is clearly defined during the contraction; it relaxes and becomes soft in the interval. The woman is now in labor. The pains become grinding and the patient feels that she is not accomplishing anything, yet under the influence of these contractions the cervix is effaced and the os is dilated.

The Course of Labor.—Labor is divided for convenience into three stages as follows:

The first stage, from the beginning of pains until the complete dilatation of the os.

The second stage, from the complete dilatation of the os to the delivery of the child.

The third stage, from the delivery of the child to the expulsion of the placenta.

The first stage is the stage of dilatation.

Usually at term, the cervix is columnar and unshortened, the canal intact, and closed at both ends, as shown in Fig. 36.

In multiparas the outer opening will usually admit the tip of the finger.

As labor proceeds, the cervix is effaced, the os slowly dilates, and the bag of waters forms.

The Bag of Waters.—When the cervix is effaced and only the os remains, the lower end of the egg with its fluid restrained by the membranes, bulges forward into the canal. The fœtal head, or breech presses into the pelvis, and the fluid in the membranes, compressed between the presenting part above and the cervix below, is called the bag of waters.

When the contraction comes on the longitudinal muscular fibers of the uterus are drawn upward and the bag of waters becomes tense and pushes farther and farther down into the opening; and by its even and universal pressure, mechanically and slowly increases the size of the opening which the muscular traction is pulling apart. At the same time, the fluid around the child prevents, for a time, direct and injurious compression on the body. When no definite cervical projection can be felt, and when the teat-like protrusion of the cervix has disappeared, the cervix is said to be effaced.

Fig. 35.—The bag of waters begins to act on the cervix. (Eden.)

The os now begins to stretch and widen, the bag of waters becomes more and more evident, vomiting occurs, and at last, when the os has expanded to a diameter of four inches (ten centimeters), the membrane can withstand the pressure no longer. It ruptures, a certain amount of fluid escapes, the presenting part comes down against the opening, and like a valve, prevents the outflow of the waters from above.

Fig. 36.—The effect of the pains. The cervix before labor begins. (Bumm.)

Fig. 37.—The effect of the pains. The cervix begins to be “effaced.” (Bumm.)

Fig. 38.—The effect of the pains. The cervix is effaced, and the dilatation of the os begins. (Bumm.)

Fig. 39.—The effect of the pains. The cervix is effaced, and the os continues to dilate. (Bumm.)

Sometimes the labor may be preceded by some hours (two or three), or days (two or three), even weeks (two or three), by the rupture of the membrane, and sometimes when the structure is thick and tough, the rupture may be delayed until well into the second stage, or even until the child is born. In the latter case, the head comes out, covered with membrane. In the old days, this was called being “born with a caul.” It was supposed to be a lucky omen, but it was lucky only that the babe escaped suffocation. The membrane should be torn open quickly.

The duration of this stage is variable. It is much longer in primiparas than multiparas. It averages sixteen hours in the former, and eight hours in the latter. Vomiting during this stage is quite common, but the pulse and temperature remain normal. The first stage of labor is usually under the entire control of the nurse. It is her responsibility.

With complete dilatation of the os, the second stage, or stage of expulsion, begins, whether the membranes rupture or not. The presenting part, usually the head, passes from the cervix into the vagina. The vagina in turn gradually dilates from above downward until uterus, cervix and vagina form a single, wide channel of the same diameter. The child is driven forward by the uterine contractions, strongly reinforced by the abdominal muscles, which the patient uses vigorously. The onset of each pain is accompanied by a deep inspiration, followed by straining or bearing down with the abdominal muscles as in a highly exaggerated bowel movement. The patient holds her breath, braces her feet, fastens her hands on bed or attendant, and uses all the trunk muscles in the effort. The face becomes congested, the pulse quickened, she perspires some, and groans deeply during the contraction. The pain is extreme and is due partly to the stretching of the vagina and vulva and partly to the distention of deeper sensitive structures.

When the head reaches the pelvic floor, the first change observed in the external genitals is the stretching (bulging) of the perineal body. Next, the anus becomes turgid, dilates slightly, the anterior wall becomes visible, and the hairy scalp of the child appears at the vulva. The actual expulsion of the head in a primipara is accomplished by a series of prolonged and severe contractions, accompanied by violent straining.

