Tokology

Labor is effected by dilatation of the cervix uteri and contraction of the uterine and abdominal muscles. This dilatation is the first stage. In the second, expulsive efforts occur, causing the advance and birth of the child. The action of the uterus in expelling the fetus is analagous to that of the rectum in expelling its contents. In each case the abdominal muscles powerfully co-operate with the peristaltic action of the organ. Uterine contractions, once established, continue intermittently until the contents are expelled. These contractions are usually attended and recognized by pain. They are called labor pains.

It is well established by physiologists that the suffering attendant upon labor is abnormal, and only a result of the violation of nature’s laws; that by a more or less thorough compliance with those laws, most women can approximate to a condition in which there shall be no suffering in childbirth.

A few days preceding labor, there is usually a muco-sanguineous discharge from the vagina. This is called the show. It indicates dilatation of the cervix and relaxation of the vagina. It is often accompanied by malaise and restlessness, and in some by headache and loss of appetite.

In 96 per cent. of all cases, the head of the child is the presenting part. At first the long diameter of the head is in the oblique diameter of the pelvis; as it passes the pelvic brim, it turns so as to lie across from back to front, the chin pressing upon the breast, and the crown of the head advancing. The first pains are grinding, scattered and irregular, felt mostly in the anterior portion of the pelvis and groin. With these, dilatation of the os progresses, which is often accompanied by severe sufferings, especially when diseased conditions exist. Afterward the pains are in the abdomen. As the head advances there is great suffering in back, hips and groin, with a disposition to bear down.

This disposition need never be urged by attendant, nor forced by the patient. Old ladies often say, “Bear down! make an effort!” supposing that this will facilitate labor. The fact is that these attempts to assist nature are retarding instead of helpful, and are often the cause of accidents. Nature indicates all effort essential to progress.

The bag of waters consists of the membranes which enclose the fetus and liquor-amnii.

Protruding through the os, when dilatation is effected, it precedes the head, prepares the way for it, and lessens the liability of contusion of the soft parts. These membranes usually rupture with an expulsive effort, before the close of the labor. The uterus then contracts firmly on the body of the child, and labor advances rapidly to completion. In rapid labor, however, the bag is sometimes expelled entire with the child.

The physician requires the assistance of but one attendant besides the husband. This should be an educated nurse or a friend, who can command herself in emergencies. The old time custom of having a neighborhood party on the occasion of an increase of the family, has happily gone out of date.

When this custom was in vogue both patient and physician were often seriously annoyed by the crowd of neighbors who thronged the house. Many times the grand “set out” for the table was so expensive as to take the whole month’s salary of the working man, while perhaps the “doctor’s bill” remained long unpaid.

Conversation should be cheery and foreign to the occasion. Obscene anecdotes and direful childbirth experiences should be avoided. During the entire process of parturition, the patient should have the advantage of pleasant, comfortable and sanative surroundings. Her mind should be free from care and anxiety. The best in the house should be appropriated to her use. Her room should be light and airy.

Every necessity and convenience should be in readiness for the occasion. Provide two yards of rubber cloth for protecting the bed, a fountain syringe, a hot water bottle, safety pins, antiseptic absorbent cotton, glycerine, arnica, ammonia, carbolic and castile soap, calenduline, olive oil, and cosmoline. Also have an abundant supply of soft rags. They should be large and clean. Remove the seams and buttons. Old sheets torn in quarters or pillow slips are the most desirable.

Make the bed as if one were going to sleep in it. Place the rubber cloth over the under sheet. Cover it with an old quilt or comfort that will wash easily. Have the bed set out from the wall so that both sides can be used. Prepare the side for the patient that will enable the physician to use the right hand.

Let the patient wear the garments she desires to have on after confinement, having care to protect them by folding back smoothly, and fastening a sheet loosely about the waist. After labor begins, she should take only liquid food. The bladder should be relieved frequently. If the bowels have not been moved within twenty-four hours, a copious enema of warm water should be taken.

Until the last stage, the patient can assume any position affording the most comfort. Usually, she is inclined to change frequently, sitting, lying, walking and even kneeling. When expulsive efforts occur, she ordinarily prefers to recline upon her back, with knees flexed and hips elevated. At this time, she naturally pushes with her feet, and pulls with her hands. A padded box should be firmly fixed at the foot of the bed for the feet. She can grasp the hand of an assistant, or have some reliable mechanical contrivance for her hands. The simplest is a strip of new muslin, ten inches wide, put around the foot of the bed, and tied, leaving it the desired length for a good purchase. In a prolonged labor, the obstetric harness is the most valuable assistance. This is a padded belt for the back, with straps extending to the knees and feet. From the knees are counter straps, with handles for the hands. With this simple contrivance, a physician requires less assistance.

Supporting the perineum is not only absolutely unnecessary, but also apt to be exceedingly injurious. Meddlesome midwifery is always to be deprecated. A natural labor needs no manual local interference. Although many authors and teachers recommend support to the perineum in the last stages, yet more ruptures may be attributed to this practice than to leaving it entirely untouched. A Canadian physician asserts that he has attended 1,700 women in confinement without giving support to the perineum, and yet in no case did rupture occur.

When the head is born receive it in the hand and support it until the shoulders are expelled. If the next contraction does not bring them, put a finger in the axilla of the child, and make slight traction. The whole body will soon be born. Pass both hands under the child and lay it as far from the mother as possible without stretching the cord. Place it upon the right side, shoulders and head slightly elevated. Wipe any mucus there may be from mouth and nostrils. Cover baby with a warm, soft flannel. Make the mother comfortable. Change her position, straighten the bed, put dry cloths to her, give her a drink, etc., leaving the infant until the pulsation has entirely ceased in the cord. This will require from ten minutes to half an hour.

