Chapter II: Treatment of Natural Labour (1)

_State of the bowels.--Form and size of the uterus.--True and spurious
pains.--Treatment of spurious pains.--Management of the first stage.--
Examination.--Position of patient during labour.--Prognosis as to the
duration of labour.--Diet during labour.--Supporting the perineum.--
Treatment of perineal laceration.--Cord round the child's neck.--Birth
of the child, and ligature of the cord.--Importance of ascertaining
that the uterus is contracted after labour.--Management of the
placenta.--Twins.--Treatment after labour.--Lactation.--Milk-fever and
abscess.--Excoriated nipples.--Diet during lactation.--Management of
lochia.--After-pains._

This is a subject of great extent as well as importance, because it comprehends the whole mass of rules for the management of a woman, not only just previous to and during, but also after, her confinement. On nothing does the course of a natural labour depend so much, as upon the careful removal of every source of irritation which may tend in any way to derange or interrupt the regular progress of that series of changes or phenomena which constitutes the great process of normal parturition. It will be necessary that the reader should have made himself thoroughly master of the subjects discussed in the last chapter, before commencing those of the present one. With each change there mentioned, the state of the system and its functions should be carefully watched, and every slight deviation from the natural course of things checked by appropriate dietetic or medical treatment. Hence, therefore, the more a woman can follow her usual avocations, and take that degree of exercise to which she has been accustomed at other times, the better; for by so doing the circulation is equalized, the digestion is kept in full activity, and the tone and general strength of the system maintained.

It would almost seem, by rendering a woman more capable of moving about during the last weeks of pregnancy (which has already been shown to be produced by the sinking of the fundus, enabling the respiration to act more freely,) that Nature intended she should use exercise at this period, and thus prepare her, by increased health and strength, for a process which requires so much suffering and exertion.

Her hours should be regular and early, her meals light and moderate, and by agreeable and cheerful occupation she should fit herself, both in body and mind, to meet the coming trial.

_State of the bowels._ Attention to the state of the bowels is of first importance, and must never be neglected. It is a subject nevertheless upon which women are remarkably careless, and they will frequently, when not attended to, allow labour to come on with their bowels in a very loaded and highly improper condition.

There is, perhaps, no one circumstance which is found to exert such a prejudicial influence on the course of a natural labour, in so many different ways, as deranged and constipated bowels. Where the contents are of an unhealthy character, the irritation which they produce in the intestinal canal is quickly transmitted to the uterus, and tends not a little to pervert and derange the due and healthy action of this organ: hence arises one of the most fertile sources of spurious pains, a subject which will shortly come under our consideration. Where the bowels are loaded, in consequence of the pressure upon the ascending cava, considerable obstruction to the free return of blood from the pelvic viscera is produced, the vessels of which become considerably engorged. No organ feels these effects more than the uterus: from the immensely dilated condition of its veins, a state of local plethora is engendered, which, from the congested state of the uterine parietes, considerably interferes with the free and regular action of its fibres, and not unfrequently predisposes to hæmorrhage.

Moreover, the rectum being distended with fæces, diminishes proportionally the capacity of the pelvis, and prevents the ready descent of the head into it; occasionally it forms, at the beginning of labour, a solid cylinder of indurated fæces, so hard, as, at the first touch, almost to induce the suspicion of a projecting sacrum. As a measure of common cleanliness, the bowels ought always to be attended to before labour, for, besides the more serious effects now enumerated, the labour may be rendered exceedingly filthy for the patient, and not less disgusting for the practitioner; for, as the sphincter ani loses all power of contraction when the head advances deeper into the pelvis, it follows that whatever fæcal matter may have been lodging in the rectum will now be unconsciously pressed out.

Hence, therefore, for the last few days of pregnancy, the bowels should be regularly opened (unless they are so spontaneously, which is seldom the case) by castor oil or other mild laxatives: and if labour has already commenced before this measure has been taken, and if, therefore, there is not sufficient time for the operation of the medicine, an enema should be given.[66] In Germany it is a rule to throw up some chamomile infusion at the commencement of every labour, by which means the process is rendered more cleanly than is frequently the case in this country; and also, for the reasons already given, the early stage is less apt to be tedious from spurious and ineffective pains.

_Form and size of the uterus._ The more regular the first precursory pains are, the more symmetrical and uniform will be the shape of the uterus; and again, on the other hand, the more uniform its shape, the more regularly and effectively will it act.

It is these slight but early contractions, which, although they produce little or no effect upon the os uteri, exert a very important influence over the first half of labour; for it is by their action, in great measure, that the form of the uterus is determined, as also the correct position of the child. Hence, therefore, some practitioners lay considerable stress on ascertaining the precise form of the abdomen as a means of determining what sort of labour the patient will have.