Fig. 40.—The cervix is effaced, and the os dilated. The second stage begins. (Eden.)

Fig. 41.—Child in second stage of labor with bag of waters unruptured and presenting at the vulva. (Braune, from Barbour.)

A short pause ensues, followed in two or three minutes by a return of the pains, which expel first the shoulders and then the trunk. As the body escapes it is followed by a rush of blood-stained liquor amnii. This is the fluid that has been pent up in the uterus by the obstructing body of the child. The second stage lasts about two hours in a primipara and from fifteen minutes to one hour in a multipara.

The third stage is the delivery of the after-birth. The after-birth sometimes called the secundines, consists of placenta, umbilical cord, and membranes.

Fig. 42.—The head passing over the perineum. (Bumm.)

After the expulsion of the fœtus, the uterus undergoes a sudden diminution in size. It is about as large as the child’s head, and the fundus lies near the level of the umbilicus. The contractions still persist feebly, but they are practically painless, and the patient is greatly relieved, possibly sleeping.

In from ten to thirty minutes, the uterus becomes smaller, harder, more globular in shape and more movable. The patient brings the voluntary muscles of the abdomen strongly into action again. The nurse presents a sterile basin and the physician sustains and slowly twists the membranes free from their final attachment and out of the uterus. When the placenta passes the vulva, a moderate sized blood clot follows it.

Fig. 43.—Normal expulsion of the placenta like an inverted umbrella according to Schultze. (Williams.)

The uterus is now much smaller, and hard and firm in consistency, but for some hours the contractions are intermittent, and while this continues, there is risk of hæmorrhage.

General Effects.—The mother’s pulse is quickened during the contraction. The fœtal heart beats more slowly and feebly during a contraction, but quickly recovers in the interval.

The amount of blood lost during labor averages from ten to sixteen ounces. The temperature may be elevated one or two degrees in a woman of moderate physique, while one with a fragile body may present the signs and symptoms of surgical shock. The chill, pallor, cold limbs and body, rapid and feeble pulse with subnormal temperature, suggest to the nurse at once the proper treatment. Heat, to all parts of the body, warm covers and hot milk or coffee. If hæmorrhage is present and the uterus relaxed, the nurse should immediately inject pituitrin (15 ♏︎) into the deltoid muscle and notify her attending physician.

CHAPTER VIII
THE MECHANISM OF NORMAL LABOR

The powers of labor are primarily the uterine contractions strongly aided by the muscles of the abdomen and diaphragm. Some assistance is given by the fixation of the legs and arms and sometimes by gravity, when a sitting or standing position is maintained.

The resistances are the bony pelvis and its relatively soft coverings of muscle and fascia.

The problem is to get the awkwardly shaped passenger through the curiously shaped passage.

In the first, and a part of the second stage, the uterine contractions do not act directly upon the body of the child, for the latter is surrounded by a wall of liquor amnii.

Pressure is transmitted by a fluid medium in all directions, hence, the weak part of the wall, which is the cervix, must give way. While the membranes remain intact, or when sufficient fluid is retained, no amount of pressure can injure the fœtus. When the membranes rupture, the force of the pains is exerted directly upon the child to drive it forward, and prolonged pressure may produce injurious effects through compression of fœtus, placenta, or cord.

The progress of labor is registered usually by watching the advance of the fœtal head.

The relation of the head to the pelvic brim is of great importance, as it travels much faster and easier in certain positions than in others. The term “presentation” is used to designate that part of the child which enters or tends to enter the pelvic inlet.

The presentation is named from the part of the child which comes into apposition with the brim. Thus, one speaks of a vertex presentation, or a breech presentation, or a shoulder presentation. The presentation is determined externally by palpation.

