taining the flexion of the head by the left hand, with the right
he presses the head backward until a pain has ceased, and then at
a favorable opportunity, having tested the elasticity of the peri-
neum by allowing it to move back and forth under the right hand
as the head descends, he slips it back over the head, allowing the
head to be born between the pains.



THE TREATMENT OF NORMAL LABOR.



8l



FIG. 46.



The nurse should have ready a solution of boracic acid and
glycerine, with small bits of old linen, and as soon as the head is
born, the eyes and mouth of the child should be cleansed with
this material. During the brief pause which occurs between the
expulsion of the head and the shoulders, the patient should be
allowed to rouse partially from the anaesthesia, although the vigil-
ance of the physician should be in no way relaxed. His left
hand should grasp the neck of the child, bending the child's
trunk by a lateral flexion so that the presenting shoulder, usually

the lower, is prevented from
ploughing downward into the
perineum. The right hand should
still support the pelvic floor, and
thus the delivery of the shoulders
be managed upon the same prin-
ciples applied to the birth of the
head. The shoulders born, the
anaesthetic should be entirely sus-
pended, and upon the expulsion
of the child the nurse or physi-
cian should place a hand upon
the fundus of the uterus, while
the child is allowed to lie upon
its right side until the pulsation
EPISIOTOMY. of the cord has ceased. A tem-

The dotted line on the patient's right shows ligature may then be

the line of incision. The dark oval shows f*"""*.J t

the amount of dilatation gained by thrown about the COrd three fing-

episiotomy on both sides.

ers" breadth from the umbilicus.

If the child is asphyxiated, and haste is imperative, the cord may
be clamped by the haemostatic forceps, and cut without ligation.




The child, when
separated from the
mother, is wrapped
by the nurse, pre-
ferably in a woolen



FIG. 47.



EPISIOTOMY KNIFE DEVISED BY THE WRITER.
blanket, and when its respiration has been observed to be normal,



82 MANUAL OF PRACTICAL OBSTETRICS.

it is placed aside until the time for its first bath (Figs. 46 and 47).
In cases of excessive distention of the perineum, serious rup-
ture may often be prevented by the simple procedure of episiot-
omy. This is effected by introducing a blunt-pointed bistoury,
or a blade of a pair of blunt-pointed scissors, between the head
and the edge of the vulva at the junction of the upper two-thirds
with the lower third. The extent of such an incision will de-
pend upon the degree of distention; but, ordinarily speaking,
from an inch to an inch and a half may be incised without dan-
ger. The blade of the knife should be turned up against the
edge of the vulva at the occurrence of a pain, when the tissues
will separate, and the perineum can often be observed to retract
to a remarkable extent over the presenting part. After delivery,
these incisions should be stitched with fine catgut, plentifully
powdered with boracic acid, aristol or iodoform, when, as a rule,
they heal promptly. The serre-fine has been used in place of the
suture with success.



CHAPTER XII.



FIG. 48.



THE THIRD STAGE OF LABOR.

WITHOUT narrating the many theories which have been formed
regarding the separation and expulsion of the placenta, it seems
in the present state of our knowledge to be the fact that the
placenta separates from the wall of the uterus by the intervention
of a clot (Fig. 48). It is expelled
from the uterus by the contractions
of that organ, and especially by those
of the abdominal muscles. The time
normally occupied for the accom-
plishment of this is sufficient, first,
to allow partial separation and the
formation of a clot to occur ; and,
second, to give the patient sufficient
interval in which to recover con-
sciousness, if she has been anaesthet-
ized, and to regain control of the
diaphragm and abdominal muscles.
When labor is accomplished with-
out putting the patient entirely to
sleep at the moment of birth, the
placenta may follow within ten or
fifteen minutes after the expulsion
of the child. When, however, the THE PLACENTA AND MEMBRANES,
patient is exhausted or has been After the expuUion of the foetus,
anaesthetized, from half an hour

to an hour may elapse before uterine contractions bring about the
expulsion of the placenta (Fig. 48).

The question as to whether active interference is demanded
must be determined by the presence or absence of hemorrhage

83




8 4



MANUAL OF PRACTICAL OBSTETRICS.