In a woman pregnant for the first time, and in a state of perfect health, the uterus is of an oval or rather elliptical form at the beginning of labour: when seen in profile, the abdomen presents nearly a uniform degree of convexity. In this state the child lies with its long axis parallel to that of the uterus, that is, with its head or inferior extremity turned towards the brim of the pelvis; and if the fundus has already sunk in the manner above-mentioned, the practitioner may very confidently prognosticate that the head presents, even before making an examination per vaginam.

In a perfectly healthy primipara there is scarcely any inclination of the uterus either to one side or forwards, its median line corresponding with that of the abdomen: whereas, in the multipara, the axis of the uterus is seldom straight, inclining more or less to one side, or, from the greater relaxation of the abdominal parietes, being somewhat pendulous. The size of the uterus should also be taken into consideration, especially in first pregnancies; a large uterus shows that either its parietes are gorged with too much blood, or that its cavity is distended with an unusual quantity of liquor amnii, or that the child is very large, or that there are twins. Whatever may be the cause of the distension, it interferes with the regular and effective contractions of the uterus, and tends to make the labour (at least the first part of it) tedious. A moderate sized uterus is much more capable of active exertion, for its fibres not being put so much upon the stretch are enabled to contract better.

_True and false pains._ If the patient is already beginning to suffer pains, it is of great importance to ascertain whether they be genuine or spurious; upon the correct diagnosis of which, the favourable or unfavourable course of the labour not unfrequently in great measure depends.

A genuine labour pain comes on at tolerably regular intervals, rises gradually to a certain degree of intensity, remains at that point for a few seconds, and then subsides as gradually; the body and the fundus of the uterus increase in hardness, and the os uteri in tenseness, in proportion as the pain rises, and vice versâ; the pain is seated in the back and loins, and is of a dull aching character: but with the spurious pains it is quite the reverse; they come on and go off suddenly and irregularly, the pain is in the abdomen, and produces a sharp twinging sensation, and the hardness of the uterus and tenseness of its mouth bear no proportion to the pain.

Spurious labour pains are the early contractions of the uterus perverted and rendered irregular, spasmodic, and painful by irritation, congestion, or inflammatory action; they sometimes come on several days before actual labour commences, and if not recognised and removed, may expose the patient to considerable suffering and exhaustion. Derangement of the stomach and bowels is one of the most frequent causes of spurious pains, for by the irritation which is thus produced, the uterus is almost sure to sympathize, and to have its action more or less disordered. This may arise from unhealthy irritating contents of the bowels producing spasmodic, griping, and colicky pains, or from diarrhoea with tenesmus arising from exposure to cold, or from irritation caused by the pressure of the gravid womb. Spurious labour pains of this character also frequently occur in patients who are accustomed to indulge in the luxuries of the table, or in the lower classes, who are addicted to the use of spirituous liquors. Constipation has been already mentioned as a cause of this condition. The state of plethora, congestion, or inflammation, acting as a cause of spurious pains, may arise from various sources: it is frequently observed in strong healthy young women, especially those pregnant for the first time; the pains do not assume the proper character of genuine labour pains, and exhaust the patient by continued but useless suffering. The os uteri probably dilates somewhat, but its edge remains thin and tense, and the pains appear to have no effect in dilating it any farther. The mucous secretion of the vagina is not of the character described at the beginning of labour in the preceding chapter. The pulse is strong and more or less excited, and the flushed face, and generally increased heat of skin indicate the condition upon which those symptoms depend. The inflammatory form of spurious labour pains is not unfrequently of the rheumatic character, a condition which has not been much noticed in this country, but which is capable of exerting a very considerable influence upon the course and progress of the labour. It is usually produced by exposure to cold and the other common causes of rheumatism in other parts of the body, and is generally accompanied with more or less derangement of the stomach and bowels. In this state each contraction of the uterine fibres is attended with much suffering, although the contraction itself may be so slight as to produce little or no effect upon the os uteri. Most of these conditions, in a severe degree, form that species of dystocia which arises from a faulty state of the expelling powers, for the farther consideration of which we must refer to our chapter upon that subject. In a minor degree they produce these slight derangements of uterine action, which we are now considering under the name of _spurious pains_.

_Treatment of spurious pains._ The indications of treatment depend in great measure upon the cause; and we cannot impress it too strongly on the young practitioner, as a rule never to be lost sight of, that, whatever is wrong in the state of the circulation or of the bowels must be first rectified before having recourse to opiates. Where the stomach is much deranged at the beginning of labour, nature frequently induces spontaneous vomiting, with considerable relief to the patient, and mitigation of the pains; if not a gentle emetic may be administered. Where the bowels are loaded, the treatment already mentioned must be put into practice, after which [Symbol: minim] xx of Liquor Opii Sedativus and of antimonial wine in peppermint water, or gr x of Dover's powder may be given. When there is diarrhoea with a good deal of griping and tenesmus, a dose of castor oil with Liquor Opii Sedativus in any aromatic water may be administered; and if the labour be not yet commenced, gr v of Pil. Hydr. and Dover's powder may be also given at night. If there be a plethoric or even inflammatory condition, the lancet will be of the greatest service; it reduces the temperature of the body, relaxes the soft parts, brings on copious secretion of mucus, and by relieving the congested state of the uterine parietes, enables the fibres to contract with more regularity and effect. In the rheumatic form, laxatives followed by diaphoretics, the warm bath, and even venesection will be necessary.

