The Prospective Mother, a Handbook for Women During Pregnancy

by J. Morris Slemons

To know the moment which marks the transition from the first to the second stage of labor can be of no benefit to the patient; but for the medical attendant the greatest interest centers about this point. Casual observation sometimes enables the physician to recognize it, for characteristically at the close of the first stage the whole picture changes. In a typical case the membranes will rupture at this instant, expulsive efforts will begin, and, as we have just learned, there may be symptoms referable to pressure. Moreover, a blood-tinged discharge, spoken of as the "show," usually makes its appearance about the same time. Since slight bleeding frequently occurs at the beginning of labor, or a little later, this manifestation, like all others, may not be implicitly trusted to indicate the end of the first stage. Such uncertainty, however, is a matter of no great consequence, for in the absence of all these symptoms the physician may, if necessary, accurately determine the degree of dilatation by an internal examination.

THE STAGE OF EXPULSION.—The term delivery has been broadly applied to include the whole of labor. More strictly, its use should be limited to the second stage, for this period alone is concerned with the actual birth of the child. Although dilatation has been completed, the uterine contractions continue, devoting their force to emptying the womb. In this they now receive assistance from the voluntary contractions of the abdominal muscles.

The second stage is very much shorter than the first; for this reason and others, too, it proves much less trying. As the child is moved downward through the birth-canal, the mother usually appreciates for herself that she is making headway; whereas in the first stage she may know of progress only through what she is told. Moreover, it is possible in this stage for the physician, by means of inhalations of chloroform, to relieve her of the pain attending the expulsion of the child.

Since the anesthetic properties of chloroform were discovered by an obstetrician who was searching for a drug with which to lessen the pain of childbirth, the facts connected with the discovery have a peculiar interest for mothers. Sir James Y. Simpson had always been anxious for some means to prevent the suffering endured during surgical operations "without interfering with the free and healthy play of the natural functions." He, therefore, welcomed the introduction of ether anesthesia from America; and in January, 1847, at the Edinburgh Medical School, administered ether to an obstetrical patient. This was the first instance in which an anesthetic was employed at the time of childbirth. Since ether, to his mind, had certain shortcomings, Simpson set about finding another anesthetic, and devoted all his spare time to testing the effect of numerous drugs upon himself. How he came to try chloroform has been vividly told by one of his neighbors. [Footnote: "Late one evening, it was the 4th of November, 1847, Dr. Simpson, with his two friends and assistants, Drs. Keith and Duncan, sat down to their somewhat hazardous work in Dr. Simpson's dining room. Having inhaled several substances, but without much effect, it occurred to Dr. Simpson to try a ponderous material which he had formerly set aside on a lumber- table, and which, on account of its great weight, he had hitherto regarded as of no likelihood whatever; that happened to be a small bottle of chloroform. It was searched for and recovered from beneath a heap of waste paper. And with each tumbler newly changed, the inhalers resumed their vocation. Immediately an unwonted hilarity seized the party—they became bright-eyed, very happy, and very loquacious—expatiating upon the delicious aroma of the new fluid. But suddenly there was talk of sounds being heard like those of a cotton mill, louder and louder; a moment more, and then all was quiet—and then a crash! On awakening, Dr. Simpson's first perception was mental—'This is far stronger and better than ether,' said he to himself. Hearing a noise, he turned round and saw Dr. Duncan beneath a chair, quite unconscious, and snoring in a most determined manner. More noise still and much motion. And then his eyes overtook Dr. Keith's feet and legs making valorous attempts to overturn the supper table. By and by Dr. Simpson having regained his seat, Dr. Duncan having finished his uncomfortable and unrefreshing slumber, Dr. Keith having come to an arrangement with the table and its contents, the sederunt was resumed. Each expressed himself delighted with this new agent, and its inhalation was repeated many times that night. Miss Petrie, a niece of Mrs. Simpson, gallantly took her place and turn at the table, and fell asleep, crying: 'I'm an angel! Oh, I'm an angel!'"—Quoted from "The Life of Sir James Young Simpson," by H. Laing Gordon; Masters of Medicine Series.]

