CHAPTER X.

CONDUCT OF A LABOR.

THE Conduct of a labor comprises the whole management of a parturient patient, from the first beginning of her pains until the complete exclusion of the secundines, and it also includes all that is done for the security of the mother and the child during the period immediately ensuing the birth. As labors are extremely various in their characters as to duration, pain, facility or difficulty, the title at the head of this chapter is a comprehensive one, and fruitful of topics which, if properly handled, could not fail to prove interesting and instructive to whatsoever reader might desire, under such a head, to seek for useful, and indeed even indispensable information.

The conduct of a labor might refer to any, and so to all possible events and circumstances of Midwifery; for Midwifery, after all, is but the conduct of labors.

Any person meriting the name of obstetrician may be supposed competent to the conduct of a natural labor where the series of phenomena proceeds with rapidity and in a perfectly natural order of succession and duration, provided he will remember the oft-repeated adage, "a meddlesome midwifery is bad," and be willing to abstain from impertinent interferences; for a kindly Providence hath so ordered this painful office of parturition, that the accoucheur, in most cases, hath really little to do except receive and protect the child, and attend to the delivery of the after-birth; extending his care to the disposal of both the mother and her offspring for the first few hours after the termination of the conflict.

The bearing of children, however natural and healthful it may be in the great majority of women, is found to be sometimes so painful, so difficult, so dangerous and even impossible without help from without, that every woman about to be confined, ought to be provided with a skilful adviser or assistant, because in the most natural labor there is at least some risk that the patient might hurt herself or that the child might suffer injury or death from the want of prompt scientific aid. This liability, which has always existed, must ever continue

to render our calling indispensable in all civilized states; for, to use the quaint expressions of the oldest English work on Midwifery, I mean the Woman's Booke; or, the Byrthe of Mankynde, by Thomas Rainalde, Physition. Fol. XI.: "The Mydwyfe muste enstruct and comfort the partie, not onlye refreshyng her with good meete and drinke, but alsoe with sweete wordes, gevyng her goode hope of a speedeful deliveraunce, encouraging and enstomakyng her to pacience and toleraunce, byddyng her to holde in breathe so much as she may; also streyking genttily with her handes her belly above the navell, for that helpeth to depresse the byrth downewarde.” The above words of Rainalde, however quaint or antiquated, really convey an idea of much that it is incumbent on the obstetrician to say and do in the exercise of his calling, and even he who practised in the reign of King Henry the Eighth, appears to have felt that if a woman in labor, affected with the wildest terror, and magnifying by a distorted view every pain, could be made to clearly understand the nature and causes of the pains, their uses and results, as well as the physician himself does, she would become tranquil, patient, contented, and even cheerful under sufferings, that should otherwise frighten her from all propriety.

To conduct a labor properly, the practitioner ought to make a correct diagnosis, which, when it is once truly made, enables him to form an opinion as to the prognosis. But, however sure he may feel that his prognosis is well founded, he should not commit the great imprudence of indicating the moment at which the labor is to end. It is quite natural and right that he should give "sweete wordes," as Rainalde says; but since it is impossible to foresee all the circumstances that may arise in the course of a labor to interrupt its course, it is best to be cautious in the making of promises, for should the appointed or promised moment arrive without bringing the expected happiness, the woman is capable of reflecting that her physician has either made a great mistake, or that he has purposely deceived her, either of which is a dilemma for him and her also. It is far better, after having acquired her confidence, to deserve it and shew her that it is well placed by telling only the truth as he knows it.

Many times does it happen that startling incidents, vexatious disappointments, and unforeseen causes of delay come to discompose the complacency, and dispel the serenity of the medical attendant. He is scarcely well fitted for his occupation who allows any signs of such influences to appear in his words or gestures, for he is there to "comfort the partie with sweete wordes," to encourage and enstomak her to "pacience and toleraunce."

For most women in labor, the pulses, the respiration, and the tem perature of the body, become considerably increased, and this excitement is liable to such great exaggeration as to bring the woman and the child into danger. As a moderate increase in the action of the heart, the lungs, and the nervous system is a natural condition for parturient women, any such normal state ought not to be interfered with, but it is important to keep watch, lest the phenomena should take on an abnormal character; and every careful and skilful physician should be ready to apply the checks and remedies for these disordered actions of nature. Any excess of excitement ought to be counteracted at once to prevent it from passing into fever, into inflammation, or convulsion, or exhaustion, which are not uncommon results.

It is only under extraordinary circumstances, as where the woman happens to be seized with some disease while in labor, where there is something wrong in the presentation or the position of the child, some fault in the form of the pelvis or of the child itself, that the accoucheur is called in to interfere with a process so natural and so healthy as that of childbirth. Indeed, the chief part of the surgeon's duty consists in giving such directions as may be requisite to prevent the woman from injuring herself, and in inspiring that confidence in her own powers, which she is apt to lose when suffering under the intoler able pains, or despairing of the hoped-for relief which seems to her to grow more and more remote as the crisis comes nearer and nearer.