The vertex presents in 96 per cent of all labors. With the vertex presenting, the head may occupy any one of four positions. The term “position” is used to explain the relation which the most distinctive feature of the presenting part bears to the quadrants of the pelvic inlet. Thus, the most distinctive feature or landmark of the vertex is the occiput, which is the point of direction, and so again, the position is the relation of the point of direction to the brim of the pelvis. The point of direction is the part that takes precedence in the process of delivery. Thus, in all cases where the occiput is in advance, the occiput is the point of direction and the position is called occipital. Where the chin is in advance, it is mental (mentum is Latin for chin.) In breech cases, the sacrum is the point of direction.

The pelvis is divided by the transverse and anteroposterior diameters into four quadrants named respectively the left anterior, the right anterior, and the right and left posterior. (See Fig. 1.) Thus, in a vertex presentation the back of the child may be (and in 53 per cent is) to the front and to the left.

The occiput is the point of direction, and lies in relation to the left anterior quadrant of the pelvis, and is spoken of as a left-occipito-anterior position. Similarly a right-occipito-anterior position is named, and right- and left-occipito-posterior positions. These occur respectively in about 21 per cent, 14 per cent and 11 per cent of the cases. (Eden.)

In passing the pelvis, the fœtus not only follows the curved line of the pelvic axis, but it describes a certain series of movements which alter its relations to the pelvis.

Fig. 44.—The child in left-occipito-anterior position. (Lenoir and Tarnier.)

There are five of these movements: flexion, descent, internal anterior rotation, extension, and external restitution.

Flexion.—Flexion is usually present before labor begins. That is, the head is bent down until the chin touches the breast. This may be modified by various conditions, but so far as it becomes extended, the mechanism is disturbed and the labor complicated, since large and less favorable diameters are brought to delivery.

Fig. 45.—The child in right-occipito-anterior position. Shows the flexion of the head intensified at the beginning of labor. (Eden.)

Flexion is increased by pressure against the pelvic brim as labor begins.

Descent.—As the driving force of the contractions becomes effective, the head passes the inlet and descends to the pelvic floor. When the large diameters of the head (biparietal) have passed the inlet, the head is said to be engaged.

Fig. 46 A.—The descent of the head in right-occipito-anterior position. Seen from below. (Edgar.) Fig. 46 B.—Side view.

Fig. 47.—Internal anterior rotation and extension of the head in a left-occipito-anterior position. (American Text Book.)

Internal Rotation.—The head most frequently enters the brim with the occiput to the left and anterior (obliquely) because it finds more room and an easier passage; but upon passing this strait and entering the roomy, true pelvis, the head must rotate so that the long diameter of the head will conform to the long diameter of the pelvic outlet, which lies in a direction just opposite to the long diameter of the inlet or brim; hence, the occiput turns forward under the pubic arch. This movement is due largely to the sloping pelvic floor and the necessity of accommodation between the head and pelvis as the child is driven forward.

Fig. 48.—Extension. A, the chin leaves the chest; B, extension in progress. (Eden.)

Fig. 49.—A, extension completed; B, expulsion. (Eden.)

Rotation is much retarded or entirely stopped when the head is extended instead of flexed or when it enters the inlet with the occiput posterior instead of anterior.

Extension.—After internal, anterior rotation, the head emerges at the vulva, the occiput coming out first, then in succession the vertex, forehead and face and chin. As the chin rolls out over the perineum, it moves away from the chest wall—it becomes extended.

External Restitution.—While the head is passing through the outlet, the shoulders are entering the pelvic inlet, and so soon as the head is released from the restraint of the vagina, it naturally falls into its normal relation to the fœtal back; hence in the position now discussed, it turns toward the left.

Therefore, we may summarize the mechanism in a normal left-occipito-anterior position of the head by saying: The head is flexed and forced into the pelvis. It descends to the pelvic floor. The occiput rotates to the front of the pelvis and impinges against the symphysis. Extension ensues in consequence of the necessity for an accommodation between the pelvis and the advancing head, and during this extension, the head delivers over the perineum. External restitution follows.

The Effect of Labor on the Fœtal Head.—As the head passes through the canal, it is moulded by contact with the resistances. The degree of moulding is proportionate to the pressure required to drive it through. Thus, in a large head, or a relatively small pelvis, the moulding may be extreme, and changes in the scalp are common.