By thus treating the spurious pains according to their cause, they will usually subside readily enough, and be either followed immediately by pains of a more genuine and effective character, or leave the patient perfectly free for several hours, or perhaps even days. It is by inattention to, or ignorance of, these conditions, that patients have been allowed to remain for several days in suffering, during which they have been treated as if they had been in natural labour, until at length they have become so exhausted that, when labour really made its appearance, they were incapable of undergoing the exertions which this process demands.

_Management of the first stage._ The preparatory pains of labour, which form the first stage, do not require that the patient should take to her bed at this early period; and this is especially the case in primiparæ, where the first stage is usually somewhat tedious. Until nearly the end of the first stage, she ought rather to be induced to suppose that actual labour has scarcely yet commenced, and that she may still sit up or walk about the room as best suits her feelings, taking care at the same time that every thing is in readiness against the moment when it shall become necessary for her to lie down. A nurse who understands her business will of course duly arrange all these matters, but it behoves the accoucheur, nevertheless, to pay attention to these little details, and to see that every thing is properly prepared: that the bed is ready, and guarded either by several folds of sheeting, or by a leather for the purpose, to prevent the blood and other discharges during labour from soaking into the bedding beneath; this must be done either on the right side or at the foot of the bed, in order that the patient may be better within the reach of the accoucheur: that the patient should be partially undressed, and covered with her dressing-gown: that all the linen should be well aired: that there should be towels, napkins, hot and cold water in readiness, and also a bottle of vinegar, and one of spirit in the room, in case of hemorrhage, suspended animation in the child, &c. &c. These and many other arrangements of less importance are by no means beneath his attention, and require but a moment's glance to assure him that every thing is properly prepared.

By encouraging the patient to sit up as long as she can, or even to move about occasionally, the pains are rendered more tolerable as well as more effective; the time passes more agreeably and quickly; and by the time that it has become necessary for her to lie down, the labour has made so much progress that the rest of its course seems to be much quicker than was at first expected. On the contrary, where the practitioner at an early period of the first stage, informs her that she must stay up no longer, that she must go to bed and remain lying on her left side, her mind is solely occupied with her pains, which become wearying and irksome; the time passes heavily away; she becomes impatient and therefore dispirited; and is much disappointed, that, after remaining in this state for some time, the termination of the labour appears to be as far off as ever. Nothing eases the pains of the first stage, or increases their effect, so much as frequent change of position and moving about; when, however, they are severe or of long continuance, and the patient becomes fatigued, she will require rest, and this opportunity, afforded by her lying down, should be seized for the purpose of making an examination.

_Examination._ The manner in which this operation should be proposed to the patient cannot be too delicate: it should, as Dr. Dewees has justly observed, always if possible be done by means of a third person, such as the nurse or any elderly female friend who happens to be present. If the accoucheur has proposed it with that degree of gentleness and good feeling which it ought to behove every one to show under such circumstances, he will rarely, if ever, experience the slightest unwillingness to accede to his request: the better the patient's rank in life is, the more docile will she prove at these times, and the more resolute to undergo whatever she is told it is necessary to submit to. The object of an examination is to determine whether the child presents rightly, whether the labour is far advanced, and to form some degree of prognosis as to its course and duration, &c.: these are points which are of such importance as well as interest to ascertain, that the dread which a patient feels at undergoing an operation so repugnant to her feelings is generally merged more or less in the intense anxiety to know if all is right.

An examination at an early period of labour is important in many respects. We ascertain the condition of the vagina, whether it be soft, cool, relaxed, and well lubricated with mucus, as described at the beginning of the last chapter; whether the os uteri be dilated; whether its edge be thin and tense, or already becoming soft, cushiony, and yielding; whether the membranes are ruptured; whether the presentation be a natural one, and whether the pelvis be rightly formed. In cases where the umbilical cord is prolapsed, it is particularly desirable to ascertain the existence of this displacement as early in labour as possible.

It is usually directed to examine during a pain, because at this moment we feel the os uteri tense, and therefore more distinct to the finger; but it is far better to examine during the interval between the pain: the os uteri being now relaxed, admits the finger more easily; the membranes being loose are not so liable to be ruptured; and, from their not being distended, we shall feel the presenting part more distinctly.