The mind of a parturient woman is often observed to be in a sort of tumult, so that she grows bewildered with doubts and fear, and pain, and she greatly needs the comfortable words which would mean nothing in her case, unless uttered by a person in whose skill and knowledge, derived from long experience, she could confide. Women are sometimes observed to become so much disordered by this doubt, fear, and anguish, as to give no heed to, and take no comfort from the words of the medical attendant, and so, fall into great danger from the reaction of mind on the body, the progress of the labor being suspended, or its course quite perverted. But if some other physician happens to be called in, one on whose knowledge and good judgment she is willing to rely, the whole scene changes, and the process begins to go on with regularity and without further complainings or any disorder whatever.

I have often supposed, in observing the good influence of kind and confident assurances, and intelligible explanations given to parturient women, that a great part of the distress they experience in childbirth is due to the alarm and doubt that attend it, and that to take away or annihilate the panic element of labor, would be to deprive the act

of parturition of a large share of its anguish. I have in a great many instances observed, that the pains have fallen, or become irregular and spasmodic, in consequence of this constitutional irritation, and that they recovered their vigor and regularity by removing the excess of bedclothes, bathing the hands, face, and throat with cool water, and by the exhibition of cooling drinks, together with free ventilation of the apartment. Great comfort and even renewal of strength, hope, and courage, commonly follow a change in the outward circumstances of the patient, as to her bed and other things relative to her labor. Thus a woman who may have been lying for seven or eight hours upon the same spot, comes, at last, to sink into a sort of pit made by the weight of her hips. The continued escape of fluids, as urine, liquor amnii, blood and serum, which are all heated by the heat of her own body, is frequently found to wet her up as far as the shoulder blades: and she remains pinioned as it were to the spot, and as if lying upon a blister, aching in every limb, and imploring death, which she really expects. Such a person should, as a mere act of humanity, be taken up, cleansed from head to foot, and replaced upon a bed made up with clean bedclothes. In cases where these simple cares would not suffice, I have often re-established the regular course of events by taking blood from the arm.

Notwithstanding most women have a greatly increased frequency and force of the pulse during the more active stages of labor, it is not universally the case; some females passing through the whole process without any change whatever in the rate of the circulation.

CASE. The following case was under my care on the 9th of February, 1828. Mrs. B., aged twenty-five years; in labor with her first child; was attacked with the pains at seven o'clock A. M., and was delivered at twelve o'clock of a healthy female infant. The whole amount of blood discharged at the separation of the ovum did not exceed three ounces. The pulse was very slow throughout the labor, not exceeding sixty-five pulsations per minute, even during the most violent expulsive pains. Some time after the complete expulsion of the secundines, the os uteri was two inches in diameter, and as hard and smooth as a ring of ivory.

CASE.-November 3, 1840, I attended Mrs. W. C. L., aged twentytwo years, in labor with her first child. The pulse during the whole process never rose above seventy-two, and soon after the birth of the child fell down to sixty-five beats per minute. The labor commenced at two o'clock A. M., and terminated at five o'clock P. M. The pains,

even the great ones, were but a few minutes apart, so that I have rarely witnessed a more tedious one, notwithstanding many have fallen under my notice which were much more protracted. I could cite from my practice many cases in which the pulse was quite unaffected throughout the whole process of parturition.

Professor Dewees was celebrated for the boldness and good judgment with which he resorted to venesection, in some cases of labor. The quantity drawn by him, in instances he reported, although, doubtless, fully demanded by the exigencies at the time, and justified by the results, may, nevertheless, have induced some persons of lesser powers of discrimination unnecessarily to resort to a similar mode and extent of depletion; hence, it is not uncommon to hear of very large bleedings, of thirty to forty ounces at a time, during labor. I must say, that I think such very large abstractions of blood not often necessary, and therefore, take this opportunity to warn the reader to discriminate carefully concerning the quantity to be drawn in each particular case. For example, where the woman has become too much excited as to her circulation, in the manner above pointed out, I have no idea that it is necessary to draw away a great quantity of blood: let him not bleed until the pulse becomes soft-he does not want a soft pulse. In labor, or at least in the violent stages of labor, the pulse ought to be full, vigorous, and somewhat accelerated. If he bleeds till the pulse becomes soft, he will substitute for a state of excitement and excessive power, one of debility and lowness, quite as much to be deprecated.

The purpose of venesection, in the instances I at present propose, is to take off the strain of the blood vessels-to mitigate the general excitement which ensues upon too rapid a revolution of the blood. I therefore think that it is better, for the most part, to limit our bleedings, for these general purposes, to something under, rather than over sixteen ounces. But on the other hand, where symptoms, strongly threatening apoplexy, convulsions, pulmonary hemorrhage, inflammation, &c., make their appearance, the lancet should be used in the most fearless manner. The same is true of those cases where a great relaxation of the tone of the tissues is required for some special and pressing object, such as the relaxation of a strictured vagina or very rigid uterus, the removal of a violent congestive or inflammatory accumulation of blood in the brain, &c. &c.

The facility and promptness with which the alvine discharge can be effected by means of enemata, makes a resort to them very common; and, in fact, where only a slight reduction of excitement is wanted they fully answer the end proposed; yet a dose of some neutral salt, mag