Inmost cases of natural labor there is not much assistance needed. The assistant should, however, possess a certaintact, ormanner, calculated to make a favorable impression on the patient. This is especially neededwhen a man officiates. It must be recollected, that the situation of the female at such times is a very peculiar one, and that the presence of one of the other sex, however necessary, must be more or less objectionable to her. He should, therefore, carefully exhibit in his behavior the most refined delicacy, combined with a warm sympathy and kind consideration; thus soothing her scruples and enlisting her gratitude. He must also appear perfectly self-possessed under all circumstances, and then she will have full confidence in his skill and judgment. It may seem scarcely necessary to state these things, but I have often known men officiate without such qualifications, and also be perfectly unaware of their deficiencies. Such accoucheurs never officiate well; they may be skillful and attentive, but yet unsuccessful, and unappreciated. They are onlytolerated, but not respected, and are never fully confided in.
When requested to see a woman supposed to be in labor, it is always advisable to be prompt in paying the visit, because delivery sometimes comes on suddenly and unexpectedly, and both mother andchild may be in great danger if no one is near to assist.
Some time before the event is expected, it is advisable to provide certain articles, which will or may be needed at the time, and which should not have to be looked for at the last moment. A pair of sharp scissors, with a piece of strong thread or cord, are indispensable, and a female catheter may be needed. A quill with the feather part on, may also be useful; and some pure lard or sweet oil is frequently called for. The professional accoucheur will also find it a good precaution to have his stethoscope in his pocket, and a lancet, if he ever relies upon bleeding in any contingency. A small box of extract of Belladonna also, may often be of great and immediate service.
The first thing required when visiting the patient, is of course to ascertain positively whether she be pregnant, and whether labor is really commenced, and if so how far it has progressed. This necessitates an examination, the proposal and making of which require the most delicate tact, particularly if it be with a comparative stranger, or in a first labor. No allusion to it should be made to the patient herself by the assistant; he should converse withherabout indifferent matters, or merely upon her health, and state his wishes to thenurseor female friend, and then retire. This gives them time to inform her of what is required, and to make the necessary preparation. On entering the room again, he should not proceed abruptly, but resume the conversation, and make some of the necessary arrangements while carrying it on. He should seat himself by the sideof the bed, with his right hand next her, and his face opposite hers. Then passing his hand under the bed clothes, after having lubricated it with lard or oil, he can proceed with the examination as if it were a simple ordinary proceeding. By exhibiting no hurry, and appearing to think it nothing unusual or in any way strange, the female herself will cease to think it so, and will not be flurried or shocked.
The hand must be passed under the female's right thigh, her knees being elevated. She should, of course, lie on her back, and as near to the edge of the bed as convenient. Not the slightest exposure is necessary, nor allowable under ordinary circumstances.
The fore-finger being introduced,ballotmentmay be practised, to ascertain if pregnancy really exists; and if the evidence from this source is not sufficient, auscultation must be resorted to. After being satisfied on this point, the mouth of the womb must be carefully examined, and its degree of dilatation noticed. If the female has pains, their character and frequency must also be noticed, and the effects they produce on the parts. It will generally be possible by these means, to discover how far the labor has progressed, and even to form an opinion how long it is likely to last. The general form of the parts and their size, should also be noticed; particularly of the pelvis, so that any deformity or deficiency may be discovered. And lastly, thepresentationshould be ascertained, if possible, so that it may be known in time whether nature will be sufficient herself or will require helping. Thepositionneed not be cared for at present, because it is of little consequence when the presentation is favorable.
The time required to make the examination neednot be long, and should always be as short as possible.
While conversing with the patient, much useful information may be gained. The general state of her health, the nature of her pains, and the time they first commenced, should all be known; and if she has had children before, it will be highly useful to know what kind of a labor she had; whether it was long or short, easy or difficult, and particularly if attended with any accident likely to occur again.
It need scarcely be remarked that great caution is needed in these cases, many eminent men having been deceived as to the patient's condition, as already stated in our chapter on the signs of pregnancy. And many times the doctor has been summoned under the supposition that labor had begun, while it was yet far off. The pains may be false ones, such as frequently occur towards the end of pregnancy, and may all pass away. These false pains, however, can usually be distinguished, being continuous and irregular, while the true ones intermit with periods of almost perfect ease, and are tolerably regular. The false pains are also felt in various parts, while the true ones are chiefly fixed in the uterus and vagina. Sometimes, however, the difficulty in distinguishing them is very great, and the accoucheur has often waited for several hours and even days; the labor meanwhile making no progress; and eventually all has passed off, and the patient has risen again from her bed. I know one case, where a gentleman attended nearlythree days, at the end of which time the patientrose and walked down stairs. She was not put to bed tillsix weeks after. I can scarcely think, however, that these mistakes canhappen very frequently, if the examination be properly conducted.
If it appears from the examination that labor has really commenced, or is about to do so, everything should be at once prepared. All useless persons should leave the room, and also those who would be likely to alarm or grieve the patient by uttering cries, or exhibiting fear; but no objection should be made to any one being present whom she wishes to see, unless they cannot be depended upon. Thus some females always wish to have their husbands with them, but others do not, though they are averse to saying so. In these cases the accoucheur, if he be an attentive observer, will soon see what is really desired by his patient, and will manage matters accordingly.