Wherever the os uteri is nearly or fully dilated, or from its condition and the effect which the pains have upon it shows a disposition to dilate with rapidity, the patient should go to bed, as we cannot be sure when the membranes may rupture, more especially in primiparæ, in whom this usually takes place early. It is equally desirable, also, in those who have already had children, that the patient should be upon her bed at this moment; because, if the pains be strong, and the os uteri yielding, the head is apt to follow the discharge of the liquor amnii, and sudden expulsion of the child might result at a moment when the patient is unprepared for such an occurrence.

The accoucheur should always examine when the membranes give way, because not only will he be able to feel the presenting part now more distinctly, but if the cord has prolapsed, a coil of it will come down into the vagina and cannot escape his notice; in fact, if there is any thing unusual about the presentation, he will be now able to distinguish it with greater certainty. In women who have had large families, the head remains very high in the pelvis until this moment, so that it is frequently extremely difficult to reach it and to ascertain its position: the same is observed with presentations of the nates and of the shoulder, which seldom descend into the pelvis until the liquor amnii escapes.

_Position of the patient during labour._ The position which the patient should take during the actual process of labour has been a subject of considerable discussion, and even at the present day varies exceedingly in different countries. In the earliest periods of history, women appear to have been delivered in a sitting posture, as is described in the first chapter of _Exodus_: this mode was revived in comparatively modern times; thus Ambrose Paré, in 1573, speaks of a labour chair with an inclined back, which he preferred to a common bed. Labour chairs were brought into very general use upon the Continent in the beginning of the last century by Hendrick van Deventer of Dort in Holland, and although they have been in great measure discontinued in modern times, there are still some districts of Germany where they continue to be used. It is a species of chaise percée furnished with straps, cushions, &c. by which the patient can fix her extremities, and thus enable the abdominal muscles to act with the greatest power. This is the very reason which renders labour chairs objectionable. The presenting part of the child is forced through the soft passage with great violence, before they have had time to yield and to dilate sufficiently; hence it has been noticed that lacerations of the perineum are of very frequent occurrence in those countries where labour chairs have been in general use. In some remote parts of Ireland, and also of Germany, the patient sits upon the knees of another person, and this office of substitute for a labour chair is usually performed by her husband. Labour chairs, as far as we are acquainted with their history, were never used in this country, nor have they been used for the last century in France, where the patients are usually delivered in the supine posture, on a small bed upon the floor, which has not inaptly been termed _lit de misére_. A modification of the labour chair is the labour cushion first used by Nuger, and afterwards by the late Professor von Siebold of Berlin and Professor Carus of Dresden; it is a species of mattress, with a hollow beneath the nates of the patient for receiving the discharges which take place during the labour. The patient is compelled to lie upon her back during the greater part of labour, and thus maintain the same posture for some time, which must necessarily become irksome and even painful to her. In this country and in Germany the patient is delivered upon a common bed, prepared for the purpose as above mentioned: in England she is placed upon her left side, the nates projecting to the edge of the bed, for the greater convenience of the accoucheur: in Germany, except in Vienna and Heidelberg, where the English midwifery has in great measure been introduced by Boer and Naegelé, the patient is delivered upon her back.[67] In former times the supine posture was also used in this country, but for about a century the position on the left side has been preferred; the patient lies more comfortably to her own feelings; her face is turned from the practitioner who sits behind her, and who, from this posture, is able to examine or to perform any other necessary manipulation without her feelings being annoyed by seeing what is going forward. It is decidedly the easiest position during the last moments of tremendous suffering and exertion; when the presenting part is passing she is not able to exert an undue degree of violence, and from the knees being kept together, there is less danger of the perineum being torn. The left side seems moreover to be the natural position for a woman at the moment of parturition, for if accidental circumstances have occurred, such as sudden labour, &c. by which she is deprived of all assistance at this moment, she will almost invariably be found upon the ground lying on her side supporting herself with one hand. In some cases she will remain during these moments upon her knees, into which posture she has gradually dropped from that of standing: in by far the majority of cases she will take the position upon her side, as above mentioned.

So long as the os uteri is not fully dilated, the patient is not involuntarily compelled to strain and bear down: hence it is important to caution patients, more especially primiparæ, not to be induced by an ignorant nurse or friend to exert themselves improperly during the first stage of labour, for not only is the process of dilatation considerably impeded, and much exhaustion produced, but frequently severe febrile or inflammatory action excited, which may lead to serious results after labour. All attempts to accelerate the course of a natural labour, especially the first stage, either on the part of the patient by premature straining, or on the part of the practitioner by attempts to dilate the os uteri and passages, or by giving her stimuli, &c. cannot be too strictly forbidden. It is a mode of practice which has long since been strongly condemned by the highest authorities in midwifery, except in Scotland, and which may very easily lead to most mischievous results. Quick rapid labours are by no means desirable, for they are seldom safe; nor is it possible to limit this or that stage (especially the first) to any given duration of time.

