248 



MIDWIFERY. 



of Parturi- the child is to be retarded rather than accelerated in 

 x *! n ' ., the last stage, that the uterus may contract on the pla- 

 ^-^x centa. This is farther assisted by rubbing gently the 

 uterine region after delivery. If the placenta be long 

 retained, or hemorrhage come on, the hand is to be 

 gently introduced into the uterus, and pressed on tlie 

 placenta, to excite the fibres to throw it off. We 

 should not rashly attempt to remove it, for we are apt 

 to tear it ; neither are we to pull the cord, for it is 

 easily broken. In those cases where premature la- 

 bour is connected with redundance of liquor amnii, 

 it is useful to introduce the hand immediately on the 

 delivery of the child, for the placenta is apt to be re- 

 tained by irregular contraction. We do not instantly 

 extract the placenta, but it is desirable to get the 

 hand in contact with it before the circular fibres con- 

 tract Great attention is to be paid to the patient for 

 some days after delivery, as she is liable to a febrile 

 affection, which may be either of the inflammatory 

 type, or of the nature of weed, to be afterwards no- 

 ticed. 



CHAP. IV. 



Of Preternatural Labour. 

 Order First. 



Of prefer- THE breech is distinguished by its size and fleshy 

 natural la- feel, by the tuberosity of the ischia, the shape of the 

 hour. ilium, the sulcus between the thighs, the parts of ge- 



neration, and by the discharge of meconium, which 

 very often takes place in the progress of labour. Af- 

 ter the breech has descended some way into the pel- 

 vis, the integuments may become tense or swelled, so 

 as to make it resemble the head. Before the mem- 

 branes burst, the presentation is usually very mobile, 

 and bounds up readily from the finger, but in some 

 instances it is from the first firmly pressed down in 

 the pelvis, and felt through the uterus very much re- 

 sembling the head. 



Many have advised, that when the breech present- 

 ed, the feet should be brought down first ; but the es- 

 tablished practice now is, when the pelvis is well 

 formed, and other circumstances require speedy de- 

 livery, to allow the breech to be expelled without any 

 interference, until it has passed the external parts. 



Order Second. 



Presentation of the feet is known, by there being no 

 rounded tumour formed by the lower part of the ute- 

 rus. The membranes also protrude in a more elon- 

 gated form than when the head or breech present. 

 The presenting part, when touched during the remis- 

 sion of the pain, is found to be small, and affords no 

 resistance to the finger. When the membranes break, 

 we may discover the shape of the toes and heel, and 

 the articulation at the ankle. Sometimes both the feet 

 and the breech present. Two circumstances contri- 

 bute to an easy delivery ; Jlrst, That the toes be turn- 

 ed to the sacro-iliac junction of the mother ; and se- 

 condly, That both feet come down together. The 

 best practice is, to avoid rupturing the membranes till 

 the os uteri be sufficiently dilated ; then we grasp both 

 feet, and bring them into the vagina ; or, if both pre- 

 sent together at the os uteri, we may allow them to 

 come down unassisted. 



Order Third. 



When the shoulder or arm presents, the case has 

 the general character of preternatural presentations. 



The round tumour, formed by the head in natural la- Of Parturi- 

 bour, is absent, whilst we can ascertain the shape and lion ' 

 connection of the arm and shoulder. A shoulder pre- 

 sentation can only be confounded with that of the 

 breech. But, in the former case, the shape of the sca- 

 pula, the ribs, the sharpness of the shoulder-joint, and 

 the direction of the humerus, together with our often 

 feeling in our examination either the hand or neck, 

 will be distinguishing marks. In the latter, the round- 

 er shape and greater firmness of the ischium, the size 

 of the thigh, its direction upwards, and its lying in 

 contact with the soft belly, the spine of the ilium, the 

 parts of generation, the size of the tuberosity of the 

 ischium, and the general shape of the back parts of 

 the pelvis, contribute with certainty to ascertain the 

 nature of the case. 



In most cases where the superior extremities pre- 

 sent, the feet of the child are found in the fore part of 

 the uterus, toward the navel of the mother. But their 

 situation may be known by examining the presenta- 

 tion. 



We should be careful not to rupture the membranes 

 prematurely ; and more effectually to preserve them 

 entire, we must prevent exertion, or much motion on 

 the part of the mother. As soon as the os uteri is 

 soft, and easily dilatable, the hand should be intro- 

 duced slowly into the vagina, the os uteri gently di- 

 lated, and the membranes ruptured. The hand is then 

 immediately to be carried into the uterus, and upwards 

 till the feet are found. Both feet are to be grasped 

 betwixt our fingers, and brought down into the vagina, 

 taking care that the toes are turned to the back of the 

 mother. The remaining steps have been already de- 

 scribed. 



But if the water have been long evacuated, then the 

 fibres of the uterus contract strongly on the child, the 

 presentation is forced firmly down, and the whole body 

 is compressed so much, that the circulation in the cord 

 is frequently impeded, and, if the labour be protracted, 

 the child may be killed. This is a very troublesome 

 case, and requires great caution. If the pains be fre- 

 quent, and the contraction strong, then all attempts to 

 introduce the hand, and turn the child, must not only 

 produce great agony, but, if obstinately persisted in, 

 may tear the uterus from the vagina, or lacerate its cer- 

 vix or body. Copious blood-letting certainly has a 

 power in many cases of rendering turning easy, but it 

 impairs the strength, and often retards the recovery. 

 If the patient be restless and feverish, or the part rigid, 

 it is to a certain extent necessary and proper, and ought 

 to precede an opiate, but if these states do not exist, we 

 shall generally succeed, by at once giving a powerful 

 dose of tincture of opium, not less than sixty or eighty 

 drops. Previous to this, the bladder is to be emptied, 

 lest it should be ruptured during the operation ; and, 

 if necessary, a clyster is to be administered. The pa- 

 tient is then to be left if possible at rest. Sometimes 

 in half an hour, but almost always within two hours 

 after the anodyne has been taken, the pains become so 

 far suspended, as to render the operation safe, and per- 

 haps easy. 



In some instances, when no attempt was made to 

 turn the child, the uterus has burst, and the patient 

 died, whilst, in others, nature has at length cffecteu the 

 expulsion with safety to the mother. 



A knowledge of the fact that the child may be thus 

 evolved does not exonerate us from making attempts 

 to turn ; for although a considerable number of cases 

 are recorded where it has taken place, yet these are 