The dress of the female should be perfectly loose, consisting of a wrapper or night-gown, but sufficiently complete and warm to allow of her getting up to walk in the chamber, if she desires it, as some do. No corsets, garters, or other tight bandages, however, should be allowed.
The bed should be prepared by placing the mattress on the top, or by removing all from it; and then placing a thick layer of blankets or quilts, with a folded sheet over them. This is to provide a firm level surface, in which the body will not sink, and also to prevent the fluids soaking through. It is an excellent plan, if the material can be obtained, to place a thin oil-skin or India-rubber cloth under the folded sheets, as this keeps all perfectly dry underneath. Some persons also place another folded sheet,or a cushion, under the pelvis, to keep it elevated; but this is not necessary, unless the bed sinks in very much. It is also advisable to leave a foot-board or other firm body, against which the female can press her feet when bearing down; and a long towel folded lengthways should be passed under the back, so that it can be raised up by a person lifting at each end. This will often be found a better mode ofpressing the back, which nearly all patients call for, than by merely forcing the hand against it, which is both tiresome and insufficient. Another towel may also be firmly fixed to the bottom of the bed, so that she canpullby it, at the same time that she pushes with her feet.
Some persons are confined on a cot, but this is not a very good arrangement, because it sinks in too much in the middle, and is not sufficiently large and firm. It is advantageous in one respect, however, as it can be placed by the side of the bed, into which the patient can be lifted when all is over, and be comparatively dry and comfortable. This is the most frequent plan in France. If the bed be properly arranged however, the under sheet can be withdrawn, and clean warm napkins then passed under the body, which will be equally as good. The covering should consist of a sheet, with blanket or coverlid, according to temperature, and should, of course, never be removed, except under peculiar circumstances.
The chamber itself should be as quiet as possible,well ventilated, and not too warm. Nothing distresses the patient more than a close, hot atmosphere.
The accoucheur need not, of course, be present while these arrangements are being made; and when he retires he should suggest to the nurse that thefemale may attend to the bowels and bladder during his absence. This precaution may both facilitate the labor, and prevent much future annoyance. It would even be advisable to administer an injection if necessary, of thin starch and a little castor oil, rather than leave the bowels unmoved.
In regard to nourishment, nothing is needed or proper in the shape of solid food; because all the energies of the system are concentrated in the uterus, and as digestion cannot therefore go on, it would only be an evil. If the labor is much protracted however, some broth or soup may be taken, or a little milk. As a general rule, no spirituous liquors or stimulating drinks of any kind should be taken; because they impart no real strength, and may produce inflammation, or congestion on the brain. Some females always prefer tea to drink, others lemonade, toast water, gruel, or barley water, and others again simple cold water, which is perhaps the best of all. In cases of great exhaustion it is sometimes advisable, and even necessary, to give a little wine, or brandy and water, but it should always be cautiously administered.
In some parts it is customary for the female to lie on her side during delivery, with a pillow between the knees; some even choose this mode, and others will desire to stand, or place themselves on their knees. The most frequent position however, and certainly the most convenient, is on the back, though it may often be changed with advantage under peculiar circumstances. In the early stages of labor she can lie, or move about, as she chooses, or even rise if more agreeable.
When everything is arranged the assistant should take his seat on the right hand of his patient and repeat the examination. If the head presents, he need not concern himself much further at present, but if it be any other part, he should prepare at once to change it, or assist, as the case may be. At this second examination the parties present, and the female herself are usually anxious to know if the child iscoming right, and how long the labor is likely to last. The answer to these inquiries should be guarded and circumspect in regard to the duration, because of its uncertainty, but if the presentation is right, it is well to say so at once, because this gives great comfort and encouragement. If it be unfortunately wrong, it is best not to say so abruptly, but remark that it is rather obscure, or cannot yet be fully distinguished, and so keep up the spirits of the female while you await the proper time, or make the necessary arrangements, to interfere; and then tell her there is a little difficulty which requires to be righted, but which will not be serious, nor cause much delay.
If the labor steadily progresses it is necessary to remain with the female and attend to it; but if it be delayed, and everything remains natural, she may be left for a time with advantage. When the second stage is fairly commenced however, and especially after the membranes are broken, the attention should be unremitting. The state of the parts should be ascertained frequently, so that the actual progress may be known, and any necessary assistance rendered. The state of the bladder especially shouldbe observed, and if it be full and the female unable to urinate, the catheter should be passed. Neglect of this precaution may lead to serious accidents. While making the examinations, the hand should be introduced with great care, so as not to bruise or lacerate the parts, and it should not remain longer than absolutely necessary.
Many females exhaust themselves unnecessarily by bearing down, and straining, with great force, from the very commencement of labor, under the mistaken idea that it is necessary to do so, or will assist. They should be told not to do so however, till after the membranes are broken, and not even then unless the neck of the womb begins to dilate. They should also be told not to make any effort exceptduring a pain, as it will not assist at any other time.
No attempt should be made, under ordinary circumstances, to rupture the membranes, or dilate the mouth of the womb, even though nature may be slow in doing so. Patience must be practised, both by the female and by her assistant, and sometimes it is severely tried.