No conscientious practitioner, who has clear and enlarged views of the process and mechanism of natural labour, would feel himself justified in interfering with its course, merely because some portion of it has extended beyond a certain fixed period; but would rather guide his conduct by the habit and strength of the individual, and by the effects which the labour has upon her. We have before stated, that no two labours are alike; we may also add, that no two individuals are similarly affected by the same degree and duration of labour, nor indeed are any two labours exactly alike in the same person: hence it will be evident, that what to one patient would prove a protracted and exhausting labour, to another would be nothing more than a perfectly regular labour, natural both in its character and progress. Among other injurious effects which premature efforts on the part of the patient will have, is, that the membranes are liable to give way too soon--this is by all means to be avoided, for nothing is so likely to render the first stage protracted as the occurrence of this accident; the course of the labour frequently undergoes an immediate change; the pains lose their regular and effective character; the os uteri remains thin, tense, and unyielding, and the process of dilatation is greatly retarded.

_Prognosis as to the duration of labour._ There are few subjects upon which an accoucheur is so frequently importuned, or about which it is so difficult to give a decided opinion, as the probable duration of labour. It is natural enough that both she and her friends should be anxious to know how long this process of suffering is likely to last: nothing, however, is more hazardous than a prognosis in these cases; and we would warn our junior brethren to be cautious how they commit themselves by venturing an opinion, which the result of the labour may prove to have been founded upon guess-work or ignorance. The character of the labour during the second stage, is frequently very different to that of the first, so that the mode in which the labour commences is by no means a criterion for its latter part. A labour which has commenced briskly and regularly, and with every promise of a rapid progress and termination, frequently becomes exceedingly lingering during the second stage, so that the expelling powers may, perhaps, even fail altogether in making the head pass through the os externum; whereas, on the other hand, a labour, the first stage of which has been slow and protracted, frequently experiences a complete alteration of character, and advances with a degree of quickness and energy, which could scarcely have been anticipated from the manner in which it commenced. In primiparæ, especially, it is particularly difficult to foretell, with any thing like certainty, the duration of labour: hence it is, that unguarded assertions in this respect are not only liable to disappoint the patient, but destroy her confidence in the practitioner.

_Wigand's views._ The celebrated Wigand of Hamburgh considered that the form of the vagina would frequently furnish the means of a pretty certain prognosis, as to the duration of labour: thus, if it were wide and yielding throughout its whole length, the labour would be quick, both at its beginning and termination; if, on the other hand, it were small, rigid, and contracted throughout, the labour might be expected to be of a very opposite character. If on examination the vagina is found roomy and well dilated at its upper part, but contracted and rigid near the os externum, the labour will be probably quick and easy during the first half, but slow and difficult afterwards; on the contrary, where the os externum is yielding and wide, but the upper portion of the vagina narrow, the labour may be expected to be slow at first, but to be brisk and active afterwards. We have already stated, that the course of labour varies in every possible way; in some cases the same peculiar character of labour shows itself through two or three successive generations: hence it has been observed, that very tedious or very violent and rapid labours sometimes seems to be hereditary; the mother, daughters, and grand-daughters, being all remarkable for their lingering or rapid labours.

_Diet during labour._ The diet of the patient during labour should be simple and unirritating; if every thing is going on naturally and briskly, some gruel or tea, with or without a little biscuit or bread and butter, will be quite sufficient; but if the process is becoming tedious and exhausting, some beef-tea, broth, or any other mild nourishment of this sort will be required to support the strength.

During the first stage of labour there is no need for the practitioner to be constantly in the room, nor even during the early part of the second, unless the pains are very violent and protrusive; for, by taking frequent opportunities of quitting the patient for a few minutes, she is left more free from restraint, and the presence of the practitioner becomes less irksome when it is really necessary; whereas, if he continues at the bed-side, she is justified in expecting that the labour must be advancing rapidly to demand so unremitting an attendance, and, therefore, becomes disappointed and impatient to find that his presence has been of so little use to her. The conversation should be light and cheerful, and every means taken to encourage her and keep up her spirits.

_Supporting the perineum._ As the head approaches the os externum our attention must be directed to giving the perineum such a degree of support, as shall secure it from any serious degree of laceration during its passage. The greatest danger of ruptured perineum is in primiparæ, for the soft parts never having been subjected to such a degree of dilatation before, do not yield so readily as in multiparæ. The anterior margin of the perineum, called _frænulum_, is, we believe almost invariably ruptured in every first case; but the laceration ought not to extend farther. The more gradual the advance of the head is through the os externum, the better will be the dilatation of the soft parts: hence therefore, when the pains are violent, and the head is thrust with great force against the perineum, it will be desirable to restrain it in some degree, until the parts shall have had sufficient time to yield; on the other hand, where the pains are more gradual, the perineum and os externum may receive the whole dilating force of the head, and every succeeding pain will show that a progressive advance is taking place.

