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

Kai Tiaki : the journal of the nurses of New Zealand, Volume I, Issue 3, 1 July 1908, Page 62

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

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

(Continued from April number)

DEI,AY IN THE THREE STAGES OF LABOUR First Stage. — So long as the membranes are unruptured there is little or no danger m delay during this stage ; the child is receiving all it requires from the mother, and the uterus is unable to contract down upon the child, which is protected by the liquor amnii. It is naturally longer m a primipara than m a multipara. Roughly speaking anything within 24 hours would be normal m a primipara, and within twelve hours m a multipara. When there is delay the pains are, as a rule, neither frequent nor strong. In other words, primary inertia of the uterus is the most frequent cause. If the woman is quite well, with normal pulse and temperature, there is no need to hurry matters, but if she is getting restless and irritable, with rise of pulse and temperature, the midwife must call m medical assistance. She must make sure whether there has been premature rupture of the membranes. If there is a watery discharge she must distinguish whether it is urine or liquor amnii, by vaginal examination. If the membranes are not ruptured they will get tight during a pain. Delay m the first stage may be due to twins or hydramnios, or abnormal presentation, or to a rigid or elongated cervix. Rigidity may arise from spasmodic action of its muscular fibres, or from the presence of scar tissue, new growths or cancer. If the membranes remain unruptured after complete dilatation, they should be ruptured artificially, as cases have been known where the child has been born with the membranes intact, and when the placenta is separated, the child quickly drowns m the liquor amnii. To rupture the membranes, the nail should be notched to roughen it, and then drawn across the membranes during a pain. A midwife must remember that she is not at liberty to use any sort of instrument for this purpose.

Second Stage. — Delay m this stage is much more dangerous, because now the head of the child descends into the pelvis, and the cervical canal and the vagina are enormously distended, whilst the surrounding parts are greatly compressed. In a primipara the second stage should not last more than two or three hours, m a multipara one to two hours. The commonest cause of delay is feeble pains or primary inertia, and this ma}', or may not, be accompanied by general weakness or exhaustion on the part of the mother. The midwife should observe whether the mother be strong and robust or the reverse. If the pains are strong and frequent and yet there is no advance, the delay may be due to a big child, to hydrocephalus, to contracted pelvis, to persistent occipito posterior presentation, or to some other cause for which medical help is required, and it is important that the midwife should recognise that there is delay. This is shown by the pains having little or no effect m expelling the child, by the patient becoming restless, and the pulse rising m frequency. Her face becomes anxious, vomiting may set m and the temperature may rise. From whatever cause delay arises, with the liquor amni draining away, the condition is dangerous and medical help is required. A pain accompanied by a shriek and followed by collapse with a thready pulse, indicates rupture of the uterus, and the midwife must at once send for the doctor. If she examines she will find that the presenting part has receded considerably, or may have disappeared altogether, or it is easily pushed back. Sometimes the pain which expels the child ruptures the uterus, and it may not be discovered, but the pulse becomes thready or imperceptible and the patient blanched and collapsed. With these abnormal symptoms the midwife must send for a doctor. Third Stage. — Delay m this stage is again most frequently caused by uterine inertia, and it is of the highest importance that a midwife should know when

to let the patient alone and when to send for help. Therefore she must remember that when all is well, the haemorrhage is only slight, the pulse below 100, often only 80, the patient not excessively pale, and she feels comfortable. On the other hand if there is much haemorrhage, if the pulse rises above 100, if the patient becomes very pale, is restless or m pain, the doctor must be sent for, the midwife m the meantime doing what she can to make the uterus contract and thus arrest the haemorrhage. THE PERINAEUM The midwife should always examine to find out how far the perinaeum is torn, and also examine with the finger (rendered aseptic) m the vagina to see if the floor of the vagina is torn, or if the perinaeum is badly torn internally although the external skin is intact. In these cases a doctor must be called to put m suitable stitches. THE CHILD As a rule the child makes an inspiratory effort as soon as it is born and begins to cry. It can usually be left for a few minutes before the cord is tied. This gives the child several ounces more blood than if the cord is tied immediately. If the child makes no effort to breathe when it is born, it may be due to asphyxia, of which there are two forms popularly called blue and white. Blue asphyxia is more likely to end favourably than white asphyxia. The blueness is caused by the circulation m the cord having been retarded before the birth of the child. Hence the supply of oxygen being cut off, the child's blood becomes venous. This causes the child to make inspiratory efforts, and sometimes mucus and blood and watery fluids are sucked into the lungs. Therefore wipe away anything that may be m the mouth or turn the child upside down m order that some of the inspired fluids may run out. When there is no effort at inspiration for two or three minutes, and if the heart is beat-

ing and the cord pulsating, the cord should be tied and the child separated. It must be made to breathe by artificial respiration, by dipping it alternately into hot and cold water, or by gently smacking the skin. In the white variety of asphyxia the chances of the child are practically nil. There is no pulsation of the cord and no beating of the heart. The child is already dead. The least nicker of the heart may give hope, and m any case all measures must be tried to stimulate the child to breathe. THE CHILD'S EYES The eyelids must be wiped carefully with some aseptic material such as gauze or cotton wool wrung out m warm boric acid lotion. This will be sufficient if the mother is healthy, but if the mother has recently had a yellow discharge, if her water scalds her, or the skin about the vulva is reddened, there is a strong suspicion of gonorrhoea, and active treatment must be used to save the child from opthalmia. Under these circumstances drop one drop of a 2% solution of silver nitrate into each eye, carefully wiping away all secretion from the lids, lashes and corners of the eye. This must be used every eight hours or alternately with a solution of mercury perchloride J m 4,000, and the discharge wiped away every hour or two during the day. Let me emphasise the fact that where there is gonorrhoea m the mother, a single application of a germicidal solution used as a routine measure will not prevent ophthalmia. The child must be examined for any defects or deformities, and for birth marks. If no urine or meconium comes away within twenty-four hours the doctor must be called m. The midwife should note position and size of the caput succedaneum, and any effusion of blood under the scalp (haematoma), or any protrusion of cranial contents (encephalocele), or any tumors along the spine (spina bifida). (To be concluded next issue)