Usually, as the child is ushered into the world, it sets up a lusty cry, indicating that respiration is established. Crying is not essential, as some authors claim, and the prompt covering usually causes it to desist. If it does not breathe at once, a little brisk spatting on the breast and thigh may establish respiration. If this is not effectual, dash cold water in the face and on the chest. Still failing, artificial respiration must be established. To do this, close the nostrils with two fingers, blow into the mouth, and then expel the air from the lungs by gentle pressure upon the chest. Continue this as long as any hope of life remains.

Sever the cord when pulsation has entirely ceased in it. Use a dull pair of scissors, cutting about two inches from the child’s navel. Following these directions, no tying is essential. This method has its advantages. By tying, a small amount of blood is retained in vessels peculiar to fetal life. This blood by pressure or irritation may prevent perfect closure of the foramen ovale, and be a cause of hemorrhage. Besides, it must be absorbed in the system, causing jaundice and aphtha, so common in young babes. Prejudices exist against adopting this treatment, as it is contrary to that usually adopted.

I first heard of this manner of treating the cord in 1870. It was so clearly explained that I was convinced that leaving the cord untied would result in great gain to the child. Still, my education and habit had been to the contrary, and my prejudices prevented my venturing upon the new method. A few years after this I met a German physician who had not tied a cord in eighteen years. He said: “Don’t be afraid; your babies will do better, and there is less danger of losing them.” I tested it and proved to my own satisfaction that it is the best method. One has only to recollect to wait until the pulsation in the cord ceases entirely, and sever as before stated.

By no means wash and dress the baby as soon as it is born. Consider the marvelous change that has taken place in all its functions. Respiration is established and the blood, instead of going to the placenta for oxygenation, goes to the lungs; the stomach and all the organs of digestion and elimination are brought into action; the skin, also, with its innumerable perspiratory ducts, begins its work. Give nature time to establish these processes before the system is taxed by being washed and dressed. An Indian papoose might be plunged into water at once without detriment, but no white baby of this country has sufficient vitality to safely undergo this shock. Rub the baby all over with olive oil, cover warmly, and leave it to rest and sleep.

While the baby is resting the mother demands especial attention. Contractions of the uterus will soon be renewed to expel the placenta. Usually these do not recur for half an hour, and it may be two hours before the after-birth is expelled. Should there be no hemorrhage and the walls of the uterus contract, there is no cause for uneasiness.

For expelling the placenta contractions can be induced by laying upon the bowels cloths wrung from cold water, or by manipulating the abdomen after dipping the hands in cold water. Also, the patient may blow into her closed hand, or give a slight cough. If there is hemorrhage, the vein of the umbilical cord should be injected with cold water. This, in many cases, removes a retained placenta. This valuable suggestion is a fact unknown to many practitioners. The placenta does not adhere as often as some suppose. If attached there is seldom danger from delay in removal, unless there is hemorrhage. After it is expelled it should be burned or buried.

The mother must be bathed in tepid water, sponging carefully her back, abdomen, thighs and perineum. Lay a cloth to the vulva wrung from a lotion of arnica, one tablespoonful to a quart of water. If there is soreness in the pelvic region a compress wet in the same lotion can be worn.

The parturient woman requires no bandage. If a compress is needed a towel can be pinned around to keep it in place. Also, if there is discomfort from undue enlargement and relaxation of the abdomen, a bandage applied loosely will give relief. Otherwise no bandage is essential. The common belief that it restores a woman’s form is a mistake. She returns to her former size better without than with it. If worn at all snug it is likely to cause inflammation that will produce bloating. It also presses the uterus down in the pelvis and in the relaxed condition of all the parts may cause prolapsus uteri. The frequency with which prolapsus occurs may justly be attributed to the unnatural pressure thus exerted. A parturient woman makes a more speedy and excellent recovery without the bandage.

After the bath, change the soiled quilts and cloths for fresh ones. Apply a large cloth over the arnica cloth at the vulva, make the bed look tidy, and leave the patient to rest. The house should be made quiet and every means used to encourage complete repose. If it is night, let the attendants retire and darken the room, the nurse remaining within call.

In case of thirst let her have cold or hot water, weak tea or thin gruel, as she feels inclined. Ordinarily she needs no remedies. Nature simply demands rest. Only a few years since a woman was not allowed to go to sleep until she had taken a bowl of panada and the inevitable dose of castor oil. One woman told me she dreaded the castor oil more than having the baby. It is unnecessary and likely to produce harm. For a few days torpidity of the bowels is natural, and if forced to action, inflammation and piles are likely to result. Surgeons have long been familiar with this same state of the bowels in other cases. Constipation is the natural sequence of amputation or fractures. The system rallies to meet one great demand and temporary torpidity of the bowels may be expected. Do not be influenced to take any drug. Simply rest. Surely at no time in one’s life is rest so sweet.

The long months of anticipation, doubt and endurance are over, the hour long feared has culminated in the bestowment of a gift which an angel might receive with rapture. A babe, the object of woman’s profoundest and most sacred passion has been given her for her very own, to nourish, guide, develop and instruct, of which even death cannot rob her. A solemn joy beyond words fills her soul, which none should needlessly disturb.