The sane conduct of normal labor.
CHARLES J. HEMMINGER, M.D., ROCKWOOD, PA.
This article considers only normal labors. It may seem rather strange that such a paper should be read at a National meeting, but statistics prove that 95 per cent. of labors are normal; therefore, it is just as important in the normal cases what not to do and what to do as it is necessary to know how to treat the abnormal conditions.
At the outset I wish to state I believe that a great deal, possibly 60 per cent. of the prolapsus and displacements of the uterus as well as lacerations of the cervix and perineum, are the result of meddlesome midwifery. I am not alone in this observation, as many of the eminent authorities are constantly proclaiming, ascertain the conditions, and, if normal, give nature the right of way and all will be well for mother and child.
The prime essentials in obstetrics are clean hands, a knowledge of the various positions and presentations; pelvic anatomy and comprehension of the mechanism and stages of labor.
The accoucheur responds to the call of the pregnant woman, it is presumed that the practitioner is engaged previous, but this is ofttimes unfortunately in country practice not the fact; at any rate, enjoy the confidence of the patient and her friends by responding to the call promptly. Cleanse the hands by scrubbing them with good soap and hot water; be sure and change the water at least two times, and then bathe in 90 per cent. alcohol, followed by bathing the hands and arms in 1:1000 bichloride solution. You are now ready to put on the sterile rubber glove, and, by the way, several cases of puerperal sepsis that have reached the courts lately have been decided against the physician on the sole fact that sterile gloves were not used; therefore, it behooves the physician to use rubber gloves to avoid losing out in the event that he should be so unfortunate as to appear as a defendant in a sepsis case before a jury. The physician who will say in this enlightened age that sterile gloves are not needed in obstetric work, will have an up-hill pull to win his case, because the precedents and medical and surgical opinion will be against him. Besides protecting yourself and the patient from sepsis, the practitioner protects himself; for we all know of cases where physicians and surgeons have contracted syphilis and blood poison by doing obstetric work without sterile rubber gloves; of course, I know it is urged that the sense of touch is interfered with, but practice soon removes this objection and the conditions are diagnosed as readily with gloves as without. The close-fitting, well-cared-for sterile glove is indispensable to the conscientious up-to-date obstetrician.
Be sure you carry no infection into the vagina. The physician visits from place to place, and comes in contact with many virulent germs, such as syphilis, erysipelas, etc., and it is incumbent upon the practitioner to not place any barriers in the way of recovery. The pregnant woman is apparently immune to low grade bacteria.
On examination with the gloved hand, thoroughly determine whether the patient is in labor or not; also determine the presentation and advancement. The majority of the cases need but one examination.
I hear some one suggest you have not given the antepartum douche, since most vagina are inhabited with virulent bacteria. Theoretically, douching is correct, but practical experience proves otherwise. The manipulating and scrubbing of the vagina invites the infections that we seek to avoid by displacing and destroying the protective mucus and protecting epithelia. Statistics prove beyond a doubt that antepartum douches increase the mortality. The labia should be wiped with an antiseptic solution, such as 1:1000 bichloride solution, or a 2 per cent. lysol solution. Arrange the patient on the back; cover the limbs with a sheet, and, in passing the finger, be sure not to touch the anus, as many times very active bacteria inhabit the region around the anus, and, if the examining finger touches, the bacteria are carried into the vagina. In order to prevent touching the rectal region it is necessary to expose the patient to vision, so that the examining finger will only touch the cleansed labia before entrance into the vagina is made.
After examination the patient will likely inquire is everything right; to which you reply in the affirmative, because encouragement is a great anchor in these trials, and if there is an abnormal condition, apprise near relatives and refrain from informing the mother until the last moment; and then use tact and judgment in answer to the inquiry, why things are so slow. Be reserved and exceedingly tactful. Do not commit yourself to a specific hour, but predicate your reply by saying it all depends on the number and severity of the pains, for nothing is more discouraging to the patient than having the physician predicting one hour after another without result.
After the examination and the assurance to the patient, the province of the physician is watchful waiting. Of course, I am speaking of the normal condition. If the examination discloses an abnormal condition, determine the treatment and bring artificial aid as soon as convenient.
In the normal case from now on it is the duty of the physician to observe the efforts of nature and not to interfere until nature has proven herself unequal to the task. If the pains are irregular and do not have the bearing-down effect, and only harass and worry the patient, give a hypodermic of 1/8 to 1/4 grain of morphine. The patient will rest and when the pains return they will be more forceful and rhythmic and labor will progress very favorable.
Anesthetics are demanded by some patients. I do not believe that they should be used very much. I will admit that a few nervous cases should have ether to the obstetric degree in the latter part of the second stage; but I am satisfied that hemorrhages and insufficient contractions are more frequent when the anesthetic is used.
The manipulations to prevent rupturing of the perineum are many, and, not unlike many other conditions in medicine and surgery where so many different methods are recommended, none are efficient, and in this case practically all the efforts do more harm than good. It is truthfully stated by our modern obstetricians, that 80 per cent. of the ruptured perineums are the result of the hasty use of quinine, ergot, pituitrin, etc., causing heavy and continuous pain, and resulting in lacerations; shortening the time that the practitioner spends with his patient, but disastrous to the patient and makes many patients for the gynecologist, and ofttimes leaves invalids that are landmarks along the way of the over-hasty practitioner.
After the delivery of the child and the tying of the cord, do not hurry the delivery of the placenta, for the reason that the forcible delivery of the placenta by traction many times leave shreds in the uterus which become a nidus for infection and even cause trouble by disintegrating, causing septic absorption and many times hemorrhage. Forty to sixty minutes should elapse from the time the child is born and the placenta delivered. The placenta by nature's method separates from the walls of the uterus gradually, and if the physician is patient he will discover that many of his supposed adherent cases and so-called hour-glass contraction cases are the result of the over-anxious physician, and if he turns about face and observes the results he will be agreeably surprised at the facility with which the uterus brings the placenta from the uterus. Nature does this by a ballooning method. The blood accumulates between the placenta and the walls of the uterus; usually three to four ounces of blood are used by nature to accomplish this, and the placenta with all the shreds come away in fine shape and patient has an uneventful recovery.
It is accepted practice to give one ounce of ergot after the delivery of the placenta to aid in the contractions of the uterus. If ergot is given too early it has the undesirable effect to contract the uterus on the placenta, and in this way cause trouble.
When the uterus is properly contracted, have the bed cleaned up and permit no visitors. Have the patient arise for the acts of urination and defecation, as in this way, self-drainage of the vagina takes place. Keep the patient in bed for eight or ten days. Be sure to advise the use of the breast pump, for it is unnecessary to have inflammation of the breasts with this age, when we have the use of the very successful pumps on the market. Advise a mild cathartic every forty-eight hours, if needed, and the normal case will progress satisfactorily and the patient, physician and friends will be pleased.
National Eclectic Medical Association Quarterly, Vol. 7, 1915-16, was edited by William Nelson Mundy, M.D.