The increasing thinness of the perineum itself, and the frænulum becoming tense during the height of a pain, may be looked upon as warnings that the expulsion of the head is not far distant, and now the support of the hand will be needed to prevent laceration; for this purpose the position on the left side is peculiarly convenient, besides having the additional advantage of relaxing the external parts more completely. If the pains be violent, and the impulse to strain very considerable, we must desire the patient to lie as passive as she can, and do her best not to bear down, for otherwise the head is sometimes driven through the os externum with a single effort, and the mischief done in spite of all our care.

The support of the perineum has been variously directed by different authors; we prefer using the left hand, because then we have the right at liberty for any manipulations which may be necessary, such as examining if the cord be round the child's neck, &c. &c. It is awkward at first, because it requires the hand to be considerably twisted, and makes the wrist ache a good deal; but a very little practice soon conquers this slight difficulty, and the superiority of the mode will then be apparent. As our object is not merely to support the perineum, but to direct the head as much forwards under the pubic arch as possible, in order that the anterior portions of the os externum should undergo their share of dilatation, and thus in some measure spare the perineum, the chief pressure should be applied near to the sphincter ani, gradually diminishing it up to the frænulum perinei in front: for this purpose the left hand protected by a napkin (partly for the sake of cleanliness and partly for the purpose of having a firmer hold upon the parts, and preventing it slipping) should now be applied with the palm in the vicinity of the sphincter ani, so that the tips of the fingers should project somewhat beyond the frænulum; the whole should be laid as flat and close to the part as possible. In order that we may be sure of the hand being applied exactly along the raphe of the perineum, we should guide it by the examining finger of the right hand, bearing in mind, that when we place this against the posterior margin of the os externum, and bring the middle finger of the left hand in contact with it, we shall hold the left hand in the desired direction.

It is desirable also to hold the examining finger of the right hand against the frænulum perinei when a pain comes on, because then we know exactly when the tension of the perineum is becoming such as to endanger its integrity, and when the head is about to pass out. Until this moment the frænulum is seldom on the stretch, although the rest of the perineum is: hence we need not apply our support until now, and thus give the parts the full benefit of the dilating force, which the head exerts upon them, until the very last instant. To relax them still farther, the patient's knees ought not to be separated by a pillow or cushion placed between them, as is usually done, although it must be confessed that in some cases she is relieved by it.

In applying the left hand to support the perineum, it should be placed somewhat more backward than the spot which we intend to support: for by this means we are enabled to push the soft parts somewhat forwards, and thus relax them. By this means, also, we not only direct the head against the other parts of the os externum but avoid the danger of its perforating the perineum. When the moment of greatest distension arrives, the process cannot be too slow; we must therefore desire the patient not to bear down, and endeavour, if possible, to make the head remain in the state of _crowning_ until the next pain comes on: the os externum having been held for some moments at its utmost dilatation, permits the head to pass with greater ease and safety. As the globe of the head passes forwards and emerges through the os externum, we feel the posterior portions of the perineum become soft and lax, while the forehead, followed by the face, and lastly the chin glide over the anterior margin of it.

The passage of the head is not the only moment of danger to the perineum, for laceration is even still more liable to be produced during the expulsion of the shoulders; any slight rupture of the anterior edge is now apt to be converted into a considerable laceration, unless the support be continued until the thorax be expelled. We have already stated that the frænulum perinei is generally torn through in the first labour; but the laceration ought not, if possible, to extend farther, because serious injury may be produced either to the vagina, or even to the sphincter rectum. To say, however, that laceration of the perineum need never happen, would be preposterous; because cases every now and then occur, where, from the contracted and unyielding state of the os externum, and from the size of the child, it is nearly impossible that the perineum can escape without injury; fortunately, although considerable lacerations are by no means uncommon, they are seldom observed to extend into the sphincter ani, the direction of the rent being usually to one side. Under the ordinary circumstances of perineal laceration, little more than mere attention to cleanliness is required; for the parts contract so astonishingly after labour, that what was a wide rent of an inch and a half long, in a couple of days will be scarcely more than two or three lines in length. Rest, great cleanliness, and gentle-relaxed bowels, constitute the chief treatment.

