There may be an interval of a few minutes before the pains return with sufficient force to expel the shoulders, but the child is in no particular danger; it is best to wait awhile, the nurse in the meantime making pressure with her hand over the uterus, before any traction is made on the head or shoulders. If the body is very large, however, it may be well soon to draw a little on the head or to reach with one finger into the axilla and to bring down the lower shoulders; then the rest will be delivered without any difficulty.
The intense suffering of the mother is now exchanged for perfect joy or ease; there is at once a transition from extreme misery to total freedom from pain, though the labor is not yet completed. Ordinarily a few pains return before many minutes, and complete the last stage of labor—the expulsion of the placenta. Sometimes the contractions that expel the child, expel also the membranes and placenta; but more generally they are only partially detached or they may be adherent and not easily removed.
After the birth of the child, and the tying of the naval string, it is proper to apply the hand upon the abdomen of the mother to ascertain whether there be another child, and whether the uterus be contracting properly. I advise that an effort should be made immediately to remove the afterbirth and secundines, making firm pressure over the womb; this will generally stimulate the uterus to make good contractions, and may assist in pressing out the placenta. I do not advise that a midwife should pull upon the cord, but it is my practice to press the fingers of my right hand well into the vagina, and as soon as possible grasp a little of the placenta; my left hand at the same time pulling slightly on the cord, and thus by combined effort removing the afterbirth pretty quickly.
I have never had much trouble about retained or adherent placenta in cases where I myself officiated in the delivery, and I attribute my good fortune in this respect to the fact that I do not tie the placental portion of the cord, preferring to let some blood discharge from the afterbirth, thus diminishing its size, and then if necessary I direct that considerable effort be made in the way of squeezing and pressure and friction over the uterus.
It is true that if nothing is done a pain will usually come on within twenty minutes that will expel the afterbirth very effectually including all the membranes, and considerable clots of blood; but I apprehend that in many cases during this delay there is an hour-glass contraction of the womb comes on, which retains the placenta and prevents its proper separation.
But before attending to the placenta, the necessary attention should be paid to the child. A little cold water sprinkled on it will usually make the child cry, if it does not breath immediately after it is born, and this makes the change in it from uterine to breathing life. The child may then be separated from the mother by cutting the cord. After the removal of the child it is proper to endeavor to deliver the afterbirth, though it may not be necessary at first to do anything more than to use friction over the uterus with moderate pressure, which may be gradually increased.
CHAPTER IV.
MECHANICAL PHENOMENA OF LABOR.
The cavity of the uterus and that of the pelvis form a continuous PASSAGE through which the child must be forced in its exit from the womb at birth. The uterus possesses the character of muscularity and is the main agent in the expulsion of the child. By its own muscular action the cavity of the uterus is diminished and pressure made on the fœtus, forcing it down towards the orifice, distending the cervix, and dilating the passage. During the second stage of labor the power of the uterus is aided by the voluntary muscles of the abdomen and by the depression of the diaphragm.
The character of the passage will be brought to mind by recalling what was heretofore said of the diameter of the pelvis. It will be remembered that the usual antero-posterior diameter of the brim does not exceed 4½ inches while the transverse is 5¼ inches, and that at the lower outlet the antero-posterior diameter is about 5 inches and the transverse about 4 inches.
The FIRST OBSTACLE which the child meets in its progress is the cervex uteri. This being composed partly of muscular fibre which acts somewhat as a sphincter, and partly of elastic celular tissue, holds the sphincter in the tissue with a tenacity which is not easily overcome. But repeated muscular contractions of the womb force down the bag of waters, which forms a sort of wedge, and this is forced down and into the os uteri, compelling it to open.