When the waters have escaped, and the orifice is opened, an examination must be made, to discover whether the cord has descended, or either of the arms, as is sometimes the case, and if so, they must be returned if possible.
As the head descends to the bottom of the pelvis it compresses the rectum, and produces a feeling as if the bowels must be moved, or even causes them to be so. This is apt to distress the female, and make her wish to rise, which cannot be permitted. If anything of the kind occurs no notice should be taken of it, or she may even be assured she is mistaken,while a clean napkin may be interposed. This, as Dr. Chailly observes, will soothe her delicacy. Such an accident is very apt to occur towards the end of the labor.
When the head has rotated, and presents at the external opening, or vulva, and begins to distend it, the greatest care is required. This is a critical period, during which the accoucheur can render more real assistance than at almost any other. There is danger at this time, as formerly explained, of the head passing through too quickly, before the parts are sufficiently relaxed, and so causing them to rupture. This is particularly the case with the perineum, against which the head presses with great force. It is necessary therefore tosupport the perineum, as it is termed, to prevent this accident. This is done by passing the right arm under the patient's right thigh, and placing the palm of the hand flat against the perineum, with the thumb encircling one side of the vulva, and the forefinger the other. The hand is then gently, but firmly, pressed against the part during every pain, so as to prevent the head passing too quickly, and also toelevate it, and thus relieve the perineum of part of the strain, and throw the occiput under the pubes.
Some practitioners also pass the left hand over the thigh, at the same time, and grasp the back of the head with it, thus holding the head as it were between the two hands, so as to direct it at pleasure.
The manner of doing this is represented in plate XXXIX.
PLATE XXXIX.The manner of supporting the perineum, during the passage of the head.The right hand is placed underneath, so as to push the head gently back, when it presses on the perineum too forcibly, before it is dilated; and also to elevate it towards the pubes.The left hand is seen above, grasping the top of the head, to assist. This may be done or not, according to the necessities of the case, or the custom of the assistant.
PLATE XXXIX.
The manner of supporting the perineum, during the passage of the head.
The right hand is placed underneath, so as to push the head gently back, when it presses on the perineum too forcibly, before it is dilated; and also to elevate it towards the pubes.
The left hand is seen above, grasping the top of the head, to assist. This may be done or not, according to the necessities of the case, or the custom of the assistant.
supporting the perineumPlate XXXIX.The manner of supporting the perineum, during the passage of the head.
supporting the perineum
Plate XXXIX.The manner of supporting the perineum, during the passage of the head.
Plate XXXIX.
The manner of supporting the perineum, during the passage of the head.
It is also necessary to request the female at this time to moderate her efforts, and not bear down too strongly. If however she be too excited, and eager to do so, more care must be used, and the head pressed back still more forcibly, till the parts are fully relaxed. For want of these precautions there is often serious lacerations of the perineum and vulva, particularly in first labors, and when the parts are unusually rigid. If proper care be bestowed however, these accidents ought to occur but seldom, even in the worst cases, and nothing can be more hurtful to the reputation of an accoucheur than for them to happen. Sometimes it is necessary to support the perineum for hours, and to bestow constant attention the whole time. It is often useful to keep applying a little simple ointment, or lard, in the intervals of the pains, mixed with the extract of Belladonna, which will soften and relax the parts. Dr. Lee also advises the application of a sponge, dipped in warm water, and which would probably do much good in many cases.
It will of course be understood that the pressure only needs to be madeduring the pains; when the head draws back the ointment or warm sponge may be applied. The knees of the female should be held up by some one, if she bears down too much, so as to prevent her from doing so too powerfully.
When it is felt that the parts are fully relaxed, and sufficiently distended, the head is left at liberty, during a strong pain, and it immediately passes the outer ring, or is born.
It should then be held up, towards the pubes, and the mucus should be cleaned from the mouth with one of the fingers, so that the child may breathe. A careful examination should also be made roundthe neck, to see if the umbilical cord is around it. If it be so, but is not tight, it may be left alone, or pulled a little over one shoulder, or even passed clean over the head, if it can beeasilydrawn out long enough. When it is very tight, and cannot be eased, it must be cut through, or it will strangle the child.
In most cases the shoulders follow immediately after the head, the uterus resting only a few moments; but if they do not the head may beslightlydrawn upon, or the fore-finger of the right hand may be linked under the arm, and alittleforce employed, though very carefully. It is better however to wait even two or three minutes, and only resort to these means when there is evidently a partial suspension of the natural efforts. Sometimes also the contractions may be brought on again by merely pressing the hand over the fundus of the uterus, and this should therefore be tried first. In all cases it being better to let the uterus expel the child than to bring it away by manual force.
During the passage of the shoulders the perineum needs as much care as during the passage of the head, and must be supported in the same way. Indeed some authors are of opinion that most cases of laceration are caused by the shoulders.
After the shoulders are expelled the limbs and body speedily follow. The child should be received in the hands of the accoucheur, and laid on its side, at a little distance from the vulva, so that it may not be suffocated by the discharged fluids. He should then take a strong ligature and pass ittwiceround the umbilical cord, about two inches from the navel, and also at about four inches, and then cut the cord through, between the two bands, with a pair of sharp scissors. The child may then be handed to the nurse.