Caput Succedaneum.—Since all parts of the scalp are in contact with a resistant wall, except in the center of the birth canal, an effusion of serum takes place here, which is due to the obstruction of the venous circulation.

Fig. 50.—A cephalhæmatomata. Do not confuse with caput succedaneum. (Bumm.)

Swelling occurs in the subcutaneous cellular tissue, and a tumor forms—the caput succedaneum—which spontaneously disappears in twenty-four or forty-eight hours. It is useful in confirming the diagnosis of the position.

Cephalhæmatoma.—Following labor a tumor is sometimes found upon the head, which is often confused with a caput succedaneum.

This tumor is caused by an effusion of blood beneath the periosteum or the covering of the bone—usually a parietal bone. It is sometimes single and sometimes double, and it varies in size from a filbert to a peach. The swelling never extends across a suture. The effusion takes place gradually, and may not appear for a day or so after birth. The cause is unknown, for it occurs after normal and easy, as well as after difficult, deliveries, and after breech, as well as vertex, cases.

At first it fluctuates, then becomes hard, and in a few weeks or months is gradually absorbed. If symptoms of cerebral pressure develop, it must be remembered that hæmatoma may occur inside as well as outside the cranium.

No treatment is necessary. Puncture is inadvisable. In extremely rare instances the tumor may suppurate and require incision.

CHAPTER IX
THE CARE OF THE PATIENT DURING NORMAL LABOR

Every case of labor must be conducted with the most scrupulous attention to surgical cleanliness on the part of the patient, doctor and nurse. Puerperal infection in most cases is due to the introduction of disease-producing microbes into the wounded genital canal. To be sure, the successful enforcement of surgical cleanliness is attained only in good hospitals, but it can be approximated in a private house if the patient insists upon delivery at home.

A nurse or doctor who is clean of person, is most apt to have an “aseptic conscience.” The possession of such a conscience may entail financial sacrifices, but it has many compensations. Neither the nurse nor the doctor is doing justice to the patient, nor to the profession, who indiscriminately takes pus cases, contagious diseases, and confinements. The public will soon learn that such a nurse and such a doctor are unsafe attendants.

How may the nurse know that the patient is in labor? This is the final assumption that must be confirmed or refuted when the nurse is called to her case. It is ascertained partly by the history and partly by the conditions found.

Thus, the patient may report the passage of a piece of blood-stained mucus, and the nurse will observe that the contractions of the uterus are regular, rhythmical and painful. She will observe that when the patient complains of pain, the uterus gets hard. She will also observe the definite regularity of the contractions by timing them.

Under such conditions, the doctor should be called at once if the symptoms develop between 7 A. M. and 11 P. M. If the pains begin in the night, say from 11 P. M. to 7 A. M., the doctor need not be called unless he has requested it, or, unless in the judgment of the nurse or the anxiety of the patient, it is desirable for him to see her.

Fig. 51.—Points of greatest intensity of fœtal heart tones. V, vertex presentations; B, breech presentations. (Eden.)

When the doctor is notified he will want to know, and the well trained nurse will be able to inform him, when the pains began, their strength, duration and frequency. He will want to know whether or not the membranes have ruptured. Many doctors also require, and a well trained nurse who specializes in obstetrics should be able to say by external examination, whether the head seems high or low, as well as the position and frequency of the fœtal heart tones.

In the hospital the following rules for summoning the resident physician may be found useful:

1. For multipara, when pains are regular and five minutes apart.

2. For primipara, when pains are regular and two minutes apart, or when head is visible if pains are less frequent.

3. If a precipitate is imminent, delivery must be delayed until arrival of attending man by—

(a) Turning patient on side with legs straight;

(b) Instructing patient to breathe deeply or to cry out with mouth wide open; then

(c) Place sterile towel over vulva, and at time of pain prevent expulsion by compressing the head by means of locking the hands over a towel on the vulva.

It is possible thus to delay delivery two hours, or until the doctor arrives. Do not permit a precipitate.

After the nurse has completed her preliminary observation, she starts her history, notes the character of the pains, the pulse, temperature and respiration. All unusual phenomena should be recorded; and after the visit of her attending man, his examination, if any, and the conditions found, are put down. Then she prepares the patient and sets up the room for the delivery.

