be so free as to amount to a discharge resembling leucor-
rhea, or whites. This symptom is indicative of a relaxa-
tion of the parts, which will facilitate the escape of the
child's head and make labor more easy.



THE SYMPTOMS OF ACTUAL LABOR. 483

A material mental change may be observed, which is
another symptom of the approach of labor. There is a
general feeling of restlessness, as if something were
wanting, or some awful calamity were to befall her. This
is a very distressing feeling, and may last for several
days.

The Symptoms of Actual Labor.

The first symptom of actual labor is pain. The
patient may be roused out of a sound sleep by a pain
more or less severe, which she may not at first be able to
locate. She may attribute it to an irregular action of the
bowels or kidneys, and feel as if the use of the chamber is
what she needs. I recall two instances of this kind where
the patients did not live over a stone's cast from my office.
Neither of the women were able to return to bed, the
uterus disloading itself with apparently a single contrac-
tion. Such labors are amazingly easy. Early in the
history of labor there is what is called the " show," which
is the discharge of the plug of mucus that occupies the
neck of the womb up to this time. This mucus is
frequently tinged with blood. The pain appears gradually
at intervals in the lower part of the abdomen, at first a
little like stomach-ache, but gradually increasing in power
and frequency. Later, when the head reaches the pelvis, the
pain reaches the lower part of the back-bone. There is a
feeling of increased weight and fullness, with marked irri-
tation of the bladder and rectum, and a constant desire to
go to stool or urinate. This depends partly on pressure



484 MAIDENHOOD AND MOTHERHOOD.

and partly on sympathy, and ceases as soon as the mouth
of the womb is fully dilated. Nausea and vomiting are
also often present at this stage of labor. " A sick labor "
is said to be an easy one. Tremors and shivering also
often accompany and are largely sympathetic. They are
not connected with cold nor headache. The face is pale
and cold. An author says that, " during labor, the entire
organism stands in solemn awe to view the performance,
and all the organs send responsive greetings to the uterus
in its parturient throes. " The depression is physical and
mental, especially in the first stage of labor. Women
generally say that .it is impossible for them to survive.
They imagine that nothing is accomplished by their suffer-
ing during the first stage, and usually complain more during
the first than the second stage of labor. The mental
depression and irritability are as much the symptoms of
the first stage as are the physical signs. The flow of
mucus and blood increases ; there should be just enough
blood to color the mucus pink. A teaspoonful of blood is
alarming. The " show " is a certain sign of progress. The
pain in the first stage of labor is described by women as a
cutting, grinding pain. The patient feels as though some
internal organ or part were being rent or torn asunder.
When the pain comes on, the woman ceases her employ-
ment of walking, talking, etc., bends over, and a peculiar
expression of pain comes over her face. When the pain
goes off, she resumes her former employment. The effect
of these pains is to dilate the mouth of the uterus. The
pain is always characteristic of this stage of labor. During



THE SYMPTOMS OF ACTUAL LABOR. 485

the second stage of labor, the sound made by the patient
is of a straining, grunting character. The first stage of
labor is long and uncertain, lasting from two or three hours
to as many days. The duration of the first stage may
differ in the same women. In some women there is
a soft, moist, insensitive, and dilated or dilatable os.
This indicates an easy labor. In others it is dry,
sensitive and rigid. This indicates a tedious labor. What
is meant by dilation of the os? Simply a relaxation and
softening of the mouth of the womb sufficient to let the
child pass through it. This condition is assisted very much
by the contraction of the uterus, forcing down into the
mouth of the womb a membraneous sack filled with water
(called the liquor amnii), which acts as a wedge, holding
open the os between the paroxysms of pain. The rapidity
of the dilatation of the os is not uniform. It generally
takes longer to dilate it sufficiently to admit two fingers
than to accomplish sufficient dilatation to permit the
passage of the child. Perhaps, as labor progresses, the
water-bag-wedge obtains more power to 'overcome the
contraction of the sphincter muscles of the os. Women
with their first child usually suffer greater and longer pain
in the dilatation of the os than they do with the birth that
is to occur afterward. The bag of waters is the prede-
cessor of the child, and, I have said, stretches the passage
for it. This bag supplies the place of a cushion of warm
water, and by it the head of the child and its cord are
saved from all undue compression. No matter how long
the first stage of labor, if the bag of water be intact, the



