Extract from an Address by Peter Horrocks, M.D.

Kai Tiaki : the journal of the nurses of New Zealand, Volume I, Issue 2, 1 April 1908, Page 47

Extract from an Address by Peter Horrocks, M.D.

On the Instruction of Midwives in the Symptoms and Signs of Abnormal Labour

In a case of abnormal labour the midwife is required under the Act to call in a doctor, and it is therefore necessary that midwives should know the symptoms and signs which indicate that labour is about to become or has already become abnormal. The subject is one of great moment, because upon the early recognition of unfavourable symptoms, followed by the prompt calling in of a doctor will depend the welfare or even the life of mother or child. One of the first points that a midwife should observe when she is engaged to attend a woman in confinement is whether the patient is well and properly developed. She should notice if she is narrow across the pelvis, and if there is any doubt measure the distances between the crest of the ilia and between the anterior superior spines, which ought to be about 11 inches and 10 inches respectively. If both are below 10 and nearly alike, she has a contracted flat pelvis,

and trouble is likely to arise. If both diameters are short, but yet not out of proportion to each other, it is probably a generally contracted pelvis. As soon as she notices anything abnormal about the pelvis, she should report to a doctor, who will decide as to the advisability of induction of labour, or assist by forceps — version or calesarean section. The midwife's duty is an important one, viz., to detect in time that there is something abnormal. A midwife should observe whether there is any spinal curvature, or a peculiarity in the gait which would suggest congenital dislocation of the hip. Any obvious deviation from a state of health should be observed, such as marked pallor, blueness of the face and lips, dysproea, emaciation, severe cough, or persistent vomiting, these indicate a state of health which may cause labour to have a serious effect on the mother. Any abnormalities about the size of the abdomen should be

u) ted, which might be caused by tumours, oscites, large child, twins, hydramnics or monsters. Abnormalities in the presentation should be noted by palpation. It is easy with a little practice to distinguish vertex from breech, and transverse from either, also posterior from anterior presentations. Particular, enquiry should be made with regard to oedema about the legs and ankles, also about the hands and the face, especially the eyelids. If any be present suspect alhuminuria, and then test the urine. Also enquire about persistent headaches and vomiting, giddiness, and dimness of vision ; Watch carefully the twitchings of the face or other muscles, as these symptoms herald the approach of eclampsia. When called to a woman supposed to be in labour it is important that the midwife should know whether the pains are those of labour or due to something else. There are three well-defined signs that the labour pains are true, first if the hands be placed flat on the abdomen, and the patient be told to say when she feels a pain, the examiner will at the same time feel the uterus contracting, hardening and standing out more prominently under her hands, and when the pain goes oft" the uterus softens and flattens again ; secondly, the " show )J is always present at the onset of labour ; and thirdly, on vaginal examination, the cervix is found to be shortening, the os dilating, and during a pain the membranes are felt to become tight like a drum. There should be no haemorrhage at this stage of labour ; if there is, and there has been a history of a fall or some injury preceding it, suspect accidental haemorrhage from partial separation of a normally placed placenta ; if there have have been several attacks of haemorrhage, some coming on while she was asleep or resting, suspect placenta praevia, and report to a doctor, as this is a grave condition. VAGINAE EXAMINATION. In making a vaginal examination there are four chief points to attend to, viz., the condition of the os and cervix uteri, the membranes and the presentation. When labour, is progressing the os begins to open and the membranes are felt bulging through it ; if the margin of the os is very tight and rigid, labour is likely to be slow in the -first stage ; if they are soft and easily

dilatable labour will progess rapidly. When dilatation is well advanced the condition of the anterior lip should be particularly noted, if it is getting puffy and swollen, it has become nipped between the advancing head and the pubic bones. Not only will this condition delay labour, but the lip will become so bruised that it will slough away, threatening septicaemia in the process. The lip must be slowly and gently pushed up beyond the greatest diameter of the head, flexion of the head being at the same time increased. The condition of the membranes must be noted, and first of all whether they have ruptured or not. This is ascertained by examining during a pain, when if they have not ruptured, they are felt tense and bulging. Too early rupture of the membranes causes delay in labour, and is fraught with danger to the child. The shape of the bulging membranes should also be noted, if they are long and sausage shaped instead of convex like a watch-glass, suspect an abnormal presentation such as breech or transverse. PRESENTATION. The next point to ascertain by vaginal examination is the presentation and position. By palpation the midwife has already ascertained whether the presentation was vertex, breech, or transverse, and whether anterior or posterior. This diagnosis is now confirmed by vaginal examination, and the exact position noted, along with the degree of flexion of the head. A midwife must especially accustom herself to the feel of the sutures and fontanelles, and the relative position they should occupy in the pelvis. A midwife's duty is an important one in this respect, viz., to recognise abnormal presentation and positions early enough to call in medical assistance that can be efficient to save life. In a normal presentation the posterior fontanelle is within the area of the presenting part, and can be felt unless obscured by the caput succedaneum, the anterior fontanelle cannot be reached until the second stage is well advanced. If it is felt while the head is still high up, an undue degree of extension has occurred and must be treated in time. If a brow or face presentation is present, a doctor must at once be sent for, with a written statement as to what the abnormality

is ; similarly with every breech presentation. In a breech the danger to the child begins after delivery of the body, as the cord get nipped between the head and pelvis, and the circulation is stopped before the head is born. In a multipara the birth of the head is likely to be more rapid, and there is not so much danger as in a primipara. Transverse presentations can easily be discovered as soon as the midwife arrives, by inspection, by palpation, by the sausagelike shape of the bag of waters, and by making out the presenting part by vaginal examination. They practically never end normally when left alone, and as they can be easily set right by external version in the early stages of labour before the membranes rupture, it is essential that a midwife should recognise these cases as soon as she is called to the patient, and while waiting for the doctor should do her best to prevent the membranes from rupturing. She should raise the hips of the patient to keep the pressure of the child off the os, and tell her not to attempt to bear down. If the membranes are already ruptured, and an arm or shoulder wedged into the pelvis, a message to that effect must be conveyed to the doctor, who will then lose no time in coming, and will come prepared to deal promptly with the condition. If the umbilical cord can be felt through the unruptured membranes, it is called prolapse of the cord ; if it comes through the rent after the membranes are ruptured, it is called presentation of the cord. In either case the midwife must know that this is a

serious condition and must send for medicyj assistance. . | . • ■ . PULSE AND TEMPERATURE. When a midwife is first called she should take the pulse and temperature. In the first stage it ought not to be more than 80 to 90, in the second stage 90 to 100, and in the third stage again 80 to 90. After that it should fall to about 70. If the pulse rises steadily to J 20 or over it is a serious symptom and may mean exhaustion, haemorrhage, or impending collapse. The temperature should be taken if possible before labour, or at least early ; in labour, in case the woman is suffering from some fever not due to the parturition. It is right to know this, so that the mistaken diagnosis of puerperal septicaemia will not be made when the temperature remains high during the puerperium. HAEMORRHAGE. After a normal labour there is a certain amount of haemorrhage but never sufficient to quicken the pulse. If a profuse ilow starts and continues, and the pulse rises, the haemorrhage is excessive and means must be taken to stop it. She must send- a message for a doctor, * and in the meantime must do what she can herself. If it is alarming, she can press with the ulnar tide of her hand on the abdominal aorta, just above the umbilicus. If not so severe she can grasp and knead the uterus, administer ergot and give a hot douche from 115° to 120 , at the same time raising the lower end of the bed. — From the "British Medical Journal" (To be continued.)