Preparation.—As soon as the patient is known to be in labor, the bowels are thoroughly cleansed with a soapsuds enema. A toilet jar should be used and not the water closet. The bladder must be emptied at the time of preparation and at frequent intervals throughout the labor. As soon as the bowels and bladder are emptied, the patient is given a bath and thoroughly soaped. The shower is preferred lest the water, contaminated by bacteria from the skin and external genitals, should enter and pollute the vagina.

Fig. 52.—Handling forceps, kept sterile in a jar of alcohol.

The hair should be braided in two braids. The vulva and perineum are shaved. No patient will object to this when its importance as a feature of protection against blood poisoning is explained to her.

Scrub thighs, hips, and abdomen as far as the navel with soap and warm water, then sterile water, followed by a 2 per cent solution of lysol. Care must be taken to remove the smegma and dried secretions from the folds of the vulva. Put on a fresh pad, a clean gown, and long stockings. A loose wrapper over all permits the patient to move about. (See Chapter XXIII.)

Guests are forbidden, and the immediate family is kept at a distance—if possible.

An air of buoyancy, composure, and competence should prevail in the sick room, and the patient should be cheered and encouraged in every possible way.

During the first stage, the patient may be up and about, as this diverts the mind. She may assist in the arrangement of the room which should always be the best room in the house. It should be well warmed and close to the bathroom. All unnecessary furniture and hangings should be removed, as previously described. After the room has been put in order, the bed is made.

Making the Bed.—Put mattress pad over mattress and cover with rubber sheet or oil cloth, and spread a sheet over all. Then a smaller rubber sheet is put on, extending from under the pillows to a couple of feet from the foot. A plain muslin sheet goes over the rubber, then the delivery pad.

When the bed is ready, a small table or stand should be placed near the head, on which is put the anæsthetic, the mask and the oil or cold cream. The patient may be lightly covered with a sheet or a sheet and blanket.

During the first stage, light and easily digested food and drinks may be served, either cold or hot, as the patient prefers.

When the doctor arrives he may want to examine the patient either externally or internally, or both. So a sheet is thrown across the lower part of the body and the night-dress pulled up as far as the breasts.

For the external examination the doctor washes his hands in warm water and green soap and scrubs with the nail brush for five minutes. This period should be prolonged to fifteen minutes, if, by any mischance, the hands have been in contact with pus or infectious material. It is extremely difficult to get them even approximately clean after such an experience.

Fig. 53.—Palpation. What is in the pelvis? (Eden.)

He now palpates the abdomen, notes the location of the head and back, finds and counts the heart tones, measures the pelvis and child, estimates the descent of the head and the character of the pains.

Fig. 54.—Palpation. What is in the fundus? (Eden.)

If he thinks an internal examination is necessary, he will now return to the bathroom, pare and clean his nails, scrub hands and arms to elbows for ten minutes in running water with green soap and a sterile brush, soak the hands in lysol solution 0.5 per cent for five minutes. Bichloride of mercury solutions have no place in obstetrics. They ruin instruments and hands, and are valueless for asepsis since the mercury unites with the albumin of the mucoid discharges and forms an albuminate of mercury, which is inert. The bichloride solutions also are nonlubricating, harsh and astringent, as well as poisonous, as soon as the mucoid protection has been removed. When the doctor takes his hands from the lysol solution, they should be wiped on a sterile towel. A sterile gown is put on, if possible. If it is not available, he should be careful not to touch anything that may destroy or contaminate his preparation. The hands are powdered and sterile rubber gloves pulled on (one will do.).

Fig. 55.—Palpation. Where is the back? Where are the small parts? (Eden.)

The nurse, meanwhile, has wrapped the legs of the patient in the ends of a sterile sheet, the bulk of which covers the abdomen. The knees are spread apart. The vulva cleansed with pledgets of cotton soaked in lysol solution. One or two pledgets are used on either side of the vulva and the same number for cleansing the introitus.

The fingers are now introduced.