486 MAIDENHOOD AND MOTHERHOOD.

child is safe. If the bag be prematurely ruptured, the
labor is prolonged, and may prove fatal to the child. It
sometimes happens that the membranes are ruptured, and
the water escapes slowly for days and even weeks before
labor sets in. It is then called " a dry birth." Such
cases are always protracted, and labor more difficult.
When a pain comes, the walls of the uterus contract, the
edges of the os become tense, and the bag of waters
bulges. Then the pain ceases and the os becomes flaccid.
The waters recede, and the presenting portion of the
child can be felt through the bag. Thus the bag of
waters goes on bulging and retracting till it bursts, and
from one to three pints of liquor amnii escape. Occa-
sionally, where there is but little water in front, the head
may act as a cork, and the water remains behind the
child during the second stage. In a typical case, how-
ever, the bag of waters bursts, the fluid escapes, the head
comes down, and the first stage of labor ends at the same
time. But this by no means always happens. When
the membranes are thin and the tissues tough, the first
symptom of labor may be the bursting of the bag of
waters. In a first confinement it is desirable to have
the membranes protrude beyond the vulva. The burst-
ing of the bag of waters may alarm a woman with her
first child. It sometimes happens that the bag of waters
does not rupture until after the head is born. There
was a vulgar opinion entertained that a child born in this
condition would neither be hung nor drowned.

With membranes ruptured, the liquor amnii escaping



THE SYMPTOMS OF ACTUAL LABOR. 487

and the head down in the pelvis, the first stage of labor
closes. After the rupture of the water-bag there is a lull
of the pain fora few minutes. Then the pain is increased,
and the woman begins to "bear down." The bearing
down is involuntary, to a large extent. She braces her
feet and wants to pull with her hands. She takes in a full
inspiration, fixes her abdominal muscles and diaphragm,
and strains ; her face becomes red, her jugulars swell and
her carotids beat. These efforts are also impulses of
nature. When the straining ceases, the breath is at first
rapid, then a calm ensues. It is dangerous for a woman
with lung disease or heart disease to strain much, as hem-
orrhage from the lungs or into the brain may result. Such
women may better be delivered by forceps. Further and
further the head advances ; the pains and straining
increase. The head at length reaches the floor of the
pelvis, and presses on the sciatic nerve, and this pressure
may produce a severe cramp in the legs, which is fre-
quently the cause of intense suffering, and may call for
delivery by the forceps. Further and further the head
advances ; it sweeps through the hollow of the sacrum,
emptying both the bladder and rectum by its pressure
upon them ; it presses the coccyx or lower end of the os
sacrum, the anus projects, the perineum bulges, the labta
are stretched, and the head is seen at the mouth of the
vulva. When a pain comes on the head advances. The
pain goes off and the head recedes. It seems as if every
pain would accomplish the delivery, while, in a primipara,
it may require one or two hours more. In a first delivery,



488 MAIDENHOOD AND MOTHERHOOD.

when the head seems about to be delivered, a pain goes
off, the head recedes almost out of sight, the perineum
ceases to bulge, the coccyx returns to its normal position,
and it seems as though there must have been a rupture
of the uterus, the child escaping into the abdominal
cavity. This, however, is not the case, for this is
one of Nature's conservative processes. It gives the
child a respite, and prevents still-births, which would
almost invariably happen from long compression of
the bones of the head. If this did not prove fatal
to it, it would die from suffocation. This is the
reason why so many unborn children die in cases of
puerperal convulsions. This period of recuperation is
also necessary to the soft parts of the mother, to prevent
inflammation or laceration from sudden stretching. After
this period of rest, the head advances and recedes as
before. Do not get scared nor get in a hurry. Take it
coolly and wear a pleasant countenance, even if it should
take some time. In the pain before the last, it seems
certain that the head will be born, but the pain stops just
short of accomplishing the work. In the next pain, the
woman makes an extra effort, utters a significant shriek,
and the head is born. Practically, the labor is finished
when the head is born. There is now an interval of rest,
the body of the child is born, the woman immediately
passes into a new existence, and is comparatively comfort-
able. She is surprised and overjoyed.