The tying of the cord is by some deemed unnecessary, and in most cases probably is so, but as children have been known to bleed to death, when it was not done, it should never be neglected. Some practitioners only tie it once, leaving that part open which is still attached to the placenta, and they suppose this is advantageous, inasmuch as it partly empties the placenta of its blood, and so helps to detach it. There is little or no fear, as some suppose, that this bleeding can be extensive enough to hurt the female, or second child if there be one, and even if it were likely to be so it could soon be stopped; it has the inconvenience however of soiling the bed more, and this is probably one great reason why the second ligature is applied, which certainly is notnecessary.
In my directions I have said that the cord may be tied about two inches from the abdomen, and this will be sufficient if the child breathes; but if not it should be left about four inches long, so as to give room to cut it again, which is occasionally needed, as will be seen further on. The knot should be drawn very tight, and great care must be taken never to tie it so near as to pinch the skin of the abdomen, which passes a little distance up it. A small portion of the intestine will enter the cord sometimes, and swell it out for an inch or more; this must be pressed back with the thumb and finger, and carefully avoided by the ligature. Some practitioners cut the cord first and tie it after, but I think the other plan is decidedly the safest and the best.
After this is accomplished the accoucheur should place his hand again over the fundus of the uterus, to discover whether it contracts, and also to judge whether there be another fœtus. If the womb is feltdrawn up intoa hard round ball, in the middle of the abdomen, all is right, and no apprehension need be felt; but if it remains unaltered in size, and is soft,floodingis to be feared, and the hand should be firmly pressed, or kneaded, over the fundus, to bring on contraction.
If there be another fœtus, the womb will remain much the same as before labor, and the child may also be felt. It is better however to make an examination internally, and then, in most cases, the membranes and presenting part of the second fœtus will be found at the upper strait. If there be any doubt after this it is even better to carry the hand a little way into the womb, than to remain in ignorance on such an important point. The delivery of the second fœtus usually follows close upon the first, though sometimes there will be a delay of some hours, or even days. And in general there is little or no difficulty with the second, owing to the parts having been already prepared; but the longer it is delayed the less easy it becomes.
Immediately the birth is fully effected the female feels, as most of them express it,in heaven; there is an almost instantaneous change, from the most agonizing pain to a state of perfect ease. She ceases her cries, and falls into a quiet and pleasing languor, strikingly at variance with the state of intense excitement she was in but a few moments before. This repose however, does not last long; the Placenta yet remains, and a new effort is required to expel that.
Unlike the Fœtus the Placenta is fast to the walls of the Womb, and can only become separated from them by the contraction of their substance, which usually commences soon after the birth of the child, and is indicated by new pains, and a slight discharge of blood. In about a quarter of an hour, or twenty minutes, the accoucheur should enquire of the patient whether she has felt any of these pains, and he should also examine whether the Placenta has reached the mouth of the Womb, or Vagina, so that he may remove it. If the pains have not yet come on, and the Placenta is not in the passage, he should press one hand on the fundus of the Womb, to promote its contraction still further, and then gently draw upon the cord with the other, holding it as high up as possible, either by a piece of linen around it, or by looping it around the finger. It should be pulled very gently, but steadily, downwards and backwards. If it be snatched, or drawn too hard, it may break, and cause great trouble; or it maypull down the Womb, and either invert it or bring on falling of the Womb afterwards. The hand placed over the fundus can detect this accident, and if the uterus be felt tosink downthe cord must not be drawn upon any longer. Pulling away the Placenta too soon, and with rudeness, has often led to deplorable accidents. In nearly every case it will gradually separate itself, and be delivered in about half an hour, and should only be assisted byslightdrawing on the cord, and by pressing the fundus.
When the Placenta is completely detached there is seldom any difficulty in its passing the neck of theWomb, and down the Vagina, but it usually requires to be drawn through the external opening by the hand. In doing this the membranes may be twisted round the cord, so as to wind them altogether, and strengthen the cord.
In case the separation does not take place we must wait, and continue the slight strain on the cord and the friction over the fundus. It is not reckoned safe however, by most authors, to wait more than an hour; and if there is no sign of its coming by that time artificial delivery is resorted to. This is accomplished by carrying the hand carefully up into the Womb, and separating the Placenta from its walls with the fingers, and then bringing it down at once.
When the afterbirth has passed the Vulva, a careful examination should be made of it, to see that no part is left behind; and for still greater security it is advisable to explore the Vagina thoroughly, so that any detached portion may be removed. The membranes are very apt to become broken, and fragments of them left, which though ever so small may cause trouble. The finger should also be passed into the mouth of the Womb, so as to clear it; for sometimes a large clot of blood, or a piece of the membranes, will remain and keep it open, and thus cause severe flooding.
It is generally considered, by those who have bestowed attention on the subject, that assistance should always be rendered, if the afterbirth does not come very soon. There is danger, if it be left too long, of the mouth of the Womb contracting and retaining it; in which case it becomes absolutely necessary to abstract it, but exceedingly difficult, and even dangerous, to do so. Dr. Lee says it should never beleft more thanan hourat most, and that it is best never to delay removing it even so long as that.