FIG. 49.



and the consistence of the uterus as felt through the abdominal
wall. If the uterus remains moderately firm, and there be no
hemorrhage, the practitioner should wait, if the labor has been
normal, until the patient has had from twenty minutes to half an
hour's rest, and is able to make voluntary expulsive efforts. The
left hand should then be placed upon the fundus of the uterus,
and that organ roused to contract by gentle friction with accom-
panying pressure in the axis of the pelvis. The right hand of
the physician, having been freshly cleansed and antisepticized,

should examine to ascertain the
descent of the placenta. Usually
a few vigorous contractions of
the uterus and abdominal muscles
will bring the edge of the pla-
centa at the vulva within easy
grasp by the physician. He
should then fold it together with
the thumb and fingers, and by a
gentle rotary motion it will be
felt to slip easily away, the mem-
branes following it in a twisted
cord. The nurse should hold a
suitable receptacle between the
patient's thighs, and thus the
placenta may be transferred with-
out exposure and with but little
soiling of the bed, and reserved
THE ABDOMEN AFTER THE FCETUS is f future examination (Figs. 50
BORN.




The placenta in the uterus.



and 51).

The attention of the physician
should next be directed to the firmness or laxity of the uterus.
In healthy, young primiparae, the mechanism of the closure of the
uterine sinuses is amply sufficient to guard against hemorrhage ;
but where repeated labors have weakened the uterus, or where it
has been relaxed by protracted or abnormal labors, it is the part
of caution to administer a teaspoonful of the Fluid Extract of Er-



THE THIRD STAGE OF LABOR. 85

got. In some cases five grains of quinine will act more efficiently
than ergot. In severe cases where the effect of the drug must be
obtained at once, it may be injected into the walls of the abdo-
men in doses of thirty minims. The patient should now be left
in charge of the nurse to be properly cleansed.

FIG. 50. FIG. 51.




THE EXPULSION OF THE PLACENTA, THE PLACENTA IN THE LOWER
FCETAL SURFACE FIRST. UTERINE SEGMENT.

The physician will have had opportunities during the progress
of labor to be aware of the presence or absence of lacerations of
the pelvic floor; if he is not satisfied as to their existence and
their extent, he will do well, before leaving his patient, to exam-
ine thoroughly, and should sufficient laceration be found, and



86 MANUAL OF PRACTICAL OBSTETRICS.

the condition of the patient permit, it should be closed at once.
The question as to just what extent of median laceration of the
perineum demands suture is a difficult one to answer. The sani-
tary regulations of some of the countries where midwives prac-
tice extensively under license require them to summon a physi-
cian to close a laceration of more than one-half or three-fourths
of an inch. In hospital practice it is safe to say that all lacera-
tions except those of the posterior commissure should be closed
by sutures. Abrasions of the mucous membrane or stellate tears
in the mucous membrane of the vagina should be heavily pow-
dered with a suitable antiseptic substance. In hospital practice,
iodoform is best; in private practice where the odor of iodoform
is so objectionable, powdered boracic acid or aristol may be
employed to advantage. It will not infrequently be found that
instead of a laceration of the perineum, the mucous membrane
of the vagina may have been dissected up from the sub-mucous
tissue for two or three inches at one side. If it can be done
without too much suffering and inconvenience, it is well to close
such a laceration.

The immediate closure of perineal injuries of slight extent is com-
paratively a simple matter. Curved needles, needle-holder and a
pair of dissecting forceps, and a good quality of antisepticized silk
will usually be sufficient. Silver wire is preferred by some, and
the over and over stitch with catgut by others, but, as a rule, the
average practitioner will do better with silk than with any other
material. The principle of closure consists in simply bringing
together lacerated surfaces, remembering that the stitch should
go sufficiently deep to bring the wound together from the bottom.
As to the time for the performance of this slight operation, if the
patient and the physician be exhausted, if the light be poor, and
the conditions unfavorable for closing a lacerated perineum,
where labor has occurred during the night, it is well to wait four
or eight or even twelve hours until the patient has become some-
what rested, and the physician can perform his duty under favor-
able circumstances. A great advantage in immediate closure is
found in the fact that the tissues are less sensitive to pain than



THE THIRD STAGE OF LABOR. 87

usual, but a mild degree of anaesthesia will relieve the patient of
suffering if the operation be deferred.