The third stage of labor comes on, which is the
delivery of the after-birth. As soon as the child is born



THE SYMPTOMS OF ACTUAL LABOR. 489

the uterus begins to shrink very rapidly. The placenta
does not shrink, but separates from the uterus. The
placenta (after-birth) falls to the mouth of the womb and
causes reflex contractions. After expulsion of the
placenta the uterus keeps on shrinking. This shrinkage
compresses the uterine blood-vessels, and prevents free
hemorrhage. If the placenta be attached to the fundus of
the uterus, it falls into the mouth of the womb and pre-
vents the escape of blood till after the expulsion of the
placenta, when a quantity of coagulated blood will follow.
If the placenta be attached to the sides of the uterus, it
will fall down edgewise, and the blood will continue to
escape during the third stage of labor. The separation of
the placenta from the uterus begins with the first labor
pain.

If the connection be weak there may be accidental
hemorrhage at the first pain. If there be abnormally firm
adhesions, it is not spontaneously detached. In such
situations the uterus may shrink and the placenta be
separated before the head is born, and hemorrhage may
result. The placenta may remain in the walls of the
vagina for hours. We might trust the expulsion of the
placenta to the efforts of Nature, as many suggest, but I
think it best not to do so, unless .Nature act speedily.
There may be reasons why it should not be done. The
woman is wet, soiled and unhappy till the placenta is
removed. I rarely wait longer on the efforts of Nature
alone than ten to thirty minutes. If the hand be applied
to the lower part of the abdomen, a hard tremor will be



490 MAIDENHOOD AND MOTHERHOOD.

felt through the abdominal walls ; if it be not, then grasp
with both hands deep down into the abdomen, and excite
through manipulations its contraction. Continue this
process until you feel the uterus as a hard, globular mass in
the lower part of the abdomen. There are two methods
practiced for the expulsion of the placenta. Pass your
finger along the cord until you feel the placenta in the
mouth of the womb or upper part of the vagina. Seize
the cord with one hand ; pass two fingers of the other
hand, one on either side of the cord, into the vagina.
With these two fingers as a pulley, make gentle tension on
the cord with the other hand back toward the spine. Do
not pull the cord forward toward the pubes. Pull gently,
that you may not detach the cord from the placenta.
Should such an accident occur, grasp the placenta with
the fingers, and encourage its expulsion. As soon as the
placenta is fairly in the hands, commence turning it round
so as to form a cord out of the membranes ; this will insure
their entire detachment and delivery.

The other method of delivering the placenta is to
grasp the uterus with both hands through the abdominal
walls and squeeze and press it in every direction toward
the centre. You can feel it shrinking from a large mass to
one not much larger than a fist. This is perhaps the best
method, especially for the inexperienced. Do not push
the uterus downward, but squeeze it. It will expel the
placental membranes and usually the clots. There is
always the loss of more or less blood during this stage of
labor, usually not to exceed a half-pint.



ATTENTION TO BE GIVEN MOTHER AND CHILD.



I have gone over the several steps in what is called a
typical case of child-birth.

Some Attention That Should Be Given the Mother and

Child.

There is little to be done during the first stage of
labor. An examination of the uterus through the vagina
with the finger is necessary ; first, to ascertain if the
woman be in actual labor ; second, if so, to see what is the
condition of the os if it be dilated or dilatable, to see what
is the presentation that is, the position of the child
relative to the size and condition of the passage. This
examination should continue long enough to examine all
the soft and hard parts of the pelvis. It is often necessary
to occasionally repeat the examination. The woman
should not be especially restrained during the first stage of
labor, but may be permitted to do very much as she
pleases, and eat and drink as is her custom unless she
be fleshy ; in such case, feed her lightly. Usually a
woman does not want to eat much. In the first stage of
labor, at least, a woman ought not to take alcoholic stimu-
lants. Ordinarily, I never give them in any stage of
labor. If the woman be nauseated to such extent as
to prevent the pains, give her some nerve stimulant, as
peppermint, lavender, sweet spirits of nitre, or a cup of
strong coffee or tea. If she have extreme rigors, give
Hoffman's anodyne.

