Twilight Sleep and Early Rising

Kai Tiaki : the journal of the nurses of New Zealand, Volume XI, Issue 3, 1 July 1918, Page 141

Twilight Sleep and Early Rising

Dr. Hatrltain's Interesting Views

A meeting of the Edinburgh branch of the Scottish Midwives' Association was held in the Royal Maternity Hospital on Saturday, March 9th, Miss Turnbull presiding. An address was given by Francis D. N. Haultein, M.D., F.R.C.P., Edin., on " Some Recent Developments in Midwifery." Dr. Haultain said he would speak about two subjects of much interest as well as of much controversy and debate at the present time, (1) The Morphine-scopola-mine Treatment, or Twilight Sleep, (2) Early Rising after the Puerperium. With regard to the first, the subject was at present of enormous interest, and had been brought more vividly before the lay public by the publication of a book by Mrs. Hannah Rion. The medical profession was in a considerably controversial state regarding its advantages and disadvantages. The anaesthesia produced by scopolamine -morphine had a great advantage over that produced by chloroform, in so far as the mere application of it did not interfere with the pains of labour. Chloroform had this disadvantage, that when it was given the pains became weakened and labour was continued for an indefinite time, forceps having to be applied as well. This method aimed at two objects — the relief of pain and the absence of memory. Two drugs were given — morphia and scopolamine. With the morphia it was hoped to relieve the pain and to keep the patient in a state of semi-conscious-ness. The pain was not absolutely relieved, Dr. Haultain thought ; it was recognised at the time, but only temporarily, the moment it was gone the memory of it passed. With regard to the injection, the first dose should be given whenever the pains were regular. The method should be started early ; people were inclined to wait too long, then the individual remembered, and the drug did not act with the same efficacy. It should be begun when the pains were in the first stage, occuring every seven or ten minutes. Whenever the medical attendant was certain that the patient had commenced

labour the treatment should be begun. The first injection should consist of quarter grain of morphia and one 150th of scopolamine. After this hyoscine alone should be continued at intervals of three-quarters to one hour. After the first dose the pains were relieved. If the treatment were commenced early enough the patient did not complain, she thought the labour had stopped ; that, however, was not the case — the labour was going on all the time in a passive way. The pains would assert themselves in due course ; when the patient had them she would make a movement or groan. The doses should be continued, and after the third or fourth dose the patient would go to sleep. She would wake up, but would go off to sleep again. She must not be disturbed in any way. If disturbed, she would wake up, recognise the fact that she had pain, and brood upon it. She should be kept absolutely quiet with cotton-wool in her ears ; the blinds should be pulled down ; she should not be spoken to. This sleep was only semi-consciousness, not complete unconsciousness as under chloroform. She should be given water to drink and she would take it. She would have no desire to pass water. But as a full bladder was one of the causes of delay in labour the water should be drawn off every eight hours ; if asked to get up, she would be wakened. In his experience it was necessary to give four doses, morphia only once, and then hyoscine in small doses, even if the labour continued for two solid days. What was the result of the method ? In seventy -five per cent, of the cases the patient was unaware of anything, and awoke surprised that she had got a baby. In twenty -five per cent, it was not so complete, perhaps owing to some idosyncrasy of the patient. These cases had some knowledge of what had happened and thought the}' had had very severe pain. There was no doubt that in every case there was a certain amount of relief from pain. In a number of cases memory remained ; some pain had been felt , but nothing like the pain experienced without the drug. It prevented to a slight degree

the strength of the second -atage pains. If the volition of the individual were taken away the full strength of the pains would be diminished, as the patient would be eager to get the labour over rapidly. Beyond that it did not interfere with the pains. Had the method any disadvantages ? Sometimes the patient became extremely restless. Out of 400 cases he had observed he thought he had seen about ten patients restless, in two cases maniacal, as an effect of the hyoscine. Sometimes the patient pulled her hair, bit the nurse, wanted to get up, and was with great difficulty kept in bed. In that case she must have chloroform. Sometimes the patient was noisy, and shouted during the pain. Sometimes he was able to put on forceps without the patient's knowledge. There were no other disadvantages. One of the great points brought against the method was the effect on the baby. Formerly scopolamine-morphine had been given in a somewhat haphazard fashion. In these cases the baby was often born drowsy ; it did not seem to breathe, it was blue to begin with, and lay in a peculiar still condition. If it were born after the first dose it was often like that — due to the morphia — but after the hyoscine the child was only slightly sleepy ; it looked blase, tired of life before it started, yawned and was lazy. There were no disadvantages to the mother. The treatment could be 'given in heart cases, in any cases. It should be given before the os opened. It could be given in eclampsia. It was of great advantage in long labour. In breech cases, with the patient shouting out "Do something," one was sometimes inclined to break up the breech, thereby endangering the life of the child by delivering too soon. Twilight sleep was imperative in such a case. Where there was a small pelvis, which delayed labour, the case going on for hours where patients could not deliver themselves easily, the longer time given them the better, so that the child's head could mould and adapt itself to the passages. It was a mistake to apply forceps to a child's head when it was not moulded. With the scopolamine-morphine treatment they could go on, even for two days ; then, with a smallish pelvis, there would