When left purposely, for observation, it is found to be expelled spontaneously, and soon, only in a few cases; usually it remains several hours, and most frequently it requires to be removed by hand. No doubt it isnaturalfor it to be expelled unaided, but it must be borne in mind that our females are usually too weak, and deficient in energy, to perform any unusual natural function without assistance. The accoucheur must use great caution, so as neither to intrude his help when not required, nor yet to refuse it when really needed; and above all he must not substituteviolenceforskill.
When the afterbirth is brought away, a bandage should be passed round the body of the female, made of soft linen, twelve or fourteen inches wide. It should be drawn moderately tight, and fastened securely. If it pass round twice it will be all the better, and it should be drawn down as near the pubes as possible. I know many ladies who prefer the India Rubber bands, recently invented, as they press more equally and firmly, and are put on with less trouble, being all in one piece and drawn over the feet and limbs.
Some accoucheurs put on the wrapper immediately the child is born, before the afterbirth passes away; but I think this is not the best plan. When properly adjusted, the supporting band gives great comfort to the female, and is very useful.
Some ladies provide a curious kind ofcorsetto put on, invented for the purpose, which however, as a celebrated author recently remarked, "Are usually stiff and unyielding, like the prejudices of their patrons, and often prove injurious." None of themare equal to the simple contrivances above-mentioned.
When the afterbirth is removed the patient should be left to repose herself for about a quarter of an hour, during which time most of the blood escapes, and then she must be made as comfortable as possible. In France, and with many persons here, it is customary to cleanse the patient with a sponge dipped in warm water, pass a clean warm sheet under her, and then put on clean linen, after which she is lifted into the clean bed, previously well warmed; the accoucheur himself carrying her there. Most frequently however, the sponging is dispensed with till some time after, and also the changing of beds—the under sheet merely being withdrawn, and a warm dry one passed in its place, while the female's limbs are gently wiped. In either case the female should be disturbed as little as possible, particularly if there be danger of flooding, and she should be carefully guarded from cold. When the soiled and wet clothes are removed, as completely as possible, warm napkins should be placed under the Pelvis and between the limbs, to soak up the discharge, and they should be carefully changed as often as needed, without uncovering the patient. If she be disposed to sleep however, and is much exhausted, these attentions need not be pressed too much till she is recovered a little.
Many persons here have a dread of using the sponge immediately, and of being carried to another bed; but there is no danger from either practice, inordinary cases, when carefully performed; and it is so productive ofcomfort, that I never knew one but what was pleased with and benefitted by it, and desirous of its being done in their subsequent labors.
Some females will even rise and take acold bath, or be wrapped in awet sheet, not only without evil effect but withpositive advantage. I would not advise any one to do this however,particularly if they are the least timid at it,or doubtful of its propriety. Without the mental stimulus offaithandhopeit may be hazardous. It shows however, that many of the popular notions, as to the requirements and susceptibilities of females, in this state, are entirely unfounded.
The patient may either experience great comfort after being thus attended to, or she may complain very much. Some will even be attacked with a kind of chill. Their teeth will chatter, and their hands and feet grow quite cold. This however usually passes off, and she falls asleep. The accoucheur ought to remain for an hour or two, even though she sleeps soundly, and appears quite well, because she may become suddenly worse, or flooding may set in with such violence as to endanger life in a few minutes, when unchecked.
If the patient desires any nourishment she may take a little simple soup, or gruel, but nothing stimulating, unless a little wine be needed from extreme exhaustion.
Inspection when born.—As soon as the child is born its mouth and nose should be cleared from mucus, if that has not been done already; and if it has not breathed, means should be resorted to immediatelyto make it do so. Sometimes the whole head is covered with a thin membrane, called thecaul, orveil, which is most probably only a portion of the Amnion, and which may cause suffocation. I remember a case of this kind in my own practice, in which the caul was unnoticed at first, and the child came near dying from it. Nothing could be seen, and as it bent before the finger, when pressed into the mouth, it was totally unobserved. The nurse however, called out that the child did not breathe, and a close examination as to the cause soon revealed why. On passing the finger under the edge of the membrane, which was round the neck, it came off like a cap, and the child cried immediately.
Washing the child.—The cleansing of the child may usually be safely committed to the nurse, or other female attendants, though some of them have very absurd and injurious practices in this respect. Thus I have known them rub the whole body over withwhiskey, orraw spirits, before washing it, which must cause great coldness from its evaporation, and also great irritation. The only thing required isperfect cleanliness, and this should be effected in thequickestandsimplestmanner. Some very mild soap, and moderately warm water, is all that is really needed, though a little sweet oil, or fresh lard, or butter, rubbed on first, appears to facilitate the operation. The drying should be done as quickly as possible, after all the mucus is washed off, and with great care; the napkin being as soft as it can be, and neverrubbedhard, for it takes but little force to remove the skin. Many persons take great trouble, and are a long time over this infantile wash without succeeding well with it. They are deceived by the tough mucus slipping under the hand, but still clingingto the body, where they leave it even after using the napkin; it then dries on and forms a hard skin, very difficult to remove, and very irritating. This can be avoided with care, and by using the oil first, which appears to soften the mucus. Some persons useflour, orIndian meal, and othersstarch, but none of these are so good as the simple means we have described.