So soon as the os is dilated to the size of a silver dollar,
put the woman to bed ; otherwise, if you permit her to be



492 MAIDENHOOD AND MOTHERHOOD.

up, an accident might occur, and the child be born while
she is on her feet. The bed I have already described and
prepared. During the first stage of labor the uterus does
everything. Sometimes the os is soft and freely dilatable,
but there is no pain, or there may have been some pain,
but it has ceased. Introduce your finger into the os through
the vagina, and manipulate it ; at the same time with the
other hand gently manipulate the bowels. Continue this
procedure for half an hour, and, nine times out often, you
will have produced very satisfactory labor. Some recom-
mend the administration of ergot, but I very rarely use it,
generally succeeding well by the method referred to. You
should be very careful never to rupture the bag of waters
in a woman with her first child. Allow the waters, by
their moisture and heat, to thoroughly relax the soft parts
of the passage. In the first part of the second stage of
labor you may encourage the woman to bear down. In
the latter part she needs no such encouragement, as there
is sufficient inclination, and she may injure herself if she
make too severe effort. When the head appears at the
vulva, or external opening into the vagina, and the head
is pressing against the perenium, it should be supported,
to regulate the rapidity of the passage of the head, and
prevent the rupture of the thin tissues. The perineum
should be carefully watched. Its rupture is a serious acci-
dent. Place two fingers of the one hand on the perineum
and two fingers of the other hand on the child's head, and
make gentle passive support to the extent of a few ounces.
Use the bare fingers, and not a towel or napkin, for by it



ATTENTION TO BE GIVEN MOTHER AND CHILD. 493

you remove the lubricating material. The fingers should
be thoroughly covered with lard. It will sometimes be
necessary, if the parts appear dry, to lubricate them with
lard during the interval of pain. A pain comes on, the
head does not advance, the woman cries out and stops
straining ; she should then be encouraged to strain.

As soon as the head has been born, find if the cord be
wound around its neck ; if so, remove it at once, or it
may kill the child. This is done by pulling on the free
end of the cord, and slipping the noose over its head. If
you cannot succeed in getting the child's head through
the cord, you may cut it. It may be necessary, in such
cases, to deliver the child at once, and, if there be no
pain, which sometimes happens, you may be tempted to
pull on the child's head. This should be avoided, lest
you dislocate the cervical vertebra. Press freely on and
rub the abdomen ; tell the woman to strain ; tell her if
she do not, the child will die. Support the child's head ;
with a cloth wound around your index finger, cleanse its
mouth, and with a towel wipe off its face and prevent the
fluids from running into its throat. The child is now
born. Place it on its side with its face from the maternal
organs, that it may not be suffocated by discharges.
Instantly place your hand upon the naked abdomen of the
woman ; make friction and pressure until the flabby
uterus becomes firm and hard. The danger is from hem-
orrhage and convulsions. As soon as the child breathes
and shows signs of vigor, tie the cord from two to two and
one-half inches from the infant's body first ; then again



494 MAIDENHOOD AND MOTHERHOOD.

two inches farther, and, with a sharp pair of scissors,
divide the cord between the two ligatures. Wrap the
child in a warm, soft blanket and hand to the nurse.
Place the mother on her back ; in the meantime, keep a
careful watch over her, and allow her to rest ten minutes.
See that the uterus is contracting ; have the attendant
keep her hand on the bowels, making pressure upon the
uterus, that the after-birth may be expelled. I have
given directions for its proper delivery.

Have the nurse, or do it yourself, wash the vulva and
thighs in tepid water and soap, and clean things up gen-
erally. But do not fatigue the woman with over-
attention. The whole toilet should not occupy more than
five minutes.

Now apply the binder. The directions for making it
have been already given. The binder is to make constant
pressure upon the uterus, compress the blood-vessels and
support the abdominal muscles. It preserves the woman's
shape, to which desideratum no woman is indifferent.
Before applying the binder, see that the uterus is well
contracted. Place a compress over the uterus, underneath
the binder. The binder should extend from the false ribs
to the pubes. Pin it as tight as will be admitted by the
patient ; it will soon get loose. Put in six or eight pins,
and see that they are not left in position to injure the
patient. Now bring the woman to the head of the bed,
but do not let her move, or make any effort at all. Apply
a large napkin below the vulva to catch the waste. Now
make the woman comfortable, covering her with blankets
adapted to the temperature of the weather.



HEMORRHAGES. 495

Hemorrhages.