It is almost needless to say that the strictest antiseptic precau-
tions should be observed in all cases of labor. After a normal
labor the patient should be given one vaginal douche of bi-chloride
of mercury, one to five thousand. Further douches are superfluous
and often injurious, unless complications arise. If, however, the
patient has been lacerated and stitches have been inserted, she
should have two and possibly three vaginal douches, in twenty-four
hours, of bi-chloride of mercury one to five or eight thousand,
creolin one per cent., carbolic acid two per cent., thymol one to
two thousand, or a saturated solution of boracic acid. After the
douche, the parts should be powdered well with iodoform or
boracic acid.

After attending to the mother, the physician should examine
the placenta and the membranes to assure himself that no part of
them has been left within the uterus. He may also note any
peculiarity about the placenta in form, size, weight, or the pres-
ence or absence of calcareous or fatty degeneration which may
be present. The child should also claim his attention, and he
may, at his leisure, grasping the cord at the umbilicus with the
thumb and finger of the right hand and cutting it freshly at the
ligature, strip or squeeze the cord from the umbilicus outward. A
cord which is not rich in Wharton's jelly may not need stripping,
but in all cases where the cord is large this procedure should be
attempted. A convenient and useful method of dressing the cord
is to powder it with salicylic acid one part, and starch five. It is
then enveloped in absorbent cotton and placed upon the child's
body, pressing gently against the trunk on one side of the um-
bilicus. A knit or flannel binder is then applied after the bath of
the child, and the cord is thus protected from violence.



CHAPTER XIII.

THE TREATMENT OF ABNORMAL LABORS, THE HEAD PRESENTING.

THE treatment of abnormal labors in head presentations must
be directed to secure the conditions requisite for a normal mech-
anism of labor. These conditions are sufficient expulsive force
on the side of the mother, the resistance of the pelvic floor, and
the flexed position of the head.

As regards failure of the mother's expulsive forces the most com-
mon example is lingering labor from weak pains. Delay from this
cause is most often seen in poorly developed, neurotic primiparse,
in old primiparae where the birth canal is not easily dilated, and in
multipart where the uterine and abdominal muscles have been so
often distended that they have lost their elasticity and contractile
power. The cessation of expulsive efforts, before the membranes
rupture, is attended with little danger to the mother and none to
the child. After the membranes rupture, both are in danger from
protracted labor. The complete cessation of expulsive efforts after
rupture of the membranes should give rise to the suspicion that
the foetus and the birth canal, in a head presentation, are dispro-
portionate. It cannot be too strongly urged that only a prelim-
inary examination by pelvimetry, palpation and auscultation can
enable an obstetrician to rationally conduct a case of even nor-
mal labor. When by such examination the pelvis has been
found normal, the position and presentation are occipito-anterior,
either left or right, and the head has engaged favorably, thus
showing a normal proportion in the size of the foetus and birth
canal, failure of the expulsive forces before the membranes rup-
ture is to be treated by anodynes and sedatives to secure rest ; by
emptying bladder and rectum; by small quantities of easily di-
gested food, and by allowing the patient to assume such postures
as conduce most to her comfort. Occasionally toughness of the
88



THE TREATMENT OF ABNORMAL LABORS. 89

membranes delays labor, when the obstetrician must rupture
them ; but as a rule the membranes should be left to rupture
spontaneously.

During the second stage of labor in these cases, failure of ex-
pulsive efforts is to be treated first by posture By turning the
patient on that side to which the presenting part is pointing, and
flexing her thighs, descent and rotation will be facilitated. In
addition, the uterine and abdominal muscles may be stimulated
by friction. This is best done by commencing to rub the abdo-
men and gently knead the uterus when a pain begins, increasing
the rate and vigor of manipulation as the pain advances. As the
pain reaches its acme, pressure may be made in the axis of the
pelvis and continued until uterine contraction abates. Drugs
which experience has shown may be safely employed to stimu-
late expulsive efforts are the diffusible stimulants, as alcohol, tea
and coffee, and quinine. The last is advantageously given in
capsules containing three grains of quinine and one or two grains
of scale pepsin, a combination which does not usually excite the
nausea so often seen at this time. The mother's expulsive efforts
may be stimulated and encouraged by her cooperation, in fixing the
diaphragm and bringing the necessary expulsive muscles into play,
by pulling upon a sheet tied at the foot of the bed, or grasping the
hand of an attendant. Whenever the sensation of pain is so acute
as to inhibit expulsive muscular action, an anaesthetic in small
doses will allow the reflex mechanism of labor to proceed success-
fully. At the beginning of a pain the patient should be allowed
to smell of the anaesthetic; at the height of the pain she may ex-
perience its effects sufficiently to enable her to sleep for a few
minutes when the pain has passed. In this way action and re-
pose alternate, and progress continues.