Dressing the child.—After the washing and drying is completed the child must bedressed, and this is a process in which comfort and utility is frequently sacrificed to mere fashion and prejudice, as it is in adults. The article next the skin should be of soft line linen, which may be followed by others of warmer material, according to the temperature. They should all be perfectly loose in their make, and quite soft to the feel. As far as possible they should all be fastened withstrings, rather thanpins. These metallic points are troublesome to fix, and often injure the child, in spite of every precaution. They are also apt to be referred to as the cause of the child crying, and thus prevents other causes being sought for, which frequently exist.
Some people put a thick flannel cap on the head, over a linen one, but others leave this part altogether uncovered, which I think is the best plan. At most there should only be the linen covering; the head being better rather cool than otherwise.
The dressing of the cord is the next duty, and this is done by taking several pieces of soft linen, oiled a little, and cutting a small round hole in the middle of each, through which the cord is passed. The linen then lies flat on the abdomen of the child, and the cord on the top of that, the holes being just large enough for it to pass easily through. Five or sixpieces are usually put on, but very frequently only one is used, and is found quite sufficient. It should be very fine, and soft. When this is done another layer is laid over the cord, and then a bandage of soft linen, about four or five inches wide, is passed two or three times over it, and round the body. This completes the dressing, and the child may now be wrapped up warmly and laid down to sleep—remembering, as Dr. Chailly remarks, that if it be laid on a chair, or sofa, it may be accidentally sat upon and killed, an accident which has happened.
Before these dressings are needed however, there are frequently other things of more importance to be attended to. If the labor has been long, or the presentation unfavorable, the child may be bornapoplectic, from the pressure it has received. The face will be puffed up, and of a blue color; the body will be swollen, and the limbs without motion, while the pulsation will scarcely be felt, either over the child's heart or in the cord. It will feel warm, and the limbs will be quite flexible, but still there will be no signs of life. In this case it should be exposed naked to the cool air, and even blown upon; and if that does not resuscitate it the cord may be cut through below the ligature, so as to let out two or three tea-spoonfuls of blood. After this it generally revives, and begins to move, while its face assumes a natural color, and the swelling goes down. The mouth and throat should also be carefully cleaned with a quill feather, of all mucus.
A more frequent accident isAsphyxia, or want of breathing, in which case the surface of the body iscold and pale, and no breath whatever is drawn, though the heart beats quite naturally. Very weak children, or those born before their time, are most likely to become asphyxiated, or those delivered by instruments. The first thing to be done is to carry the child to the open window, if it be not exceedingly cold, and expose its head and chest to the air, while the rest of the body is wrapped up warm. This will often make it gasp, but if it does not a little cold water may be dashed on its face and chest, and the throat may be tickled with a feather. The breech may also be smartly slapped, and the chest well rubbed with the cold hand. When it begins to breathe a little it may be put into a warm bath up to the middle, and a warm injection may be given to it. In most cases these means will speedily bring it round, but if they do not the attendant should place his mouth close over that of the child and breathe into it, so as to fill the lungs, and then press down the chest to empty them again, repeating the process several times. This may be called artificial breathing, and if it succeed once only there is a probability of its effecting the desired object. The breath however, must not be blown in too hard, or it may injure the child's lungs, nor too rapidly. Sometimes a tube is used, which is passed down into the throat; but it is troublesome, and not much better than the mouth, if any at all. These efforts may be repeated twenty or thirty times if necessary, or even more. In some cases it is requisite to continue using some, or all of these means, for an hour or two without intermission, before the child begins to breathe freely. I knew an instance even, where the nurse continued to do so forfive hours, and at last fully recovered the child, though all present, including the doctor, hadgiven it up. She said she did not despair while it continuedwarm, though it was doubtful whether the heart beat or not. This may show that the attempt should not be abandoned too soon.
In cases of asphyxia no blood should be lost at all, but on the contrary the cord should be carefully examined to see if it is tied fast; the bleeding from it frequently aggravating the evil.
Congenital weakness.—Some children are born extremely weak, and remain constantly debilitated and cold. This is very apt to be the case when they are born before the full term, or when the mother is diseased. They should be carefully wrapped in cotton, or very soft flannel, and kept warm by bottles of warm water. Many instances are on record of these weak children becoming afterwards extremely robust, so that they need not be regarded with unmixed apprehension, nor neglected from a supposition that they must die.
The child may be deformed.—The accoucheur should also carefully examine the child, to see if it be deformed in any way, or has met with any accident, because in some of these cases assistance is required immediately, and may be rendered at once.
The child's capability of endurance.—The capability of the new-born infant to endure extremes of cold is almost as great as that of its mother, and sometimes even it is benefitted by them. With many persons it is customary to plunge it in cold water, immediately when born; and in Russia, we are told, it is evenrolled in the snow. In some cases these extremes may be beneficial, but in others I have no doubt they prove fatal. A medium course is best, in most instances, leaving the extreme to be resorted to when we wish a sudden stimulus.
When all these matters are carefully attended to, and both mother and child have remained for an hour or two without any unpleasant symptom, they may be left to the care of the ordinary attendants, giving them strict orders to send for proper assistanceimmediately, if anything unusual transpires.
