Obstetrics

“ Anyone who practices obstetrics in these days appreciates how careful he must be, especially of the cleanliness of his hands. Energetic scrubbing with soap and water and the free use of antiseptics, as physicians now employ both these measures, appear ridiculous to some women who have witnessed deliveries under a less stringent regime. They may be bold enough to express their disapproval. They may remind us that many women have been successfully delivered without such care. ”

“ The superstitions surrounding childbirth are peculiar and cruel. Those who practice obstetrics are generally old women, a doctor is seldom called in except on rare occasions, and the midwives endeavor to aid natural labor by means of domestic medicines, shampooning, etc, at times doing much serious mischief. The cruelest part of their procedure is immediately after childbirth, causing the mother to lie by a hot fire for a period of from five to thirty days. ”

“ Preventive treatment really begins very early. In the chapter on menstruation we referred to the importance of a young woman’s ascertaining the cause of painful menses, in the interest of good obstetrics, since inflammation of the uterine lining or a uterine misplacement might be responsible not only for the dysmenorrhea, but if neglected might, later, be factors in causing interrupted pregnancies. ”

“ The art of turning does not appear to be known, neither 19 is blood-letting practised in their obstetrics. We heard of no case of retention of the placenta after parturition, nor of the affection of longing, or of nausea of the stomach during pregnancy. ”

“ Their ideas on obstetrics are equally unscientific, and a medical man going near a woman at her confinement appeared to them more out of place than a female medical student appears to us in a dissecting-room. ”

“ At birth the physical connection between the child and its mother must of necessity be severed. One of the mistakes in modern obstetrics is the wide-spread practice of cutting the umbilical cord before the cessation of its natural pulsations. ”

“ Further, many occur in first weeks and pass under the diagnosis of delayed or profuse menstruation. Finally, many abortions are deliberately concealed. Page 426.
194PRACTICE OF OBSTETRICS. By J. Clifton Edgar, M.D.
Immediate dangers of abortions are: hemorrhage, retention of an adherent placenta, sepsis, tetanus, perforation of the uterus. They also cause: sterility, anemia, malignant diseases, displacements, neurosis, and endometritis. ”

“ And thus, through the courage and great skill in obstetrics of Queequeg, the deliverance, or rather, delivery of Tashtego, was successfully accomplished, in the teeth, too, of the most untoward and apparently hopeless impediments; which is a lesson by no means to be forgotten. Midwifery should be taught in the same course with fencing and boxing, riding and rowing. ”

“ EARLY SIGNS OF COMPLICATIONS OF PREGNANCY It is evident that by teaching the principles of personal hygiene to the expectant mother so convincingly that she will adopt them, and sometimes, by employing simple nursing procedures to relieve the various discomforts of pregnancy, much will be accomplished toward promoting the welfare of both the patient 142and the expected baby. But this is not enough. The nurse must also be on the alert to detect and report the early symptoms of complications, for there may be times when she will be the first one to see the patient after a symptom has developed. ”

“ The treatment and nursing care vary widely because so little is definitely known about the cause, and because of the varieties of theories concerning it which are held by different obstetricians. Some believe that prompt emptying of the uterus is about the only course which is effective, while others feel that because of the probable toxicity of the patient it is advisable also to stimulate all of the excretory organs. Accordingly, they give free purges, colonic irrigations, hot packs and copious amounts of sugar and saline solution by mouth, rectum, intravenously and by infusion. ”

“ It is maintained, viitoo, that say what we may, childbirth is, and must necessarily be, in all civilized societies, a serious thing to enter upon. What woman who has ever passed through this ordeal does not regard it so? and what physician, no matter how old, or experienced, or skillful he may be, does not, every time he enters the lying-in chamber, feel this responsibility to be a great and trying one? Admitting all that can be done by the water-treatment in matters of midwifery, and much, very much, certainly may be—childbirth is yet an agony, and must ever continue so to be. ”

“ The intimate relation between the breasts and the uterus manifests itself in such a variety of ways and with such force that no one doubts its existence. Thus, if a nursing mother becomes pregnant her infant is usually deprived of sufficient nourishment or suffers some digestive disturbance; if not, and the mother, ignorant of her condition, continues with the breast feeding, she may jeopardize the newly begun pregnancy. Very likely she will be warned of the fact by the signs of threatened miscarriage. ”

“ Buhl, Gütterbock, and others are of the opinion that the disease may be communicated by the mother to the foetus.
Pregnancy undoubtedly exercises an unfavorable influence on the course of the disease, chiefly from the tendency to uterine hemorrhage. Pregnancy is interrupted in over 50 per cent. of the cases. Premature labor is observed more frequently than abortion. The prognosis with reference to the life of the child is absolutely unfavorable.
In very exceptional cases the evacuation of the uterine cavity has seemed to exercise a favorable influence on the course of the disease. ”

“ Are the plans of medical treatment, such as are usually adopted in childbirth, calculated more and more to undermine the constitution? Are people almost universally in the habit of debilitating themselves by connubial excesses in the married state? These are questions of vital importance to all who expect to be mothers.
After-pains proceed from the contraction of the uterus, caused by the presence of bloody clots, the blood having oozed from the orifices of the torn vessels, and becoming coagulated in its cavity. ”

“ Normal Course.—We have already delineated the normal course of abortion at this period. The death of the embryo has usually preceded, often for weeks, and is characterized by the feeling of pelvic congestion, gastric and vesical irritation, weariness, weakness, and increase of uterine and vaginal secretion; the membranes have developed more or less; expulsion is inaugurated by hemorrhage. If the cause be more violent, the flow of blood is free. Usually there is but a slight oozing, which ceases at times, but gradually increases; the suffering which accompanies uterine contraction is present. ”