The introduction of chloroform met with violent opposition, not upon medical grounds alone, but also for moral and religious reasons. "To check the sensation of pain in connection with the visitations of God," zealous theologians announced, "was to contravene the decrees of an all-wise Creator." Simpson reminded them "that the Creator, during the process of extracting the rib from Adam, must necessarily have adopted a somewhat similar artifice—for did not God throw Adam in a deep sleep?" Nevertheless, a number of years passed before the prejudice against artificial sleep was overcome. Chloroform only became popular after Queen Victoria consented to its use at the birth of her seventh child, Prince Leopold, in 1853.

There is still some difference of opinion regarding the routine employment of chloroform in obstetrical practice, though the weight of authority favors its use during the contractions at the end of the second stage, providing always that no preexisting organic derangement renders the drug dangerous. Under no circumstances, however, should chloroform be given in the first stage, and seldom at the beginning of the second. Prolonged administration will exert an injurious influence upon both mother and child; under these conditions it ultimately weakens the uterine contractions and delays the delivery. Such an effect must be avoided, since it would endanger the life of the child by asphyxiation as well as exhaust the mother. On the other hand, a few drops of chloroform inhaled with each pain toward the end of the second stage will dull sensibility, although consciousness remains unaffected. When the drug is thus administered, the uterine contractions are scarcely, if at all, altered, and the assistance which the patient is willing to give herself generally becomes more powerful. Should the anesthetic have the opposite effect, it must be withheld; but that is seldom necessary. As the head advances the anesthesia is deepened, and the mother sleeps soundly while the child is being born.

As long as dilatation is in progress, the patient may sit up or walk about; but with the advent of the second stage she should go to bed, for there she will be able to make the best use of the expulsive pains. The appropriate posture for delivery is still the subject of dispute, though modern views in no instance advocate the unnatural absurdities formerly supported by custom or superstition. Students of ethnology relate that among savage tribes almost every conceivable position was advocated for women in labor. Subsequently it became customary to have delivery take place in specially constructed chairs which are still used in semi-enlightened countries. With civilized nations at present women are always delivered in bed; yet national peculiarities still prevail. Some physicians favor what is known as the English position, in which the patient lies on her left side with her face inclined toward the chest, the trunk bent toward the knees, and the legs drawn up toward the abdomen. The majority of obstetricians, however, prefer that the patient should lie flat on her back. With the average case, and from the standpoint of facility in delivery, which of these postures happens to be chosen is a matter of indifference. But it is so much less awkward for the physician when the patient is on her back that this position has been widely adopted in America.

During the expulsion of the child the mother intuitively desires to help herself; generally she cannot resist straining, and rarely needs encouragement. Assisting the uterine contractions with voluntary muscular effort, the act commonly described as "bearing down," may be performed most effectively when the patient is lying on her back. The knees are drawn up and spread apart; the feet are braced against some firm object; the hands grasp straps fastened at the foot of the bed; and the head is slightly raised so as to bring the chin near the chest. When the contraction begins the patient takes a deep breath and holds it while she strains vigorously, as if to make her bowels move. All voluntary effort should cease as the contraction wears away, for straining between the contractions can accomplish nothing. Her own inclination to "bear down" will clearly indicate to the patient when she ought to act.

In the second stage patients regularly experience a feeling of pressure against the rectum, and this sensation, since it depends upon a low position of the child's head, is a welcome sign. Cramps in the legs also indicate progress, for they result from similar pressure against nerves adjacent to the lower part of the birth- canal. The cramps disappear immediately after the child is born, and are consequently never dangerous. Straightening out the legs or rubbing them usually gives relief. Most women, however, complain during the expulsive period only of pain in the back, and find nothing so grateful as firm pressure over this region.

Energetic efforts quickly bring the head to the outlet of the birth- canal, where it may be seen, at first only during the contractions, but later during the pauses as well. The crown of the child's head is generally directed upward and becomes fixed against the pubic bones of the mother, which lie just in front of the bladder. Around this firm pivot the child's head rotates upward, and, as a result of the movement, forehead, eyes, nose, mouth, and chin successively emerge from the birth-canal. Following the birth of the head, natural forces turn the body upon one side, the better to accommodate the shoulders to the passageway. After these are born, the rest of the body slips easily into the world, and the second stage ends.