The Bladder.—One of the most important points to attend to is the urine. A few hours after the delivery is fully effected, unless the female is reposing, she should be asked whether she has any desire to urinate; and, if she has, the convenience should be at once afforded to do so. There is always more or less danger of retention of urine, from the pressure that has been exerted on the bladder; and if it be allowed to continue too long its removal becomes exceedingly difficult. If on making the attempt the urine does not flow, the catheter must be used, and the sooner the better. The pain arising from retention of the urine has often been supposed to arise from inflammation of the womb, or bowels—neither patient nor physician knowing its real source, till the passage by the catheter gave relief. There have even been instances of females dying, merely from an overcharged bladder, while their attendants were industriously treating them for uterine inflammation. This accident therefore, should always be suspected, and a very little attention will prevent any mistake in regard to it. When allowed to become too full the swollen bladder may be felt, just above the pubes, hard and tender, so that the least pressure upon it causes great pain. If not relieved it will at last burst.
The Bowels.—If the bowels are not opened naturally, it will be well, the following day, to administer an injection of thin starch and water, or to prescribe a small dose of castor oil, or a seidlitz powder. This should also be repeated for two or three days, till the natural power is restored.
The Food.—But little solid food should be taken, and nothing stimulating. Gruel, milk, toast and water, Indian meal, light puddings, or broth, should be the chief articles for some time. Roast apples are also very good, being pleasant and relaxing. For refreshing drinks, if there be any fever, lemonade or tamarind tea may be taken.
The After Pains.—After the expulsion of the after-birth most females experience, more or less, severe pains, almost like those of labor, arising apparently from the further contraction of the uterine walls to expel the coagulated blood. These pains are seldom or never felt in first labors, but afterwards they are often most acute. I have known many patients suffermuch morefrom them than they did during labor. They sometimes last only a few hours, or a day, and sometimes even extend to six or eight days. Nothing that we know of can prevent them, though many means are known of mitigating their severity. If there be no tendency to flooding, a large poultice may be placed over the abdomen, or it may be fomented, or covered with cloths wrung out in hot water. An injection may also be used, either in the Vagina or Rectum, consisting of warm thin starch, with about twenty drops of laudanum; or either of the following recipes may be used internally:—Pills of Gum Camphor, two, about the size of ordinary pills, to be repeated, if necessary, in an hour.—Or,Syrup of Poppies, twodrachms;Mucilage of Gum Arabic, two ounces; andSolution of Sulphate of Morphia, ten drops; to be made into a mixture,one-halfof which may be taken at first, and the remainder intwo hours, if the patient is not relieved. This seldom fails.—It is necessary to bear in mind that the pains arising frominflammationhave been mistaken for ordinary after-pains, and serious consequences have resulted from the error. The after-pains however, are concentrated, andintermittent, while the sensations from inflammation are more diffused and constant, and are also usually attended by fever.
The Lochial Discharge.—From the time of delivery until the uterus has returned to its ordinary condition, there is poured from it a discharge, at first like blood, and afterwards thin and light colored, called theLochia. The duration of this discharge varies from one week to a month, and its quantity from one ounce to six or eight ounces, daily. It gradually diminishes however, and frequently stops for a few days altogether. In women who do not nurse it is both more abundant, and lasts longer, than in those who do. The bloody color usually disappears after the first or second day, though sometimes it will show itself again, even when the discharge has nearly ceased, particularly if the female exert herself too soon.
It appears that this discharge is essential to health, and great attention should therefore be bestowed on the patient, if it be too small, or cease too soon, or too suddenly. In most cases it ceases naturally during themilk fever, and of course its disappearance then need not excite alarm. Sometimes also, it does not attain its full quantity till some days after its commencement. If however, it remains small past thethirdday, or does not appear when the milk fever is over, means should be taken for increasing it. The best means for this purpose arewarm poulticesandfomentationsover the abdomen, and injections in the rectum of simple warm water. Some practitioners advisetwo drachms of powdered Camphorto be sprinkled on each poultice, and probably it is an excellent addition. Occasionally the lochia is very offensive, and in that case a simple cleansing injection may be frequently used of thin starch, or Chammomile tea.
During the whole period of the Lochia in fact, even in ordinary cases, the female will be all the more comfortable, and better, for an occasional injection, and frequent washing. This is very much neglected, though it never ought to be so. The only care required is not to expose her to cold, which is quite unnecessary.
The Milk Fever.—About the second or third day there usually commences a peculiar temporary excitement in the system, called themilk fever, which requires to be described because it may be confounded with something more serious. It is generally ushered in by headache, flushed face, and a hot dry skin; the pulse beats slowly, and the breasts become hard, while the veins upon them appear very full. In a short time however, the pulse becomes quicker, a perspiration breaks out, and the breasts become still larger and fuller, so that the female can scarcely bring her arms to her body. These symptoms last about a day, or two days at most, and seldom become much aggravated.
Occasionally the milk fever is preceded by a slight chill, or by a furred tongue, or sick stomach, but not very frequently.
The precise causes of this temporary fever are unknown, though probably it is connected with the full establishment of the secretion of milk, and hence its name. It is seldom very severe in those who nurse, and frequently does not appear at all. During its continuance, and for some time after, the female must carefully avoid exposure to cold, and keep herself quiet; her diet should also be rather restricted, and light and unstimulating. An occasional seidlitz powder may also be of service, or a simple injection.
