If the after-birth comes away of its own accord, as will generally happen when due patience has been exercised, it may be severed from the child and put aside for the inspection of the doctor, for he should learn by examining it whether everything has come away properly. The cord must be securely tied in two places with the sterilized bobbin mentioned in the list of articles for confinement. One ligature is applied about two inches from the child's abdomen, the other an inch nearer the placenta; the cord is then cut between them with a pair of sterile scissors. Anyone fearful of injuring the infant may prevent accident by spreading a diaper under the part of the cord to be severed. This precaution also protects the bed from soiling, for there will be a single spurt of blood the instant the cord is cut. So long as the child is in good condition there is no urgent need of this operation. If the child is breathing satisfactorily it may generally be deferred until the doctor arrives. When this course is chosen the attendant will wrap the infant in a warm blanket, place it along with the after-birth in a safe spot, and subsequently devote herself to making the mother comfortable.
The vulva and neighboring parts are bathed with a 1-1000 bichlorid solution. Soiled dressings are removed, the gown changed, and, if necessary, clean sheets put on the bed. A sterile sanitary pad is placed over the vulva and a fresh one substituted as often as necessary, but none of the pads should be destroyed. All the dressings must be saved so that the doctor may see how much blood has been lost. As we have learned, bleeding regularly occurs while the placenta is separating and thereafter; excessive bleeding will rarely follow a normal delivery if the attendant has heeded the precaution to leave everything to nature. If ever the loss of blood should become alarming before the doctor arrives, it is advisable to raise the foot of the bed, to keep the patient quietly on her back, to grasp the womb through the abdominal wall, and to massage it constantly until the nearest physician can be gotten.
Of these directions the most important is that which relates to the management of the womb, for in cases in which labor has been normal in other respects the relaxation of its muscle is most often responsible for flooding. What to do in this event must therefore be made plain. First the patient should try to empty her bladder, and, if she cannot, pressure made above the organ will usually expel the urine. The attendant will then take her seat on the edge of the bed, facing the patient's feet, and will locate the womb. When there is flooding one may expect to recognize the womb as a large, rather soft mass lying in the mid-line of the abdomen with its upper margin somewhat above the navel. With one hand, or with both if necessary, the mass is grasped in such a way that the fingers cover the top of it and pass backward toward the spinal column; the thumb remains in contact with the front of the organ. The womb is stroked and squeezed much as one kneads dough, and for this reason the procedure is technically called kneading. Such manipulations cause the muscle fibers to contract firmly, and in consequence the blood vessels are tightly closed and bleeding ceases. Similarly, cold applications to the abdominal wall tend to provoke uterine contractions; placing over the womb an ice-cap or towels wrung out of cold water and doubled several times often have a beneficial influence when there is a tendency toward relaxation. Some physicians also recommend that the child be placed at the breast, since suckling is known to cause uterine contractions. There are other measures which are occasionally employed, but they should be used only by physicians, for in the hands of an inexperienced person they may do more harm than good.
Very often a slight chill follows labor. It has a nervous origin and need never give uneasiness; a drink of warm milk, hot-water bags to the feet, and extra blankets will be sure to make the mother comfortable. On the other hand, excitement of any kind aggravates this condition. In general, recently delivered patients must be kept quiet no matter how well they feel. A few hours of sleep, or, at least, of repose, are justified by the fatigue incident to labor, and nothing should be permitted to interfere with it.
METHODS OF REVIVING THE CHILD.—Complications which interfere with the child's vitality rarely occur when labor proceeds so rapidly that there is not time to get a doctor. Nevertheless a description of child-birth would be incomplete without reference to the measures intended to revive asphyxiated infants.
Such measures aim, first of all, to make the infant breathe for itself, and if breathing does not begin promptly we resort to artificial respiration. Mucus in the mouth or in the lower air- passages hinders the entrance of air into the lungs; consequently it is the duty of the attendant to remove this mucus by means of gauze or some light fabric wrapped about a finger and passed backward over the tongue. In most cases nothing else will be necessary. But if breathing is not immediately established, the child should be grasped by the feet with one hand and held downward while its back is vigorously slapped with the other. Usually, it gasps at once; when it does not, the attendant may stroke its face and chest with her hand, which has been previously held in cold water for a moment; or she may dash a handful of cold water upon its body. With very rare exceptions these procedures make the child cry.
One must always be alert to see the very first attempt at breathing, for unduly prolonged manipulations may defeat their own object; the natural inclination always is to do too much rather than not enough. In some instances, however, the measures thus far indicated will not prove successful, and, if not, the cord must be tied and cut through, for subsequent treatment cannot be conveniently carried out while the child remains attached to the placenta. As soon as the cord is severed the child is placed in a tub of warm water, about the normal temperature of the body, and is moved about in the bath for a few moments, the attendant watching closely all the while, for the breathing is often very superficial. Should signs of beginning respiration not appear, the attendant should grasp the child by the shoulders, dip it up to the neck in a basin of cold water and quickly return it to the warm tub. This operation may be repeated five or six times; generally the instant the child touches the cold water it draws up its feet, opens its eyes, and cries. One must take care that the plunge lasts but a moment; if the child becomes chilled efforts to revive it will likely be unsuccessful. Indeed, the necessity for keeping it warm must be constantly borne in mind.
With the very exceptional cases in which hot and cold tubs are ineffective, the following method becomes valuable. Wrap the child in a blanket and lay it face downward upon a table or chair, allowing the head to hang over the edge. Roll the body on one side or a little beyond; then slowly roll it back upon its face and onward to the other side. This maneuver is repeated fourteen times to the minute, but not more frequently. When properly performed it secures a flow of air to and from the lungs with the same rapidity as in the normal respiration of an infant. Efforts to revive the child must not be quickly given up, as a successful outcome occasionally requires half an hour of work or even longer. One method after another should be tried in the order which I have indicated. A physician always perseveres so long as the heart-sounds can be heard; but, since an inexperienced person might be unable to decide upon this point, the most reliable course for the layman is to persist in the resuscitation until the physician arrives.