An abnormal position of the head will be usually discovered
when the membranes rupture, as the obstetrician should then
thoroughly examine the patient. It can best be remedied by
the insertion of the antisepticized hand, aided by the administra-
tion of an anaesthetic. In face presentation extension is to be
sought. If the physician detects, early in labor, that the occiput

4*



90 MANUAL OF PRACTICAL OBSTETRICS.

is turned posteriorly, he will do well, before the membranes rup-
ture, to place the patient upon the side toward which the occiput
is pointing. By so doing, the fundus of the uterus is allowed to
incline toward that side, and the rotation of the presenting part
is favored by bringing the foetus more perfectly into the axis of
the birth-canal. As the head descends the hand may be used to
push up the forehead and favor flexion. The expulsive forces of
the mother should be conserved by the administration of tonics
or stimulants, and should these forces fail the forceps is indi-
cated. It must be remembered that labor, when the head turns
posteriorly, is usually longer and more painful than normally,
but it should also be borne in mind that nearly nine tenths of
these cases terminate spontaneously with an anterior rotation of
the occiput.

When the occiput turns into the hollow of the sacrum, great
caution is needed in attempting to complete delivery. A choice
lies between the forceps and craniotomy, and should the child
have perished, the latter, in skilful hands, is the better of the two
procedures. The method of applying the forceps in these cases
will be described under the general consideration of the use of
this instrument.

The treatment of brow presentations consists in the endeavor
with the antisepticized hand to convert a brow into an occipital
presentation, with craniotomy should impaction and foetal death
occur. Version in the early stages of labor, when dilatation is
complete, is also indicated in brow presentation, when the pelvis
is normal and the foetus proportionate in size.

Face presentations must be treated by securing as complete ex-
tension as possible, by retaining the membranes unruptured to
the latest moment, and occasionally, by the use of the forceps.
When the head is turned transversely at the brim of the pelvis,
causing the presentation of a parietal bone, the case demands
most cautious treatment, and will be considered under the head
of The Treatment of Labor in Contracted Pelves.



CHAPTER XIV.

THE FORCEPS.

A FREQUENT complication in labor, when the head is presenting,
is failure of the mother's expulsive power, necessitating instru-
mental delivery. In the early days of obstetric science, such
cases invariably terminated by the death of the child, and its
mutilation and extraction by sharp hooks. When, however, the
idea of blunting these hooks and converting them into a harm-
less tractor arose, the forceps was invented.

Its model was doubtless suggested by the shape of the hand
about to grasp a round object like the head. It consists of two
blades, named in accordance with the sides of the pelvis nearest
which they lie, the left and the right. Each blade is composed
of an expanded portion for grasping the head, an intermediate
portion bearing some device for fastening the two blades together,
and two handles, one at the extremity of each blade. The ex-
panded portion for grasping the head resembles the hand ren-
dered concave by flexion. This concavity gives to this portion
of the forceps blade a curve called the Cephalic Curve, because it
is intended to favor the approximation of the instrument to the
head. From the tip of the expanded or head portion of the for-
ceps blade to the handle the entire blade describes a curve some-
what resembling the axis of the pelvis. This is called the Pelvic
Curve of the forceps.