“ Amongst the former class are included—Cessation of menstruation (which may occur without pregnancy) ; morning vomiting; salivation; enlargement of the breasts and of the abdomen; quickening. It must be borne in mind that every woman with a big abdomen is not necessarily pregnant. The tests which afford conclusive evidence of the existence of a fœtus in the uterus are—Ballottement, the uterine souffle, intermittent uterine contractions, fœtal movements, and, above all, the pulsation of the fœtal heart. The uterine souffle is synchronous with the maternal pulse ”

“ Happily, the present-day obstetrician, who assumes the care of an expectant mother, does so with confidence and optimism because of the available knowledge upon which he may draw for her benefit. Progress in the various branches of medicine and nursing is steadily pointing the way toward greater and more effective safeguards for the maternity patient and her baby. ”

“ Malformations of the pelvis, accidental injuries and the diseases and displacements to which the uterus is liable, on the one hand; and, on the other, various morbid conditions of the ovum or placenta leading to the death of the foetus, are among the direct local causes. The general causes embrace certain states of the system which are apt to exercise a more or less direct influence upon the progress of utero-gestation. ”

“ It is because so many women fail to appreciate this that abortions and premature births are often followed by ill health and invalidism. Under proper care, an abortion 80or premature labor is not, of itself, any more serious for a woman than a normal delivery.
Bleeding from the vagina, or a sudden increase in the size of the abdomen with perspiration and a sudden feeling of faintness, may be the beginning of severe bleeding, or hemorrhage, from any one of a number of causes, and in such a case the expectant mother should notify her doctor, go to bed at once and keep quiet until he arrives. ”

“ It may be at the end of two weeks, or it may not be until the close of four or five weeks, in the case of the mother who cannot nurse her child; for the nursing of the breast greatly facilitates the shrinking of the uterus. Extensive lacerations may hinder the involution as well as other accidents of childbirth, so it must be left with the physician to decide in each individual case when the mother may enter into the activities of life and assume the responsibilities of the care of the baby and the management of her home. ”

“ THE CAUSE OF ABORTION [129] may exist in the constitution of the female herself, being the result of weakness and irritability, or of an overfull habit or a diseased condition of the womb; or the fœtus, or child, may die or be deficient in development, when it is cast off like a blighted fruit. Suckling after conception has taken place is not infrequently a cause of miscarriage. Active diseases occurring during pregnancy, such as fevers, severe inflammation, eruptive fevers, etc., are almost certain to occasion the expulsion of the uterine contents. ”

“ It is the mother, and more often the family physician, who must see that a free and healthy development is permitted: let it be remembered that the close-fitting corset, the heavy dresses suspended from the hips, exertion whether for pleasure or work, frequent intercourse, as well as mental condition, all affect the fate of the ovum. The menstrual congestion, recurring with greater or less periodicity at the usual time of the flow, is a period of especial danger at which still greater care is necessary. ”

“ The pain, the discharge, and, at the same time, the danger of an abortion, are in proportion to the advancement of the pregnancy. When a miscarriage goes on, the pains increase in force and frequency, and continue, with discharge of blood, fluid or in clots, until the ovum, or first formation of the child, is expelled; after which both become moderated till they cease altogether and the [130] red flow gives place to a colorless one. It is very important that those in attendance upon the patient should examine every clot that comes away. ”

“ An anxious frame of mind also causes real ailments to assume an importance out of all proportion to their actual significance.
Patients who have followed my advice to place themselves in the care of a physician as soon as they clearly recognize the existence of pregnancy will receive his assistance in properly estimating the significance of what they notice. This service is by no means the least the obstetrician renders his patients. His opinion should always be sought when symptoms are not understood ”

“ Many years ago I succeeded in saving the life of a patient of high rank, then in the country, who was sinking under an almost total loss of blood, consequent on a miscarriage of this kind, in which a large portion of the 12semi-coriaceous envelopes had remained behind adhering partly to the inner orifice of the womb, thereby producing and keeping up the hemorrhage. In all these cases, the Ovum could not have been in existence more than three months, reckoning from the cessation of the menses. ”

“ An incomplete abortion is one in which the fetus is expelled but the placenta and membranes remain in the uterine cavity. The treatment is removal of the retained tissues, followed by the same care that is given during the normal puerperium. Prompt action in completing the delivery is important because of the hemorrhage that usually persists until the uterus is entirely emptied of its contents. ”

“ Should a post-partum hemorrhage occur, in the absence of the doctor, the nurse should massage the fundus, unless she has been instructed not to, and have some one elevate the foot of the bed on blocks or the seat of a firm, straight chair. The use of ice bags or cold compresses on the abdomen is sometimes helpful and some physicians advise placing the baby at the mother’s breast immediately, since the suckling stimulates the uterine muscles to contract. ”

“ A final class of labours includes the cases where some complication or anomaly arises and becomes a source of danger, independently of disturbances of the mechanism or of any operative interference. These complex labours are due to complications that may be maternal, such as hemorrhage and convulsions; or foetal, such as twins or prolapse of the umbilical cord. To cope with these anomalies an obstetrician requires all the resource of a physician and all the dexterity of a surgeon. ”

“ Notwithstanding this, in cases of abortion, or where the fœtus is dead, or, in fact, when any difficulty arises in the delivery so as to require manual aid, it is better that the feet should come first; they act as a wedge on the narrow uterine passages. Hence, when we chiefly depend upon the fœtus, as being lively and active, to accomplish delivery, we must do our best that the head escape first; but if the business is to be done by the uterus, it is advisable that the feet come foremost. ”