The internal examination may be conveniently postponed until the waters break, or it may be omitted altogether if the heart tones of the child remain good, the labor progressive, and the head continually advances into the pelvis, as determined by the external examination. The great advantage of an internal examination at this time is the diagnosis of the degree of dilatation and the assurance that the cord has not been washed down into the vagina by the rush of fluid.

If the first stage is prolonged, the nurse should try to get the patient to rest, and she should herself snatch a few moments of repose if possible.

Fig. 56.—Patient draped for internal examination. (Williams.)

The condition of the os and the character of the pains may make the doctor feel safe in leaving the house, but his whereabouts and telephone number should be ascertained and the exact time of his return.

Second Stage.—During this stage, the patient should go to bed and the doctor should remain nearby. The nurse may observe the vulva at intervals and note bulging, if present, or she may press a finger against the soft parts outside the labia and see if the hard resistant head has come into the outlet.

The pains are severe and all accessory muscles are called into action. Partial anæsthesia should be maintained in most cases, which should merge into complete narcosis as the head passes the vulva. The nurse may have to administer this.

When this stage begins, or is well under way, the patient should be prepared. A sterile pad should be placed under her, then a sterile bed pan. The nurse having prepared her hands and arms as previously directed for the doctor, scrubs abdomen, legs, and vulva with green soap and warm water, followed by lysol solution 0.5 per cent and a rinsing with sterile water. The cleansing of the patient should take about ten minutes. Cover with a sterile towel and put on the sterile linen.

If in the hospital, the drums have been packed for sterilization so that when they are opened each article will appear in the order of its need:

No. 1. (Beginning at the bottom.) A receiving blanket, which has a ticket, marked with the weight of the blanket, attached to it.

1 abdominal binder with pad holder attached.

1 pillow slip folded half way back.

1 gown for patient.

2 surgeon’s gowns.

3 sheets.

1 pair surgical stockings folded half way.

1 surgeon’s gown for nurse.

No. 2 contains cotton pledgets.

No. 3 contains strips of gauze and combination pads.

Application of Sterile Linen—Normal Case.—Sterile linen is to be applied as follows, by a clean nurse;

1. Lay sheet across foot of bed and half way up. 2. Put surgical stocking on one foot and draw sheet up for foot to rest upon. 3. Second foot as above. 4. Lay sterile sheet across bed under patient, letting ends hang. 5. Lay sterile sheet over abdomen of patient.

In many hospitals the sterile stockings and protective sheet are all made in one piece, which greatly simplifies the application of the linen.

As soon as the second stage begins, the packet containing the perineorrhaphy and cord set, carefully sterilized, is brought out and placed in convenient reach of the doctor.

This set contains—

8 in. forceps.

2 scissors curved on the flat.

1 dissecting forceps.

1 duck bill speculum.

1 needle holder.

1 metal catheter.

8 gauze sponges.

1 medicine dropper.

1 cord clamp, or

2 cord tapes.

2 case numbers, attached.

12 needles, 4 round, 4 half-curved cervix needles, and 4 skin needles.

This is the stage of expulsion and the patient may want to pull or push on something to aid the straining effort. Unless the nurse needs time to set up the room or to get the doctor, this tendency may be encouraged.

A sterile sheet may be attached to the foot of the bed and the ends (corners) given into the patient’s hands as a knot or loop to pull on, or she may push upward against the head of the bed. Under no circumstances must she be permitted to touch or contaminate the clean linen in her movements, either consciously or unconsciously. The hands should be restrained, if necessary, to avoid this.

The face may be sponged and a cold towel laid across the eyes. Rubbing of the back and legs will bring great comfort, and cramps of the limbs may be removed by straightening the legs and rubbing the muscles underneath. Everything is now ready for the delivery. If the husband insists upon being in the room, he should take off his coat and vest and wear a gown, or if the labor is in the home, drop a clean night robe over his clothes.

The prepared room will show at close hand-reach, the basins of solutions, the pledgets of cotton, tape or clamp for cord, scissors, nitrate of silver solution (1 per cent) for the eyes, with dropper, the sterile douche can in readiness for hæmorrhage and a large reserve of supplies. Whatever anæsthetic has been chosen for the second stage, is now administered. Throughout this stage, the heart tones of the child must be watched, as well as those of the mother, for intra-partum death may occur at any moment.