_Treatment of perineal laceration._ Where, however, the laceration extends into the rectum, the case becomes exceedingly troublesome and difficult to cure, and the patient is liable to be rendered a miserable object for life; for the action of the sphincter being entirely destroyed, she is unable to retain fæces or flatus in the rectum; besides which, from the injury to the posterior wall of the vagina, prolapsus uteri is an almost certain consequence. In these cases the slightest movement of the thighs upon each other alters the position of the lips of the wound, and thus tears it open afresh, so that at length the edges of the wound become callous and refuse to heal. A great deal in these cases depends upon the patience and good conduct of the patient herself; for if she have the resolution to lie perfectly still for at least a week, she will have every chance of a perfect cure. If there be much swelling of the edges, and a disposition to slough, a warm poultice of chamomile flowers should be applied, and the bowels kept in a nearly liquid state by gentle and repeated doses of salines, in order to prevent distension of the rectum when the evacuation is passing; she should preserve the supine posture, and have her knees confined together by a piece of tape, as is done with patients after the operation of lithotomy. Straps of adhesive plaster are seldom or never of any use, but if the rent be very severe a suture or two may be required. The great fault in applying these means for bringing the edges of the wound together is the attempting to unite them throughout their whole length; for by so doing the tension of the parts is increased, and therefore there is less disposition to unite; and even if we succeed in effecting complete union of the whole wound, the perineum is so contracted and unyielding from the cicatrisation, that it can scarcely escape a repetition of the injury in succeeding labours. It is, therefore, much better that we should content ourselves with uniting merely the posterior half of the laceration; the parts heal much more readily, and the os externum is left of a sufficient size to escape all danger of laceration on future occasions.

Where the edges have become callous and refused to unite, they require to be pared and brought together again; this, however, does not always succeed, and the case becomes very difficult and protracted: under these circumstances, the treatment adopted by Dr. Dieffenbach, of Berlin, is well worthy of attention. Having pared off the callous edges of the wound, he brings them into the closest opposition by transfixing them with needles in several places, as is done for the operation of hare-lip; and in order to isolate the wound as much as possible from the surrounding parts, and prevent any tension, he makes a free incision through the integuments, parallel with the wound, at a little distance from it, and nearly of the same length; by this means, every cause which might tend to separate the edges is removed; whilst the parallel cuts, being fresh incised wounds, soon close by granulation.[68]

It sometimes, although rarely, happens that the perineum, instead of being torn from before backwards, is perforated through its centre by the head, so that the child is not born through the os externum, but through a lacerated opening in the body of the perineum. This accident may arise from a variety of circumstances: the direction of the pelvic outlet may be faulty, or the inclined plane formed by the lower part of the sacrum, by the sacro-sciatic ligaments, &c. may be insufficient to guide the head forwards under the pubic arch; or the perineum may be unusually broad; in which cases the power of the uterus being directed against the centre of it, the head becomes enveloped in a bag of protruded perineum; and if the pains are violent, and the head not properly supported, it at length bursts its way through the centre without even injuring the frænulum. The treatment of this form of ruptured perineum is the same as that of the more common species; the bowels must be kept open, and a fomentation of chamomile flowers applied to the wound, which, from the gradual contraction of the surrounding parts after labour, diminishes remarkably, so that in the course of a short time it will have entirely or nearly closed.[69]

Besides the above-mentioned advantages in supporting the perineum, we may mention another which is not generally noticed, and which is sometimes of considerable service. In cases where the head has completely descended upon the perineum, and begins to protrude somewhat through the os externum, the pains occasionally fail at this moment, the labour becomes very lingering, while the advance of the head and state of the parts show that two or three active pains would bring the child into the world; firm pressure applied at the lower end of the sacrum, in a direction forwards, materially adds to the effect of each pain in bringing the head through the os externum, and seems also to excite the patient to make a more powerful effort with the abdominal muscles. On several occasions we have thus assisted the expulsion of the head, when otherwise the labour would have been very protracted, or would have even required the forceps to disengage it. Madame La Chappelle is the only authority in midwifery, as far as we know, that has noticed this fact.

_Cord round the child's neck._ As soon as the head is born, we must examine whether the cord be twisted round the child's neck; and here the advantage of supporting the perineum with the left hand becomes evident: it is ready to support the shoulders when they begin to pass, while the right hand is at liberty to perform any manipulations which may be necessary. If it be important to support the head during its passage over the perineum, still more so will it be to support the shoulders; for if a small laceration has already been produced, it is invariably converted into a wide rent at this moment, if great care be not taken: indeed, we are justified in saying that most of the cases of severe perineal rupture are produced by the shoulders, not by the head.

_Passage of the shoulders._ If the pains cease for a time, or the child be large, the shoulders do not pass immediately: in this position the face swells and grows purple from the pressure upon the neck, although it does not necessarily result from the cord being round it; if, however, we find that this is the case, we can in most instances loosen it somewhat by the finger, and as the shoulders advance, slip it first over one and then the other: we must recollect that the shoulder, which is forwards, passes out first, and that, therefore, we must slip the cord over it first.