In the centre of the cephalic portion of the forceps blade is an
ovoid aperture called the Fenestra of the blade. The device for
fastening the forceps blades together, called the lock, consists in
some instruments of a large screw with thumb-piece by which the
upper can be fastened firmly to the lower blade ; in others of a
button-like knob placed upon the lower blade, while a niche in
the upper blade receives the stem of the button when the blades



92 MANUAL OF PRACTICAL OBSTETRICS.

are brought together ; the lock may also consist of a loosely fit-
ting joint formed by a niche in the lotver blade receiving a loose-
ly fitting ledge upon the upper. The lock most frequently in use
is the last, which is exemplified in the Simpson forceps. The
material of which the forceps is made is tempered steel, plated
with nickle ; the handles are often of hard rubber, darkly stained
wood, and, occasionally, of metal entirely, the purpose of the
last being to avoid a corrugation which in wooden handles may
give lodgment to septic material.

Forceps are divided commonly into long and short, the long
being, as the name implies, several inches greater in length than
the short forceps. The various modifications of this instrument

FIG. 52.




DAVIS FORCEPS, PERFORATED FOR Axis TRACTION TAPES.

are so many that only those most in use will be mentioned, and
especially those whose merits have been proven by personal ex-
perience. Forceps may be divided into two classes as construct-
ed with direct reference to the manner of application. For ex-
ample, the Simpson forceps, one of the most commonly used, is
constructed to be applied to the sides of the pelvis without re-
gard to the rotated or unrotated condition of the head. On the
other hand, the Davis forceps was shaped to be applied to the
sides of the child's head. Various other instruments are inter-
mediate in construction, but each is made with some reference to
this manner of application (Fig. 52).

The indications for the use of the forceps are, danger to the
life of the mother or child, or both, arising through delay in
labor. Occasionally, in precipitate labor, the head may be so



THE FORCEPS.



93



grasped and its progress controlled by the forceps as to render the
birth a normal one so far as the rate at which the child is ex-
pelled is concerned. While the forceps has powers as a lever,
compressor and rotator, yet these are secondary and accidental,
and its chief and important function is that of a tractor.

The conditions under which the forceps may be safely applied
are a vertex presentation, very rarely a presentation of the breech
or face. The size of the child should be proportionate to that of
the birth-canal of the mother, the folly of attempting to drag a large
head through a small pelvis being self-evident. The birth-canal
must be dilated, and the foetal membranes must have ruptured.

The dangers attending the use of forceps are laceration of the
maternal tissues, laceration of the child's scalp, compression
and injury of the child's brain, and the increased risk of septic
infection accompanying the use of instruments. Although this
instrument, improperly used, is one of the most dangerous to
mother and child, yet its proper employment, under antiseptic
precautions, does not increase the mortality and morbidity of labor
beyond a very slight extent.

The first and simplest complication of labor for which the
forceps may be employed occurs when the vertex presents ; rota-
tion has occurred ; the head has descended to the pelvic floor, but
the mother's expulsive forces failing, the life of the child is
threatened through asphyxia, and the mother's tissues are in danger
through pressure, while her strength is well-nigh exhausted. The
application of the forceps under such circumstances is known as
the Low-application or Low-forceps-operation, because the head
is resting upon the pelvic floor when the instrument is applied.
Danger to the foetus in such a case is recognized by weakness of
the foetal heart, with rapid beating, and sometimes a much dimin-
ished frequency in cardiac action. Danger to the mother in such
a case can be diagnosticated by her exhausted condition, rise in her
temperature, rapidity of her pulse-rate, and a dry and swollen
condition of the birth-canal. A careful physician, however, will
not wait until the conditions mentioned are present in the birth-
canal, but will interfere when the other indications exist.



94 MANUAL OF PRACTICAL OBSTETRICS.

To apply the forceps, the patient is placed upon her back across
a bed, her hips brought to the edge of the bed, and her feet in
chairs. An antiseptic douche should be given before the appli-
cation of the instrument, and the physician should be sure that
the bladder and rectum are empty. In primiparae an anaesthetic
should always be administered ; in multiparae it is sometimes
possible to avoid anaesthetizing the patient. The physician should
prepare his instrument by dipping it in hot water, washing it
carefully in soap and hot water, rinsing it thoroughly ; the forceps
should then be placed conveniently in a pitcher of a hot anti-
septic solution, creolin two per cent., carbolic acid two and a half
per cent., being convenient. The instrument may be lubricated
by slightly smearing the outer surface with some antiseptic oint-
ment, or with carbolized oil. The physician should then place
himself directly opposite his patient, so that he can appreciate
any deviation from the central line of her body. The left blade