A second examination may be desirable now to confirm the diagnosis and to secure an estimate of the advance. As a rule, the examinations should be as few as possible on account of the danger of infection.

This is the period of greatest responsibility for the doctor whose duty it is to watch and, if necessary, to restrain the advance of the head in order to protect the perineum from rupture.

This may be done at times most successfully, or in the case of too few assistants, most desirably, by delivery on the side. To secure this, as the head becomes more and more visible, the woman is turned upon her left side; a pillow rolled tightly and pinned in a sterile covering is placed between the knees, and a sheet flung across the body.

Fig. 57.—Delivery in side position. The hands should be gloved and the upper leg raised on a hard cushion or pillow. (American Text Book.)

The hips must be brought to the edge of the bed while the chest and head are pulled over to the other edge of the bed, leaving the legs just enough space to double up along the side of the bed parallel with its long axis.

The doctor may now sit on the edge of the bed, or on a high stool at the back of the patient and facing the buttocks. This is a most convenient and easily managed position.

As the head is born, the fæcal matter, blood and discharges must be sponged away, and the field kept clean, with the whole perineum visible. Always sponge from vagina toward rectum and throw away the sponge. Should the hand touch nonsterile things or septic material, like fæces, the glove must be changed. The hands must be kept surgically clean.

It is a part of the nurse’s duty tactfully to warn the doctor when such a thing occurs, as it may happen accidentally while his attention is concentrated elsewhere, and a conscientious man will be grateful for the information. As the head passes the perineum the anæsthesia should be deepened.

As soon as the head is born and the first respiration established (see Asphyxia, p. [278]), the cord is cut and clamped. There is rarely any necessity for haste in this maneuver. The eyes are treated, and if in a hospital, a numbered tape is tied about the wrist and a tape with a corresponding number about the mother’s wrist.

The baby is now placed in the receiving blanket on its right side, with artificial warmth at its back and feet. The head must be lower than the body so any retained mucus can drain out of nose and mouth. Meanwhile, the doctor (or nurse) keeps a hand on the fundus of the uterus to watch its contraction, see that it does not balloon up, and massage it occasionally if necessary while he awaits the onset of the third stage.

Third Stage.—The patient is turned upon her back as soon as the child is delivered. The pulse and face must be watched for signs of hæmorrhage. While waiting for the placenta, the perineum is examined to note the degree of laceration, if any. To do this, the vulva must be spread apart with clean fingers so as to bring the posterior wall into view, and the discharge is sponged away with cotton pledgets taken from the lysol solution and squeezed dry.

The patient may now have the saturated dressings removed and clean, dry ones substituted. The new pads catch the oozing blood and give an estimate of its amount.

At this time, if desirable, the perineum can be repaired. The woman is partly unconscious, the tissues numbed, and the needle hurts much less than it will later. Nevertheless, anæsthesia may be required.

In a period varying from a few minutes to an hour, the hand on the uterus will note a hardening, the mass will become smaller, more globular, and rise slightly in the abdomen. A gush of blood appears at the vulva and usually the placenta follows. If it does not, or if hæmorrhage or the condition of the mother requires it earlier, the uterus may be compressed (see Credé expression) and the placenta constrained to deliver.

The nurse holds a sterile basin for its reception. As the mass drops into the pan, the membranes drag after and it should be gently twisted, or the loose portions drawn upon until the end slips out. The placenta is set aside for examination, and ergot or pituitrin may be given to enforce the uterine contraction. The process of expulsion is generally assisted by a strong voluntary contraction of the abdominal muscles.

After a short rest, the blood is washed off the genitals, clean linen and clean pads applied, and the abdominal binder or girdle is put on to hold the pads. Warm blankets are thrown over the patient and within an hour, a glass of hot milk is administered.

The legs should be kept together, and in case of hæmorrhage, the feet crossed.

The placenta is now inspected and not only its completeness or incompleteness noted, but anomalies of every kind should be looked for.