It is seldom necessary to assist the shoulders by applying any extractive force to the head, for in the course of a minute or two the uterus generally resumes its activity and expels it: on the other hand, when the shoulders pass through the os externum, the right hand should be in readiness to prevent the body of the child from being born too rapidly: the uterus can scarcely be emptied of its contents too gradually, for by this means it contracts equably, powerfully, and permanently, and throws off the placenta without difficulty; whereas, if suddenly evacuated, it frequently becomes powerless for a time, or if contraction does take place, it is so irregular and incomplete as to endanger partial separation, retention of the placenta, and hæmorrhage.[70] If, however, the cord be twisted exceedingly tight round the child's neck, and imbedded so deeply into the skin, as to render it impossible to push the coil over the shoulder, it may become necessary to divide it in order to let the child pass, in which case the practitioner must seize the divided ends as well as he can, and apply a ligature the instant the child is born. We believe that this is rarely, if ever, necessary; for in proportion as the child advances, so does the fundus descend, and thus relieves, in some measure, the tension to which the cord is exposed. This subject, however, belongs rather to the third species of dystocia, to which we must therefore refer.

_Birth of the child and ligature of the cord._ As soon as the child is born, we must place it in such a position as will enable it to breathe with ease. The sudden exposure to the external air is generally sufficient to excite respiration; if not, a gentle pat on the nates, or blowing suddenly in the face, will usually succeed: if, however, the child still remains insensible, recourse must be had to those means which are recommended under the head of _Asphyxia neonatorum_. The cord should not be tied until it has ceased to beat, for unless the circulation be well established in its new course, the breathing is apt to stop, and the child relapse into insensibility: the cord should be tied about three inches distant from the umbilicus; it should be applied tightly, because otherwise it is apt to become loose, as the cord grows flaccid. In tying the ligature, one hand should be supported against the other to prevent giving the cord any jerk in case the ligature breaks; we are able also by this means to tie it more firmly.

The cord should be divided at some little distance from the ligature, so as to prevent all chance of its slipping off, and it should be done with a pair of blunt scissors, by which means the vessels of the cord are so bruised as to be rendered nearly impervious. There is no need to apply two ligatures; in fact it is better not, for, as Dr. Dewees justly observes, "the evacuation from the open extremity of the cord will yield two or three ounces of blood, which favours the contraction of the uterus and expulsion of the placenta." It has been recommended, in case of twins, to apply a second ligature, to prevent all chance of the second child bleeding through the cord of the first. There is, however, no connexion between the two placentæ, although they usually form what appears to be one mass. We only know of one case where the umbilical arteries of one cord anastomosed with those of the other, an anormality of very rare occurrence: still, however, it is better to apply a second ligature upon the cord, where we find that twins are present, as a precaution: and also to prevent it being said, in case the second child is still-born, that it had died from no ligature having been applied upon the placental extremity of the cord. It has been questioned whether it was really necessary to tie the cord before separating the child from the mother, from the well known fact that nothing of the sort is required in animals; and that, in cases of rapid labour, where the child has been unexpectedly dashed upon the floor and the cord broken, no hæmorrhage has resulted. This arises from the bruised and lacerated condition of the cord under these circumstances: animals not only bite the cord, but also draw it through their teeth several times, so as to contuse the vessels for a considerable extent; whereas, if it was merely divided with a sharp instrument, there is no doubt but that the new-born animal would quickly bleed to death.[71]

_Importance of ascertaining that the uterus is contracted._ As soon as the child is separated from its mother and removed, or even sooner, if this process has gone on slowly, we ascertain if the uterus has contracted: this we shall know by its feeling like a large hard ball behind the symphysis pubis: if there be one rule more important than another, it is this, for without it we cannot be certain of the patient's safety for a single minute: so long as we feel the fundus to be hard, we know that the uterus is contracting, and that it will expel the placenta quickly, and ensure the patient against hæmorrhage; but if it be soft and relaxed, she cannot be considered safe even if their be no hæmorrhage; for the placenta may have been separated, and may be lying across the os uteri, or the os uteri itself may be contracted, or blocked up with coagula, so as to prevent the blood from escaping; it therefore collects in the cavity of the uterus in large quantities, to the imminent danger of the patient. Even where the uterus has contracted, the patient is not permanently safe, for it may again relax and grow soft, and hæmorrhage come on.

_Management of the placenta._ The placenta sometimes follows the child immediately, and occasionally is expelled by the same pain; usually, however, a few minutes intervene, during which time the uterus remains more or less in a state of inaction; it then begins to contract, and the dull and peculiar pains which characterize the separation of the placenta are now felt. The interval after the birth of the child varies considerably, and depends in many cases on the degree of rapidity with which the uterus has been emptied: hence in some cases we feel the fundus hard almost immediately, whereas, in others some considerable period elapses before it resumes its state of activity, a period which, if any separation of the placenta has already taken place, will be attended with the greatest danger. The occurrence of pains indicates fresh contractions, and therefore we should now examine to ascertain if the placenta has been detached. As a general rule it may be stated, that if we can reach the insertion of the cord with our finger we may presume that the placenta is ready to be expelled; if not, that it is still partially or wholly attached to the uterus. So long as this latter is the case, the less we meddle with the cord the better, for by pulling at it we only excite the os uteri to contract, and thus seriously impede its removal.