Accidental hemorrhage occurs from detachment of an
abnormally-situated placenta. Inmost cases it takes place
during the latter months of pregnancy, or during labor.
During the last three months hemorrhage sometimes comes
on suddenly, without any apparent cause, especially in
cases of placenta prcevia, that is, where the placenta leads
the way, or occupies the lower end of the uterus below
the child. In many cases the hemorrhage ceases spon-
taneously. It may come on in large quantities or it may
be continual called slow hemorrhage. There may be
no bleeding until labor comes on, when a sudden rush of
blood may prove fatal. In some cases of placenta pravia,
the os dilates freely, the placenta is spontaneously thrown
into the vagina, and labor goes on safely for the mother,
but the child is still-born. This, however, is quite rare.
This is an important crisis, and ignorance or timidity may
cause the death of the parent. During the last three
months the best treatment for accidental hemorrhage and
placenta prcevia is rest in bed ; elevation of the hips ; sup-
positories of opium and belladonna of one grain each ;
cold cloths to the lower part of the abdomen and vulva ; if
the woman be cold, use hot applications ; if the hemorrhage
do not cease or be quite free, tampon the vagina.

Hemorrhage After Delivery.

This is the most formidable complication of labor, and
gives no time for dallying ; you must act at once. The



49^ MAIDENHOOD AND MOTHERHOOD.

attack is swift and unexpected. It frequently occurs, and
you should ever be on the watch. If you have fully
followed the directions given to contract the uterus you
will rarely have any trouble. I have long been in the
practice of obstetrics and have had but one case give me
any serious trouble, that was the premature birth of a
child. Through over-attention to the offspring, I neglected
to see to the proper contraction of the uterus, to which
cause I attributed the subsequent hemorrhage.

The premonitions of hemorrhage after delivery are a
flaccid uterus, pallor, quick, fluttering, feeble pulse,
vertigo, dimness of vision, faintness, yawning and gaping,
which should be particularly noted. Fainting is itself
dangerous from the liability to produce heart-clot.
Locally is seen the rush of blood. The hemorrhage may
be concealed on account of a clot of blood in the os, or
from its being corked up by the placenta or tampon. In
such cases the uterus fills with blood before you are
aware. The preventive treatment is by manipulations, to
stimulate the uterus to contract. Come down on it with
both hands, force contraction, and rid yourself of further
trouble.

The medication is ergot. Give a teaspoonful of the
fluid extract every fifteen to twenty minutes. Empty the
uterus of its contents, placenta, membranes and clots. If
the uterus do not contract, introduce the hand into the
uterus, and at the same time manipulate externally. This
will nearly always cause contraction. If it do not, apply
cold water, which produces contraction by shock, and if at



TREATMENT OF PLACENTA PR^EVIA. 497

all, it will-do it immediately. It should not be tried more
than five minutes. If these means fail, dip a clean rag
into vinegar, introduce it into the uterus, and squeeze it
out. Vinegar excites extreme contraction (is styptic), is
not dangerous and is always at hand. Sucking the
breast, either by the child or other means, frequently aids
contractions. If the patient "be faint and feeble, give
stimulants. Aromatic spirits of ammonia, Hoffman's
anodyne, or ether. Keep the head lower than the body.
Give salty food, animal broths, essence of beef, wine,
whey, meat soups, milk, or raw eggs. Quiet the nerves
by opium and bromide.

Treatment of Placenta Praevia.

When labor has come and you have hemorrhage from
placenta frcsvia, the treatment will depend upon the
presentation of the placenta. In complete placenta
prcevia the best treatment is to tampon with soft rags
until the os is dilated or dilatable, and then turn the child
and deliver it by the feet. Watch carefully the progress
of the dilatation, and lose no time unless the hemorrhage
is slight ; if it be severe and dangerous, introduce your
hand before complete dilatation, rupture the membranes,
seize the feet and deliver as speedily as possible. In
general, the child is not hard to turn, as the loss of blood
renders the uterus weak and non-resistant to the hand.
Separate the placenta at one side to permit the entrance
of the hand. Carefully examine as to where it be least
attached, and then peal it off. You do this by pushing



498 MAIDENHOOD AND MOTHERHOOD.

your finger in at different points, ascertaining where
entrance is easiest. If the patient be weak, give stimulants
and ergot. Give a full dose of laudanum. Lose no time.