Making the Bed.—It is not customary to disturb the female, for the purpose of making her bed, till the milk fever is passed; or, if that does not appear, till the tenth or twelfth day; and then it should be done with care, and so as not to expose her unnecessarily.
First sitting up, and Going out.—This must of course be determined more by the condition of the patient, and the state of the weather, than by any rules. It may be as well to remark however, no matter how the patient mayfeel, that thefirst attemptshould always be made with care. Very frequently she thinks herself stronger, and more capable, than she really is, and premature or undue exertion may do great injury. In most cases the female is allowed to rise within the first week, and sit for a short time in an arm chair; after which she begins to walk slowly about the room. The first going out is fixed,by fashion, at one month. Many females however, are unfit to leave the house till long after that time, and others should by no means be confined to itso long. Of course these proceedings should depend, as already remarked, upon the patient's strength and inclinations, and upon the stateof the weather, and not upon any fashionable observances. Some females are quite able to rise, and even walk out, in a few days, with benefit to themselves; and it exhibits as great a want of correct feeling, or common sense, for any one to make disparaging remarks on them for their early appearance, as it would if they were to blame the poor invalid for keeping her bed.
The apartment should be kept constantlywell ventilated, particularly if the female is confined to it, and all soiled linen, or other sources of foul air, should be removed as quickly as possible. There is reason to believe that inattention to this, and to properly cleansing thepersonof the female, frequently produceschild-bed fever.
Attentions to the Child.—If the infant's bowels are not opened by the end of the first day it should have a little sugar, or molasses and water, given to it, and if this does not succeed about half a tea-spoonful of syrup of Rhubarb may be added. This is however but seldom needed, if it be put to the breast within a few hours, as the first secretion of the milk possesses sufficient laxative power itself. It should also be observed whether it has urinated, and if not it should be placed in a warm bath immediately.
Some persons prefer to let the child wait till the milk fever is established, before they let it nurse, but this is very improper. The early feeding does it no good, and the purgatives it requires are injurious. As soon as the female is sufficiently reposed, if there is nothing special to forbid it, the child should go to the breast.
Sometimes the child will remain sleepy and dull, and not seem to require food at all, for several days, and even die at last of starvation, unless aroused.If this lethargy continues it should be put in a warm bath, and afterwards well rubbed, while a little sugar and water is poured down its throat. These attentions may be required to be repeated for some time.
About the fourth or fifth day the portion of the cord above the knot usually separates and falls off, if it has not already done so. If the navel is inflamed, or suppurates, a little simple ointment may be rubbed on, and it should be regularly and carefully washed. In some infants it swells out very much, in which case a pad should be made of soft linen, and laid upon it, over which the ordinary bandage may be drawn. The complete healing of the part does not occur till about the twelfth day, and the bandage must be carefully worn till then at least, and is better continued a little longer, particularly if there is any swelling, or if the child cries much, or strains.
From the explanations given above of an ordinary natural labor, it will be evident that but little manual assistance is required, either to the mother or the child, and also what really is called for is of so simple a character as to be easily rendered. It would undoubtedly be improper, and cruel, to leave females at such times without aid altogether; but it is also equally improper and injurious to interfere too much. Excepting in cases of disease and deformity, or of very unfavorable presentations of the fœtus, Nature herself will nearly always effect the delivery; and much better, in most cases, when left to herself. Numerous females and infants have beenkilled, and still more have been grievously injured for life, byrude and uncalled for manipulations; so that it has been a question with some accoucheurs, of great experience, whether as many would die, or seriously suffer, from receivingno assistance, as do now from being improperly handled. Without going so far, it is undoubtedly true that great mischief is done in this way, which can only be prevented by both accoucheur and patient bearing in mind thatNature herself is usually competent, and at most only requires skillful and gentleassistance. Some practitioners seem to think that labor is a meremechanicalprocess, like the removal of a block of stone, and hence they depend altogether uponforce; overlooking altogether the wonderful vital powers inherent in the system, which operate with such certainty, and yet so safely; and which frequently succeed of themselves when brute force is completely foiled.
The nature of the assistance proper to be given, in any particular stage of labor, will be evident on inspecting the structure of those parts, of both mother and child, which are brought in connection at the time, and by considering how their mutual relations require to be changed and modified. If those relations are already such as are required, and the system retains sufficient force, nothingcanbe done with any advantage—we mustwait, and let Nature operate herself. Even many unfavorable conditions may be spontaneously corrected, and it should always be a matter of consideration, when the means of assistance are not very obvious, whether it will not be better to rely upon the natural powers than to interfere. Great evil has resulted from teaching females that laborcannotterminate, safely, without a great deal of assistance, which can only be rendered properly by those who possess a vast amountof skill and experience. They are thus led to think themselves totally dependent upon the accoucheur, and many of them actually seem to believe that he is as necessary to deliver the child as a dentist is to extract a bad tooth. If they were better informed they would feel more confidence in their own natural powers, and would not be so unnecessarily alarmed when unforeseen difficulties occur, or when professional aid cannot be immediately procured.
In most cases there is more dangerafter the labor is over, frompuerperal fever, various local inflammations and other causes, than there was during its progress. Indeed the real danger may be said properly to commence several days after, and the physician is really needed then more than at the time.