be a long first stage ; in the second stage, though pains were strong, twelve or fourteen hours could be allowed for moulding to take place ; then, when they knew it was moulding, forceps could be put on. In long cases there was nothing like it. Twilight sleep to many a patient meant midnight sleep to the doctor. He could start the patient off on the method and say to the nurse, " I'll look in after breakfast." Without this method he would be wanted every hour. The beauty of it was that the patient did not want the doctor. It was a most delightful sensation for the doctor and not bad for the nurse either ! He gave the treatment in every case. He had not seen a baby die yet . It was a method of treatment which would become more and more popular. Dr. Haultain referred to the use of this treatment for the poorer classes. Some of the medical profession said the patient must have personal attendance by the doctor. This was unnecessarj^. He did not see the patient till the head was in the perineum . Would the nurse be allowed to give it ? He hoped the time would soon come when she would be able to give it on her own responsibility. If there were no danger in giving it there was no reason why it should not be given everywhere. The initial dose went a long way to alleviate the pain. In a multipara, if given in the first stage it was helpful ; if in the second, not much use ; for a primapara or a difficult labour it was a splendid thing. People were coming round to it. With reference to the second part of his lecture, " Early Rising," Dr. Haultain said that lying in bed for a period of from ten days to a month after childbirth was merely an old conventional habit. We found it in the Bible : a woman after childbirth was supposed to be unclean. The poor individual, ostracised by surrounding society, had nothing to do but lie in bed. The result was that she had lain there ever since. Was there any advantage in so doing ? For the last ten years he had got his patients up on the third day. After labour the woman should rest in bed for one day, sit up on the second day and have food, and get up on the third day. Labour was a natural process. After the child was born the main thing was to keep the uterus forward. If the woman lay on

her back the uterus tumbled back, and there were retro versions . There were other advantages from early rising. When the woman sat up or rose, the discharge of the vagina would get out. If there were an asepsis, and she lay, this formed an incubator for the germs. If she sat up on the second day the discharge had an easy exit. Again, after the patient was delivered, in the abdominal cavity there was the sudden diminution of a large tumour. What happened ? There was a diminution of pressure in the abdomen and result Was that the veins in t-ne abdomen became enormously distended with blood, the uterus lay in a congested state, surrounded by enormously distended veins. Circulation was slow ; there was no pressure on these veins to make the blood circulate. So the blood clotted, leading to varicose veins. Since he had had his patients up on the third day he had never had a case of these. Another thing brought about quickly by early rising — a point much thought about by the fashionable lady — was the return of the figure. After childbirth the abdominal muscles were soft and flabby. What was to make them firm ? Only the nurse pulling the binder ? But why a binder at all after the first day ? The moment a woman rose the muscles of the addominal wall contracted, and the normal condition of the figure returned in ten days or a fortnight. Otherwise she lay in bed, like a bolster tied in the middle. Again, the muscles of the leg became flabby ; result, when she did get up she could hardly walk. She should get up before the muscles atrophied. Another point was the condition of the bowels, naturally if the abdomen was in a flabby condition the bowels could not act, and there was constipation. This getting-up helped in getting the bowels into a good state. He could not think of a single disadvantage of early rising. To lie in bed was to get weak. The patient should sit at the fireside a little, and move about ; that was a healthy rest. To lie in bed was un-

healthy rest. From a duchess to a woman in the Cowgate, if the woman were healthy she should get up on the third day. She wanted to get up, unless she were particularly lazy. He did not mean she should get up and work hard at a wash-tub, using her abdominal muscles, causing prolapse of uterus ; he was not asking that. For ten years he had " waited/' and he had " seen " — nothing. His conclusion was that it was the correct thing for a woman to do to rise on the third day.—" Nursing Times."

The above inteiesting account of Dr. Hauitain's lecture will interest the matrons and nurses of the St. Helens Hospitals. We would be glad for next issue of an expression of opinion or of an experience of the trials of the treatment so warmly recommended which have been essayed in the State maternity hospitals, or in any of the private hospitals carried on by St. Helers nurses.