The first duty that devolves upon the accoucheur, upon entering the lying-in room, is to ascertain that the female is actually in labour. Now, from the close resemblance which subsists, in many instances, between the false and the true pains, this can only be done by an examination per vaginam; but, as this operation must at all times be offensive to the delicate feelings of the sex, it should not be proposed too abruptly: it is well, therefore, to enter into a little conversation before it is had recourse to. The most convenient position in which the patient can be placed is on her left side, the buttocks being close to the edge of the bed the knees elevated towards the abdomen, and the chest bent rather forwards towards the knees. The forefinger, having been previously anointed with some unctuous substance, is to be passed into the vagina, and carried forward till it reaches the os uteri, which, at the beginning of labour, is usually high up, and directed backwards towards the sacrum. If the pains are not the true parturient paroxysms, it will be found that, however violent they may appear, still no effect will be produced upon the os uteri; it will remain closed. But if we find that, during (heir continuance, the lips of the OR uteri are gradually opening, and that a portion of the membranes is protruded between them, in the form of a tense bladder, then we may rest assured that labour has actually begun. Before the hand is withdrawn, the presentation should be carefully ascertained: for this purpose the ringer must remain in the vagina until the pain has subsided, and then gently carrying it forward within the uterus, it is to be cautiously passed round the presenting part. If it be natural, the vertex will be distinctly felt, and, by tracing the sutures, the situation of the child may also be ascertained. Being satisfied that the patient is in labour, and the presentation natural, on withdrawing the hand (which ought to be wiped, under the bedclothes, with a napkin), the patient may be informed that every thing is going on favorably. This intelligence will have the effect of quieting her mind, and should always be afforded her.
No further manual interference is either necessary or proper during the first stage of labour. The patient is to be encouraged occasionally to empty the bladder and rectum; and, in order to afford her an opportunity of so doing, the practitioner should leave the room. Some light unstimulating; nourishment may from time to time be given, and she may be allowed to walk, sit, stand, or lie down, according to her inclination.
But, when the second stage has commenced, she must be confined to the bed in the position just recommended; the practitioner taking his seat by her side. A broad belt or bandage (a long towel answers the purpose exceedingly well,) is now to be applied round the abdomen, the two ends being given to an assistant to hold firmly; or they may be pinned together with three or four stout blanket pins. The bandage must be progressively tightened as the head descends, so as to keep up a constant and uniform degree of pressure upon the uterine region. This should be particularly attended to during and after the expulsion of the child. A napkin is to be placed under the hips, which is to be removed when it becomes soiled, and a dry one applied in its stead.
When the head is beginning to protrude through the labia, the palm of the left hand should be placed flatly, but not forcibly, against the perineum, in order, by thus supporting it, to protect it from laceration, The fore and middle finger of the right hand may also be pressed gently against the head of the child, in order that it may not be too suddenly expelled.
As soon as the head is born, if the cord be coiled around the neck, (which it frequently is,) it may be gently drawn forward, and passed over the occiput: if this cannot be accomplished, it should be loosened by the finger, and pushed back over the shoulders during their expulsion. The hand is also to be passed over the face, to ascertain that no portion of the membrane is still covering it; several well-authenticated cases being upon record where respiration has been prevented by this circumstance. At this period it is also common for the nurse to bring a small flannel cap, which is to be placed upon the child's head.
It is of vast importance that the body and lower extremities of the child be not forcibly dragged away by the accoucheur. It is far better rather to retard than to accelerate their birth: this may be done by placing the hand round the nape of the neck, and opposing a slight degree of resistance. By so doing, the uterus is made to act with greater force; and the consequence is that, in a very large majority of instances, the same pain that expels the feet also detaches the placenta, and propels it into the upper part of the vagina.
As soon as the child breathes, two ligatures, formed of about ten threads each, are to be lightly tied round the funis; one about three inches distant from the child's abdomen, the other a little nearer the placenta. The cord is to be divided between them; the scissors used for this division being pro be-pointed. The infant is then to be removed, and placed in the receiver, which is merely a piece of flannel prepared for that purpose.
Owing to the compression which they undergo, children are sometimes apparently born dead. From this stillborn state, as it is called, they may, however, very frequently be recovered by proper management. Where there is the slightest pulsation in the funis, it must be allowed to remain untied till the breathing is established. Friction over the region of the heart may be employed with the hand alone, or with a small quantity of ardent spirit. Artificial respiration is also necessary: this is accomplished by inflating the lungs, alternately blowing into the mouth, and depressing the ribs by pressure with the hand; care being, at the same time, taken to close the nostrils. The opening into the oesophagus should also be shut, which may very effectually be done by pressing the larynx pretty firmly backwards against the spine. If this precaution were not taken, the air would, of course, find its way into the stomach and bowels. Immersion in hot water is another powerful means of restoring stillborn children: warm water is not sufficient: it ought to be as hot as can be borne without injuring the delicate skin of the child. The breathing of newly-born infants is frequently impeded by the collection of a quantity of mucus around the mouth and fauces: where this is the case, it should be carefully wiped away with a clean napkin.
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From Charles Waller
Elements of Practical Midwifery: Or, Companion to the Lying-in Room, 1829
