Duties during the Second Stage.
“The second stage of labour having commenced, we are summoned to the patient’s room, if we have been absent, and told that ‘the waters have broken.’ She is most likely found reclining on the bed, and, probably, the pains are more urgent than they were before; or, perhaps, they are somewhat suspended. We now require to make another examination, because it is possible that the head may have fully entered the cavity, and may be soon expelled. Finding it low in the pelvis, finding the os uteri almost entirely dilated, the membranes broken, and the pains strong and coming on frequently, it is right not to leave the room; but unless the perineum is somewhat on the stretch, we need not yet take our post exactly by the bed-side. But as soon as the head has come to press upon the external parts—particularly when it has made its turn, and is beginning to extend the structures at the outlet of the pelvis, it becomes our duty to take our seat by the bed-side, and never to move from our position till the child has passed. This we do to protect the perineum, in order to prevent laceration.[28]
“For the purpose of supporting the perineum we sit rather behind the patient, and apply the palm of the left hand—guarded, for the sake of delicacy, cleanliness, and convenience, with a soft napkin—steadily and firmly against the perineal tumour. I have already mentioned that the thighs must be drawn up towards the abdomen, and the legs bent a little back upon the thighs, and the whole person lying on the left side; and the patient is usually placed so that her feet may rest against the bed-post.[29]
“We render the shoulders also another fixed point, so as to steady the upper part of the body, by tying a long napkin, or a round towel, to the same bed-post, and desiring her to hold it in her hand. We tell her, when the pain comes on to press with her feet against the bed-post, and pull gently at the towel, cautioning her against straining violently. The consequence is she so fixes her person as to render it almost impossible for her to jump away suddenly, or to recede to any distance from us. Independently of this little manœuvring, when the head is in any degree extending the vulva the nurse must be required to raise the right knee to some distance from the other, by which means the thighs are separated, and an increased facility given to the exit of the head through the external parts, as well as some control exerted over the patient’s movements.... After having examined the uterus through the parietes of the abdomen, we must make an internal examination, more perfectly to assure ourselves in what way the placenta is disposed of. Twisting the funis umbilicalis around the first two fingers of the left hand, and bringing it to its bearing, we pass the first finger of the right hand, previously anointed, into the vagina, as in a common examination. If the placenta be entirely in utero, which, as just remarked, is most commonly the case immediately after the child’s expulsion, we shall either not be able to touch it at all, or if it be within reach, we shall only detect a very small portion of it; we may just feel it offering itself at the os uteri; but we cannot surround its volume, nor can we probably discover the insertion of the funis.
“Removal of the Placenta.—There is no part of natural labour which requires so much judgment as the conduct of the third stage; for the slightest mismanagement of the placenta may be productive of most serious mischief, by converting a perfectly natural into a most dangerous and complicated case. As long, then, as the placenta remains in utero, so long we must wait, within a certain limit—provided there be no flooding—for those contractions which are to expel it from the uterus into the vaginal cavity, &c.; while we are thus watching, we shall most likely be informed of the return of uterine action, by the woman complaining of two or three comparatively trifling pains affecting the back and loins. As it is probable that under these pains the placenta may have somewhat descended, another examination may then be made per vaginam to satisfy ourselves on this point, &c.
“The removal of the placenta from the vagina is easily effected. Twisting the funis umbilicalis two or three times around the first and second finger of the right hand, we draw it down in a line tending towards the coccyx, and receive it in the left, placed under the perineum; or we may introduce the two first fingers and the thumb of the left into the vagina, embrace the mass between them, squeeze it as we would a sponge, and slowly extract it....
“Having perfectly satisfied ourselves on this point, we may a second time take away the napkins soiled with the accumulated discharges, and envelope the lower part of the patient’s person in others that are warm and dry. Three will be sufficient: one must be partially slid under the left hip; another may be placed over and around the right hip; and the third carried between the thighs, directly on the vulva, &c....
“Some practitioners adapt the bandage themselves, and apply it immediately after the placenta has been removed. I think it preferable, in common cases, to leave this duty to the nurse; and that it should not be put on until the body linen of the patient is shifted; because, in the first place, it appears to me more desirable that perfect quietness should be preserved until the first changes in the uterus consequent upon labour are effected, that no disturbance may interrupt their progress; and, in the second, I cannot help thinking that there is something highly indelicate in its being applied by a man—much more so, indeed, than any of the duties we are ordinarily called upon to perform under natural labour. It is of most service when next the skin. It must be sufficiently broad to reach from the pubes almost to the ensiform cartilage; and it cannot be properly adapted unless the abdomen be quite uncovered. In addition, I would remark that the nurse must know very little of her duties, if she cannot draw a properly contrived bandage round the person, and give it the due degree of tightness without incurring danger.”
The reader of the preceding extracts will have observed that they begin with a panegyric on the extraordinary powers of nature in adapting means to an end; which, nevertheless, the author forthwith proceeds to qualify, as if he had admitted too much, in giving nature credit for the due execution of her own work, and her capability for enforcing her own laws, by enlarging on the profound and scientific knowledge required in the man-midwife, the opinion expressed by the Royal College of Physicians to the contrary notwithstanding; and in effect impiously detracting the infinite power and wisdom of God, “who created man in his own image, in the image of God created He him; male and female created He them. And God blessed them, and God said unto them, be fruitful and multiply.”
“And God saw everything that He had made, and behold, it was very good.”