A NATURAL LABOR has been described as one “in which the head presents, and descends regularly into the pelvis; where the progress is uncomplicated, and concluded by the natural powers within twenty-four hours, (each stage being of due proportion), with safety to the mother and child, and in which the placenta is expelled in due time.”
A skillful, careful examination in the commencement of labor will enable you perhaps to decide whether the labor will be natural or otherwise. But it may be your duty first to know if your patient is in ordinary health, or if she have any fever or organic disease, and you should enquire about the bodily functions generally, the condition of the pulse, skin, &c. Before making a digital examination you should notice the character of the pains, their frequency, force and regularity, the amount of voluntary effort, the character of the outcry, &c. From these enquiries you probably will be able to decide whether she is suffering from real labor, or false pains.
She will, however, probably not object to a digital examination and your opinion will be founded principally upon that. The modern practice is to wash the hands in antiseptic soap or some solution before making an examination.
We are directed by most writers to have the patient lie upon her left side near the edge of the bed when we examine her. The fore finger of the right hand (sometimes the left) after being well oiled or soaped should be passed along the perineum into the vaginal orifice, and is to be pressed upward and backward towards the promontory of the sacrum until the os uteri or the presenting part is found. Sometimes this is not reached without an effort. When reached endeavor to find the fœtal head or to determine what is the presenting part—feel sufficiently to distinguish the lips of the os uteri from the presenting portion of the fœtus. Do not be hasty in making the examination; wait till you examine sufficiently to know if the child is forced down; observe both during the time of a pain and during an interval, and observe if the pains dilate the os. Sometimes during a natural labor there may be a severe pain, and when the pain is hardest, the os contracts. By waiting to take a number of pains you will learn if there is real progress. When examining, note the calibre, heat and moisture of the vagina; the general condition of the cervix; the dilatability of the os uteri and the actual dilatation by the bag of waters or the fœtal head during a pain. If the head presents you can best learn the particular position when the pain is off; and after the membranes are ruptured you can decide better than previously. Ordinarily the sagittal suture can be felt, and perhaps both fontanelles, but you must not be discouraged at all if you cannot determine the exact position. Doctors ordinarily do not deem it necessary.
If you can decide that it is a head presentation and that the woman is undoubtedly in labor, you may probably decide that the labor will be natural, and you may properly tell the friends so, adding perhaps, that it will depend upon the character of the ensuing pains whether the labor will be protracted or short.
Various circumstances of which you are possibly not yet cognizant may make your case of labor a tedious or difficult one. You have decided, perhaps, that there is no obstruction to the passage of the child, no deformity of the pelvis, scirrhus or other tumors in the vagina, no cystocele, no prolapsed ovary, and that there is not a rigid perineum or imperforate vagina. If there is, you need to have a medical man present, but should none be obtained you will need to repeat your examination from time to time. Observe if each pain presses down the bag of waters and dilates the mouth of the womb, and if the soft parts are in a relaxed state, and if there is a show. Even if the appearances are thus promising, the labor may be slow and tedious from various causes.
1. Possibly hardened feces maybe in the rectum; if they are you may be assured of the fact when you make a digital examination, as they seem like tumors posterior to the vagina. The remedies are physic, enemas, rest—possibly opium.
2. Inefficient pains may be due to a bladder distended with urine. When this is suspected we should observe whether there is abdominal swelling (not tympanitic) low down; pain on pressure which gives rise to a desire to urinate; a constant desire to pass water though the patient has just performed the act, or a dribbling of water from the parts. If the bladder cannot otherwise be relieved a catheter should be used, and as a precaution to avoid wetting the bedclothes it is well to have a catheter made long enough by affixing a piece of India rubber tubing to the end of it to reach a vessel at the side of the bed. Never use force in passing a catheter in. It is very seldom that it is necessary to use it at all during labor.
3. If there is a hernial protrusion of the bowel, or a calculus of the bladder falling down in the passage you will probably have a medical man to officiate. But I may say that if there is need of your doing anything to replace them, or if it is necessary to return a prolapsed bladder, you can best do it when your patient is in the knee-chest position.
4. The lack of expulsive power is sometimes due to the want of sleep. If the first stage, that of dilatation, is prolonged the subsequent uterine contractions seem to want efficiency. In such cases if the patient can have a dose of opium or morphine administered to induce sleep it acts favorably. Where there is nervous excitement particularly, the efficiency of the pains are increased if we give opium and first procure a period of rest.